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Dealing with Delaware Health Insurance Claims

Before you make a claim: Review your policy or employee booklet carefully to be sure the service in question is covered. Follow any managed care rules, including pre-certification requirements and use of network providers. Give claim forms to the provider, with your policy number and other identifying information.

To submit a claim properly: Find out if your provider submits the claim for you or if you need to do it. If you need to do it, review the information to be sure it is complete and correct. File it as soon as you get the bill from the provider. Send it to the right address. Keep a copy for your reference.

Time frame for claims: Delaware's "Prompt Payment" regulation basically requires the insurance company to pay a claim, reject it or ask for more information within 30 days. It also requires that a health insurance company only ask for additional information once, rather than repeatedly making requests. The company must send you an explanation of benefits that explains its decision.

If your claim is paid: If you assigned benefits to the provider, the benefit check will be sent directly to the provider. You will pay any deductibles and co-insurance. If you did not assign the benefits, the check will come to you and you will need to pay your providers for the entire amount.

If your claim is denied: The reason for denial should be stated on your explanation of benefits. If you disagree with the basis stated for denial, check your policy or employee booklet for the company's appeal procedures.

The company should be able to answer procedural questions about appeals over the phone. Your appeal should be in writing and may require information from your doctor or health care provider.

If, after going through the company's appeal process, you feel that your claim was unfairly denied, contact the Insurance Commissioner's Office at consumer@state.de.us or call 1-800-282-8611. Often, companies will resolve disputes after a Consumer Services representative intervenes on the consumer's behalf.