Delaware Medical Billing and Payer Rules

Timely Filing in Delaware

Delaware Law and the Federal No Surprises Act

Delaware's rules cover fully insured plans and send many disputes to Department of Insurance arbitration. Self-funded plans follow the federal process.

Major Payers

How Does Delaware Medicaid Work for Billing?

Delaware Medicaid is run by the Department of Health and Social Services (DHSS), which the General Policy Manual names as the single state agency for Medicaid. Day to day, the Division of Medicaid and Medical Assistance (DMMA) operates the Delaware Medical Assistance Program (DMAP). Most members are enrolled in a managed care plan, and fee-for-service claims go to the fiscal agent, Gainwell Technologies.

Providers work in the Delaware Medical Assistance Portal for Providers, which lets you submit claims, check status and eligibility, and upload 837 files. Provider Services answers at 1-800-999-3371, 8:00 a.m. to 4:30 p.m.

Which Claim Forms and Formats Does DMAP Accept?

Only electronic claims. The General Billing Information manual requires electronic submission effective July 1, 2023, through a clearinghouse, vendor software, or the portal and X12 EDI. Inpatient hospital claims use the 837 Institutional transaction (the electronic UB-04) with revenue codes, ICD-10 diagnosis codes and, for surgery, ICD-10 procedure codes. Payment arrives by EFT and the remittance advice is a portal PDF kept four weeks, so download it weekly. A claim missing from the remittance after four to six weeks should be resubmitted.

Which Managed Care Plans Are in Delaware?

Delaware's Medicaid managed care programs are the Diamond State Health Plan (DSHP) and Diamond State Health Plan Plus (DSHP+), which the manual describes as managed care programs administered by DMAP. The portal lists: Highmark Health Options, AmeriHealth Caritas Delaware and Delaware First Health. Our Highmark billing guide covers one of them. Pediatric dental moved into managed care on January 1, 2025.

What About Enrollment and Revalidation?

DMAP denies claims from unenrolled providers. The portal says it mails revalidation instructions 60 days before the due date and terminates providers who miss it. Since January 1, 2026, institutional providers pay a $750 fee at initial application, reactivation, revalidation, reenrollment and when adding a location.

What Is the Delaware Medicaid Timely Filing Limit?

Delaware Medicaid fee-for-service claims must reach DMAP within twelve months of the date of service. Section 1.19.1 of the General Policy Manual calls this a federal requirement and says a late claim is denied unless one of its listed exceptions applies. The manual's latest revision entry is December 20, 2024.

For the 24-month exception the manual accepts the original claim number in the note section or on the remittance.

How Is Managed Care Filing Different?

The twelve months belong to fee-for-service. Each plan sets its own windows. Delaware First Health's 2024 quick reference guide gives 120 calendar days from the date of service for initial Medicaid claims, 90 days from the explanation of payment for corrected claims and reconsiderations, and 120 days from service or 60 days after the reconsideration decision, whichever is latest, for disputes. That is a 2024 edition, so confirm it against the plan's current manual. This page cites no published numbers for the other two plans.

What Does Delaware Give You Against Commercial Plans?

Under 18 Del. C. § 3370C(b), a carrier must give a provider at least 180 days from the date of service to submit a claim, whatever the provider's network status. The section excludes Medicare, Medicaid and similar government plans, and a contract that allows more time is not a violation. A contract cannot shorten the 180 days.

Who Is the Medicare Contractor in Delaware?

Novitas Solutions is the Medicare Administrative Contractor (MAC) for Part A and Part B in Delaware. The CMS list of MACs by state puts Delaware in Jurisdiction L (JL), together with the District of Columbia, Maryland, New Jersey and Pennsylvania. The list is the March 2023 edition.

The same list assigns Delaware to DME A (Noridian Healthcare Solutions) and to Jurisdiction 15 for home health and hospice (CGS Administrators). Under 42 CFR 424.44(a)(1), a Medicare claim must be filed within one calendar year after the date of service. Our Medicare billing guide covers claim mechanics.

How Does Medicare Interact with Delaware Medicaid?

Medicaid is the payer of last resort under the General Policy Manual, so Medicare is billed first for dual-eligible patients. For Qualified Medicare Beneficiaries, DMAP pays only the Medicare coinsurance and deductible, up to the Medicaid rate, and the provider accepts that as payment in full.

What Is Delaware's Prompt Pay Rule for Insurers?

A carrier must act on a clean claim within 30 calendar days of receiving it. Regulation 1310 of the Delaware Administrative Code, issued by the Insurance Commissioner, lists four actions: pay in full, pay the payable part with a written reason for the rest, deny with a written reason, or request more information in writing. The regulation counts days as calendar days.

A request for information must be specific, happens once per claim, and gives the carrier 15 days after your answer to pay, part-pay or deny.

What Counts as a Clean Claim?

A paper claim is clean on the CMS-1500 (professional) or the UB form (institutional) with all relevant fields completed, and an electronic claim is clean in ASC X12N 837 format. A claim with an unspecified code needs a narrative, and a repeat of an earlier claim is a duplicate. The text still names the UB-92, the predecessor of the UB-04.

What Happens When a Carrier Pays Late?

The remedy sits with the Commissioner. Section 8 lets the Commissioner order the claim plus interest at the maximum rate allowable to lenders under Delaware law, counted from the date payment was first due. Three failures within 36 months create a rebuttable presumption of an unfair practice under 18 Del. C. § 2304. The regulation creates no private cause of action and cannot be waived by contract, so file a complaint with the Department when a pattern forms.

The regulation exempts Medicaid plans, Medicare supplement and other coverages. Check the current Register for later amendments.

Does Delaware Have Its Own Surprise Billing Law?

Delaware regulates out-of-network payment through several sections of Title 18 and arbitration rules run by the Department of Insurance. They apply to insurance delivered or issued for delivery in Delaware, meaning fully insured plans. The federal No Surprises Act (NSA) supplements them: CMS says the NSA does not replace state surprise billing laws, and that a state law generally applies when it gives equal or stronger protection.

Self-funded ERISA plans sit outside state insurance law. CMS states that a state cannot enforce its surprise billing protections against a self-insured group plan unless the plan opted in. For those plans, federal IDR is the path, and our state surprise billing law comparison shows how Delaware sits beside other states.

Which Delaware Sections Cover Which Situation?

What Does the Emergency Care Section Require?

Section 3349(b) requires coverage of emergency care by non-network providers at an agreed or negotiated rate. If the two sides cannot agree, the provider is entitled to the charges and rates the Insurance Commissioner allows after arbitration, and the provider may not balance bill the insured. Before the Commissioner decides, the insurer must pay the highest allowable charge it allowed any other network or non-network emergency provider during the 12 months before the service. The insured still owes deductibles and copayments.

What Do You Owe the Patient Before Non-Emergency Out-of-Network Care?

Section 3370A(d) puts the duty on the facility and the provider. A facility scheduling a procedure must make sure the patient received a timely written disclosure that says whether the facility is in network, that facility-based providers such as anesthesiologists may be out of network, and that charges come on top of cost sharing, with a consent form. If you skip the disclosure or the signed consent, you may not balance bill for services the contract does not cover. Estimates are due in writing within 3 business days of a request. Section 3370A(d)(6) excludes services under §§ 3348 and 3349.

How Do You Dispute an Out-of-Network Underpayment in Delaware?

Pick the pathway by service type and plan type before any clock starts. Emergency care for a fully insured member goes to the Department of Insurance under Regulation 1316, other non-hospital reimbursement disputes under 18 Del. C. § 333, and a self-funded plan to open negotiation and federal IDR, which our out-of-network billing and IDR service runs.

How Does Regulation 1316 Emergency Arbitration Work?

Regulation 1316 uses a range, not a formula. For a provider once in network with the carrier, it runs between the allowable charges under its last participation agreement and the highest it receives from other carriers. For a provider never in network, it runs between the carrier's highest allowable charge in the prior 12 months and the highest the provider receives elsewhere. Its history line shows an August 1, 2023 amendment.

When Does § 333 Apply, and What Does It Exclude?

Under § 333(b), a carrier must arbitrate a reimbursement dispute on a health-care provider's request, filed within 60 days after receiving the carrier's decision. The definition of health-care provider excludes any hospital and any long-term care facility, so a hospital's own claims do not use this route. Arbitration is administered by the Department of Insurance, the statute caps the fee at $100, and the Department lists $75 for health insurance matters. Try informal resolution first, since the arbitrator may dismiss a petition without prejudice if you did not. The losing party may seek a new trial in Superior Court by filing notice within 30 days.

Regulation 1313 requires a carrier that does not pay a charge in full to include a notice of the right to arbitrate, stating that requests are due within 60 days of receipt. The Department says arbitration is not available to contest medical necessity denials.

Which Payers Matter Most in Delaware?

We name only payers we could show operate in Delaware. Medicaid managed care is Highmark Health Options, AmeriHealth Caritas Delaware and Delaware First Health, all listed on the DMAP portal. Delaware First Health's parent materials also show Wellcare for Medicare Advantage and Ambetter for the individual marketplace in the state. Novitas covers original Medicare.

This page cites no Department of Insurance market share report, so it gives no commercial shares.

What Do Delaware Hospitals and ERs Need to Watch?

Acute inpatient Medicaid claims are paid one of two prospectively set amounts per discharge, nursery or general, by room and board revenue code. DMAP will not pay separately for outpatient services another hospital provides during the stay.

Free standing emergency rooms must bill electronically, and the fee-for-service payment is a global encounter fee per visit. Multiple visits in one day go on a single claim detail with units and documentation for each. Most members get FSER services through their plan. These manuals carry 2023 revision dates.

Our hospital and facility billing work covers the UB-04 side of both programs. Nearby states have their own rules: see Maryland, New Jersey and Pennsylvania, which share Novitas JL with Delaware but not Medicaid or state law.

How We Handle Billing in Delaware

We route each Delaware claim by payer first: fee-for-service Medicaid through the portal, one of the three managed care plans, Novitas JL, or commercial. Each route gets its own clock, with the twelve-month Medicaid limit and the 180-day commercial minimum loaded separately, and we keep the portal submission record that proves timeliness.

For underpaid out-of-network claims we check plan type and service type, then run federal IDR or the Delaware arbitration route that fits. Book a call and we will review your Delaware payer mix first.