![]() ![]() Note the reason the claim or issue merits reconsideration.Clearly mark the request as an “Appeal”.The claim appeal and supporting documentation must be received within 120 days of the date of service or no later than 60 calendar days after the reconsideration decision, whichever is latest. To request a non-clinical claims appeal the provider must:Ĭomplete the Claim Appeal Form that can be found on the Delaware First Health website and submit the form in writing to the address below. Prior to submitting the claims appeal, a provider must have submitted a timely claim reconsideration request. If a provider does not agree with a non-clinical reconsideration decision, a provider may file a formal claims appeal. Include the patient's medical record, chart notes and/or other pertinent information to support the request for reconsideration.Include a copy of the EOP that indicates how and when the claim was processed.Submit a request in writing, within 90 days of the EOP or as defined in your Delaware First Health contract. ![]() The most common codes are listed below but are not all-inclusive. If you prefer to refund the overpayment by check (on your check stock), include a copy of the EOP and send to:ĭelaware First Health utilizes a claims adjudication software package, for automated claims coding verification and to ensure that Delaware First Health is processing claims in compliance with general industry standards.Ī provider may request re-evaluation of claims denied by code auditing software. Return uncashed Delaware First Health checks to: If the claim involves COB, a copy of other insurance EOP must be sent to the Delaware First Health Claims Department to recoup along with the description of processing codes. Delaware First Health will recoup the amount of the overpayment as outlined below. Providers are required to report and return any overpayments received within 60 days of the discovery of the overpayment, and must notify Delaware First Health in writing of the reason for the overpayment. To access this function, provider representatives must become a registered user at: Ĭorrected or adjusted paper claims can be mailed to:įor Behavioral Health corrected or adjusted paper claims mail to:Ī provider may receive more payment for a claim than is expected. Omission of these data elements may cause inappropriate denials, delays in processing and payment or may result in the claim being denied as a duplicate, or for exceeding the filing limit deadline.Ĭorrected or adjusted claims submission can be submitted via our provider portal. For the EDI 8371, the data should be sent in the 2300 Loop, segment CLM0S (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted. UB-04 should be submitted with the appropriate resubmission code in the 3rd digit of the bill type (for corrected claim this will be 7) and the original claim number in field 64 of the paper claim.For the EDI 837P, the data should be sent in the 2300 Loop, segment CLM0S (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted. CMS-1500 should be submitted with the appropriate resubmission code (value of 7) in field 22 of the paper claim with the original claim number of the corrected claim.A claim correction or adjustment is not considered an appeal. Corrected claims must be received within 90 days of the date of the EOP or as defined in the provider’s contract with Delaware First Health. Indicate that the provider needs to resubmit the claim as a “corrected claim”Ī provider may submit a corrected claim to correct a billing error in the initial claim submission.The request must be received within 90 days of the date of the EOP or denial, or as defined in a provider’s contract with Delaware First Health.Ī representative will evaluate the payment and, if appropriate, will:.Make a request via Provider Services at 1-87, the provider portal, or in writing at the address below:.A request for reconsideration precedes a claims appeal. Informal Request for Claim Reconsideration (Non-Clinical)įor claims that do not require any correction or change to the original billed claim, a provider may file a request for reconsideration of a claims payment unrelated to a medical necessity determination, including but not limited to a claims payment received being less than the payment expected. to 5 p.m., Monday through Friday.īe sure to have the following information on hand: The provider call center can be reached from 8 a.m. To check the status of a previously submitted claim, call the Delaware First Health Provider line at 1-87. A provider can inquire on the status of the claim at anytime via the provider portal or calling Provider Services.
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