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Medicaid Open Enrollment begins October 1st. To join Delaware First Health, call the Health Benefits Manager at 1-800-996-9969
Medicaid Open Enrollment begins October 1st. To join Delaware First Health, call the Health Benefits Manager at 1-800-996-9969

Provider Inquiries, Claims Reconsideration, Claims Corrections and Adjustments, and Appeals

A provider can inquire on the status of the claim at anytime via the provider portal or calling Provider Services.

Verbal Inquiry

To check the status of a previously submitted claim, call the Delaware First Health Provider line at 1-877-236-1341. The provider call center can be reached from 8 a.m. to 5 p.m., Monday through Friday.

Be sure to have the following information on hand:

  • Servicing provider’s name
  • Member ID number
  • Member name
  • Member date of birth
  • Date of service
  • Claim number, if applicable

Informal Request for Claim Reconsideration (Non-Clinical)

For 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. A request for reconsideration precedes a claims appeal. To submit a request, a provider must:

  • Make a request via Provider Services at 1-877-236-1341, the provider portal, or in writing at the address below:

Delaware First Health
ATTN: Claims Department
P.O. Box 8001
Farmington, MO 63640-8001

  • 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.

A representative will evaluate the payment and, if appropriate, will:

  • Request reprocessing of the claim, or
  • Indicate that the provider needs to resubmit the claim as a “corrected claim”

Claim Correction or Adjustment

A provider may submit a corrected claim to correct a billing error in the initial claim submission. 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. A claim correction or adjustment is not considered an appeal.

  • 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. 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.
  • 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 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.

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.

Corrected or adjusted claims submission can be submitted via our provider portal. To access this function, provider representatives must become a registered user at: delawarefirsthealth.com

Corrected or adjusted paper claims can be mailed to:

Delaware First Health
ATTN: Claims Department
P.O. Box 8001
Farmington, MO 63640-8001

For Behavioral Health corrected or adjusted paper claims mail to:

Delaware First Health
ATTN: BH Claims Department
P.O. Box 8001
Farmington, MO 63640-3001

Claim Overpayment

A provider may receive more payment for a claim than is expected. 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. Delaware First Health will recoup the amount of the overpayment as outlined below. 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.

Return uncashed Delaware First Health checks to:

Delaware First Health
ATTN: Returned Checks
P.O. Box 8001
Farmington, MO 63640-3001

If you prefer to refund the overpayment by check (on your check stock), include a copy of the EOP and send to:

Delaware First Health
P.O. Box 8001
Farmington, MO 63640-3001

For Behavioral Health Claims, send to:

Delaware First Health
ATTN: Behavioral Health Claims
P.O. Box 8001
Farmington, MO 63640-3001

Code Review Denial

Delaware 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.

A provider may request re-evaluation of claims denied by code auditing software. The most common codes are listed below but are not all-inclusive.

EX Code List

x1

x2

x3

x4

x5

x6

x7

x8

x9

xa

Xb

Xc

Xd

Xe

Xf

Xg

Xh

Xo

Xp

Xq

Xr

Xy

Ya

Yd

Ye

Yq

Ys

Yu

57

58

Providers must:

  • Submit a request in writing, within 90 days of the EOP or as defined in your Delaware First Health contract.
  • Include a copy of the EOP that indicates how and when the claim was processed.
  • Include the patient's medical record, chart notes and/or other pertinent information to support the request for reconsideration.

Mail to:

Delaware First Health
ATTN: Medical Review
P.O. Box 8001
Farmington, MO 63640-8001

Non-Clinical Claim Appeal

If a provider does not agree with a non-clinical reconsideration decision, a provider may file a formal claims appeal.  Prior to submitting the claims appeal, a provider must have submitted a timely claim reconsideration request.

To request a non-clinical claims appeal the provider must:

Complete the Claim Appeal Form that can be found on the Delaware First Health website and submit the form in writing to the address below. 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.

  • Clearly mark the request as an “Appeal”.
  • Note the reason the claim or issue merits reconsideration. Please be specific.
  • Include a copy of the claim in question and a copy of the EOP that indicates how and when the claim was processed.
  • Include all medical records, chart notes and other pertinent information to support the request for the appeal.

Formal claims appeals must be mailed to the address below.

Delaware First Health
ATTN: Claims Appeals Department
P.O. Box 8001
Farmington, MO 63640-3001

Behavioral Health claims appeals must be mailed to:

ATTN: Behavioral Health Claims Appeals
P.O. Box 8001
Farmington, MO 63640-3001

Note: Any formal appeals sent to addresses other than what is listed above will not be accepted and will be returned to the sender. Further, the use of USB flash drives, CDs, etc. are restricted from company authorized devices, and will not be accepted for review of medical records and will also be returned to the sender.

A final determination of the review will be communicated within 45 days of receipt of the appeal.

Medical Necessity Appeals (Post-Service Appeal)

When an emergent service has been denied based on medical necessity and the member still received care, a provider may file a clinical appeal.

To file a clinical appeal, a provider must follow these guidelines:

Submit a request in writing, which must be received within 120 days of the date of service or no later than 60 calendar days after the payment or denial of a timely claim submission, whichever is latest.

  • Clearly mark the request as an “Appeal”.
  • Explain the reason the claim or issue merits reconsideration. Please be specific.
  • Include a copy of the claim in question and a copy of the EOP that indicates how and when the claim was processed.
  • Include all medical records, chart notes and other pertinent information to support the request for the appeal.

Note: Any formal appeals sent to addresses other than what is listed below will not be accepted and will be returned to the sender. Further, the use of USB flash drives, CDs, etc. are restricted from company authorized devices, and will not be accepted for review of medical records and will also be returned to the sender.

Mail medical necessity appeals to:

Delaware First Health
ATTN: Appeals Department
P.O. Box 8001
Farmington, MO 63640-3001

Mail medical necessity appeals related to Behavioral Health claims to:

ATTN: Behavioral Health Appeals
P.O. Box 8001
Farmington, MO 63640-3001

Medical necessity appeals are reviewed and decided by a different Delaware First Health medical director than the medical director who made the original adverse decision.

Second Level Medical Necessity Appeals (Post-Service Appeal)

If a provider is not in agreement with Delaware First Health’s decision on the initial medical necessity appeal and has additional information to support the appeal that has not been previously submitted, a provider may request a second level clinical provider appeal. To request a second level medical necessity appeal, the provider must:

  • Submit the request for a second level appeal in writing within 60 calendar days of the date of the first level provider appeal decision letter.
  • Clearly mark the request as a “Second Level Clinical Appeal”.
  • Note the reason why the provider does not agree with the first level appeal decision.  Please be specific.
  • Include a copy of the claim in question and a copy of the EOP that indicates how and when the claim was processed.
  • Include all medical records, chart notes and other pertinent information to support the request for the appeal.

The second level medical necessity appeal is reviewed and decided by a different Delaware First Health medical director than the medical director who made the original adverse decision and the first appeal.

PROVIDER COMPLAINTS

Complaint Process

Delaware First Health maintains written policies and procedures for the filing of provider complaints. A provider has the right to file a complaint with us. Provider complaints written expressions of dissatisfaction.

Providers may file a complaint regarding Delaware First Health policies, procedures, or any aspect of Delaware First Health administrative functions including but not limited to claims, payments, and service authorizations.  Delaware First Health wants to resolve provider concerns. We will not hold it against the provider if he/she files a complaint. We will not treat providers differently.

Providers may file a complaint in writing that is non-claims related within forty-five (45) calendar days of the date of the dissatisfaction. Complaints related to claims, may file a written complaint within twelve (12) months from the date of service or sixty (60) calendar days after the payment or denial of a timely claim submission.

Provider complaints will be acknowledged within three (3) days of receipt. Provider complaints will be resolved within ninety (90) calendar days. If the provider’s complaint is not resolved within thirty (30) calendar days, documentation why and a written notice of the status to the provider will be provided every thirty (30) calendar days thereafter until the complaint is resolved.

How to File a Complaint

A provider can file a complaint in any way that works best for them.

Filing a Complaint Not Related to a Claim

To file a complaint unrelated to a claim, a provider can:

Delaware First Health
ATTN: Complaints
P.O. Box 10353
Van Nuys, CA 90410-0353

How to File a Complaint Related to a Claim

A provider can file a complaint in a way that works best for them. They can:

Delaware First Health
ATTN: Claims Complaints
P.O. Box 8001
Farmington, MO 63640-8001