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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJanuary 2016

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18 DE Admin. Code 1313
INSURANCE COMMISSIONER KAREN WELDIN STEWART hereby gives notice of proposed Department of Insurance Regulation 1313 relating to Arbitration of Health Insurance Disputes Between Carriers and Providers. The docket number for this proposed regulation is 3001.
Email: rhonda.west@state.de.us
1.1 The purpose of this Regulation is to implement 18 Del.C. §333, which requires health insurance carriers to submit to arbitration any dispute with a health care provider regarding reimbursement for an individual claim, procedure or service upon a request for arbitration by the health care provider. This Regulation is promulgated pursuant to 18 Del.C. §§311, 333 and 6408 and 29 Del.C., Ch. 101. This Regulation should not be construed to create any cause of action not otherwise existing at law.
2.1 "Carrier" or "insurance carrier" shall have the same meaning as defined at 18 Del.C. §333(a) (2) means any entity that provides health insurance in this State. Carrier includes an insurance company, health service corporation, managed care organization and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. Carrier also includes any third-party administrator or other entity that adjusts, administers or settles claims in connection with health insurance.
Department” means the Delaware Insurance Department.
2.2 "Health care provider" or "provider" shall have the same meaning as defined at 18 Del.C. §333(a)(1).
Health care services” means any services or supplies included in the furnishing to any individual of medical care, or hospitalization or incidental to the furnishing of such care or hospitalization, as well as the furnishing to any individual of any and all other services for the purpose of preventing, alleviating, curing or healing human illness, injury, disability or disease.
Health insurance” means a plan or policy issued by a carrier for the payment for, provision of, or reimbursement for health care services.
Petition filing” means either each patient or each procedure code, determined by the basis of the filing.
“You have the right to seek review of our decision regarding the amount of your reimbursement. The Delaware Insurance Department provides claim arbitration services which are in addition to, but do not replace, any other legal or equitable right you may have to review of this decision or any right of review based on your contract with us. You can contact the Delaware Insurance Department for information about arbitration by calling the Arbitration Secretary at 302-674-7322 or by sending an email to: DOI-arbitration@state.de.us. You may also go to the Delaware Insurance Department at The Rodney Building, 841 Silver Lake Blvd., Dover, DE 19904 between the hours of 8:30 a.m. and 4:00 p.m. to personally discuss the arbitration process. All requests for arbitration must be filed within 60 days from the date you receive this notice; otherwise, this decision will be final.”
4.1.1 A health care provider or his authorized representative may request review of a carrier’s final reimbursement decision through arbitration by delivering a Petition for Arbitration and all supporting documentation to the Department so that it is received by the Department no later than 60 days after the date of mailing receipt of the carrier’s final reimbursement decision. The Department shall make available, by mail and on its web site, a standardized form for a Petition for Arbitration.
4.1.3.1 send a copy of the Petition and supporting documentation to the carrier by certified mail, return receipt requested;
4.1.3.3 deliver to the Department a non-refundable filing fee. The fee shall be $50 for claims of $1,000 or less, in all other cases the fee shall be $100 of $100, per Petition filing.
4.2.1 Within 20 days of receipt of the Petition, the carrier must deliver to the Department an original and three copies one copy of a Response with supporting documents or other evidence attached.
4.3.1 If the Department Arbitrator determines that the subject of the Petition is not appropriate for arbitration or is meritless on its face, the Department Arbitrator may summarily dismiss the Petition and provide notice of such dismissal to the parties.
4.4.1 Upon receipt of a proper Response petition filed in proper form, the Department shall assign an Arbitrator who shall schedule the matter for a hearing so that the Arbitrator can render a written decision within 45 days of the delivery to the Department of the Petition for Arbitration.
4.7.1 In arbitrations commenced pursuant to 18 Del.C. §333, the Arbitrator shall allocate to each party a percentage of the costs of arbitration. The arbitrator may award to the health care provider the filing fee, if the health care provider should prevail.
5.1 A carrier shall maintain written or electronic records for five years, after completion of the arbitration process, documenting all Petitions for Arbitration including, at a minimum, the following information:
6.1 Any carrier having a dispute resolution method established by contract with its providers which method the carrier believes to be substantially similar to the arbitration method described by this regulation may submit information regarding said method to the Insurance Commissioner for a determination as to whether the carrier should be exempted from the arbitration requirement of 18 Del.C. §333. The information submitted shall include a copy of the contractual language as well as any other information the carrier believes is relevant to the Insurance Commissioner's decision.
7.1 A carrier shall not terminate or in any way penalize a provider with whom it has a contractual relationship and who exercises the right to file a Petition for Arbitration solely on the basis of such filing.
8.1 Nothing in this Regulation shall supersede any federal or state law or regulation governing the privacy of health information.
This Regulation shall become effective 10 days after being published as a final regulation.
Last Updated: December 31 1969 19:00:00.
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