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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsNovember 2016

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18 DE Admin. Code 1313
Proposed amended Regulation 1313 relating to Arbitration of Health Insurance Disputes Between Carriers and Providers was published in the Delaware Register of Regulations on September 1, 2016. The comment period remained open until October 3, 2016. There was no public hearing on proposed amended Regulation 1313. Public notice of the proposed amended Regulation 1313 was published in the Register of Regulations in conformity with Delaware law.
1. 18 Del.C. §§311, 333, 3371 and 3571S require a regulation to set forth rules and procedural requirements which the Commissioner deems necessary to carry out the provisions of the Code.
Based on the provisions of 18 Del.C. §§311, 333, 3371 and 3571S; and 29 Del.C. Ch. 101, and the record in this docket, I hereby adopt proposed amended Regulation 1313 as may more fully and at large appear in the version attached hereto to be effective 10 days after being published as final.
The text of proposed amended Regulation 1313 last appeared in the Register of Regulations Vol. 20, Issue 3, pages 150-154.
IT IS SO ORDERED this 1st day of November, 2016.
The purpose of this Regulation is to implement 18 Del.C. §§333, 3371 and 3571S, 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, 3371 and 6408 3571S and 29 Del.C. Ch. 101. This Regulation should not be construed to create any cause of action not otherwise existing at law.
"Carrier" or "insurance carrier" 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.
"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.
4.7.1 In arbitrations commenced pursuant to 18 Del.C. §§333, 3371 and 3571S, 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.
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.
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.
Nothing in this Regulation shall supersede any federal or state law or regulation governing the privacy of health information.
9.1 Arbitrations conducted pursuant to 18 Del.C. §§3371 and 3571S shall reflect the objectives of those statutory provisions of protecting consumers from surprise bills and not creating incentives for providers to be out-of-network.
910.0 Computation of Time
101.0 Effective Date
Last Updated: December 31 1969 19:00:00.
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