Medical billing services in Delaware

Billing in Delaware: what's different

The rules below change how a claim is filed and paid in Delaware. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Delaware claims are billed

• Being enrolled with DMAP comes before any plan contract¹

  Delaware First Health's billing manual executes participation agreements only for providers it has validated as enrolled with the Delaware Medical Assistance Program, and asks each provider to keep its name as shown on the W-9, its NPI and its tax identification current with provider relations. Its clean claim is one in a nationally accepted format, compliant with standard coding guidelines, needing no further information, adjustment or alteration from the provider, and a claim not submitted within the filing deadlines is a non-clean claim by definition. Electronic claims go through Availity or another clearinghouse under payer ID 68069, and providers who bill electronically carry the same timely filing requirements as paper billers.

• Three plans since January 1, 2023⁶

  On July 12, 2022 Delaware First Health announced that the Department of Health and Social Services' Division of Medicaid and Medical Assistance intended to award it a statewide contract for the Diamond State Health Plan and Diamond State Health Plan Plus, with services expected to commence on January 1, 2023 and to integrate physical health, behavioral health and long-term services and supports. CMS's 2024 count then shows Highmark Health Options of Delaware with 119,253 members, AmeriHealth Caritas of Delaware with 70,089 and Delaware First Health with 29,825, so a practice that credentialed with two plans before 2023 has a third contract, portal and appeal route to add.

• The 1115 demonstration behind DSHP runs through 2028⁵

  CMS's demonstration page shows the Delaware Diamond State Health Plan approved with an effective date of January 1, 1996 and an expiration date of December 31, 2028. The 2024 state tables describe the program as statewide managed care with managed long-term services and supports, mandatory for low-income adults, aged, blind or disabled members, children, full dual eligibles, children with special health care needs and Native American members, with members pre-assigned to a plan, NCQA accreditation and National Core Indicators reporting required, and Mercer as the external quality review organization. Full dual eligibles in a DSHP Plus plan mean Medicare crossover claims land with the plan, not the state.

• One documentation request, then a decision⁷

  Insurance Regulation 1310, adopted under 18 Del. C. sections 311, 2304(16) and 2312, requires a carrier to act within 30 days of receiving a clean claim by paying it, paying part with a written explanation, denying it with a written reason or requesting additional documentation, and allows only one request for additional clinical information per claim, followed by 15 days to decide once the documentation arrives. A clean claim is on the CMS-1500 or institutional claim form on paper or in the ASC X12N 837 format electronically, carrier includes HMOs and third-party administrators, three failures in 36 months create a rebuttable presumption of an unfair practice, and the Commissioner may impose interest at the maximum lender rate. The amended rule applies to claims submitted on or after November 1, 2005.

• Transportation sits outside the plans³

  CMS's 2024 state tables mark non-emergency medical transportation as a benefit of the Modivcare program and of PACE but not of the Diamond State Health Plan, and record the brokerage as statewide since July 1, 2002 under section 1902(a)(70) with Modivcare as the enrollment broker. The 2024 plan table puts 236,213 Medicaid members in the Modivcare program, more than the 219,537 in the three health plans combined, because members outside the plans ride too. A transportation company bills Modivcare against its trip authorization for every Medicaid member, whichever health plan the member belongs to.

• Two medical carriers and two dental carriers on the 2027 marketplace⁹

  The Delaware Department of Insurance's September 4, 2026 release on plan year 2027 marketplace rates names Highmark Blue Cross Blue Shield and AmeriHealth Caritas as the medical carriers and Delta Dental and Dominion Dental as the dental carriers, with open enrollment starting November 1, 2026, and the department's rate filings page lists AmeriHealth Caritas and Highmark BCBSD for individual plans on and off the marketplace and Highmark BCBSD for small group plans. So a Delaware practice deals with a short list of commercial carriers, and each one's filing window, corrected-claim process and appeal levels sit in its own provider manual.

Services for Delaware practices

Remitwright serves Delaware practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits