Provider Complaints, Claim Appeals, Corrections and Reconsiderations

Delaware First Health uses a claims adjudication software to automate coding verification and ensure claims are processed in accordance with general industry standards. If a claim is denied due to code auditing, providers may request a re-evaluation of the denial. While the most commonly audited codes are listed separately, this list is not all-inclusive.

Providers must follow the steps below to request a reconsideration of a claim through medical review:

Submission Requirements:

• Submit the request in writing within 90 days of the Explanation of Payment (EOP) date, or as defined in your Delaware First Health provider contract.
• Include a copy of the EOP showing how and when the claim was processed.
• Provide supporting documentation, such as:
  • Patient medical records
  • Chart notes
  • Any other relevant information that supports the reconsideration request

Please send all documentation to:

If a provider receives more payment than expected for a claim, they are required to:

• Report and return the overpayment within 60 days of discovering it.
• Notify Delaware First Health in writing, including the reason for the overpayment.

Delaware First Health will initiate recoupment of the overpaid amount as outlined in its policies.

Coordination of Benefits (COB) Claims

If the overpayment involves Coordination of Benefits (COB):

• Include a copy of the other insurance's Explanation of Payment (EOP).
• Provide a description of the processing codes.
• Send this documentation to the Delaware First Health Claims Department.

Returning Overpayments

If you are returning an uncashed Delaware First Health check, mail it to:

If you prefer to refund the overpayment using your own check stock, include a copy of the EOP and mail it to:

For claim-related overpayment inquiries, send supporting documentation to:

For Behavioral Health claims, send the refund and supporting documentation to:

For claims that do not require any corrections or changes to the originally billed information, providers may submit a request for reconsideration regarding the claim’s payment. This applies to issues unrelated to adverse benefit determinations, such as receiving a payment amount that is less than expected.

Note: A reconsideration request must be submitted before initiating a formal claim appeal.

To submit a request, providers may use one of the following methods:

• Phone: Contact Provider Services at 1-877-236-1341
• Online: Use the secure provider portal (legacy)
• Mail: Send a written request to:

Deadline:

Requests must be received within 90 days of the date on the Explanation of Payment (EOP) or denial notice, unless otherwise specified in the provider’s contract with Delaware First Health.

Once the request is received, a representative will review the payment. If appropriate, they will either:

• Request reprocessing of the claim, or
• Advise the provider to resubmit the claim as a corrected claim

When a service has been denied due to lack of prior authorization after service has been provided to the patient, please follow the retro-authorization process.

A provider may submit a corrected claim to address billing errors in the original claim submission.

Corrected claims are not considered appeals and must be received within 90 days of the date on the Explanation of Payment (EOP), unless otherwise specified in the provider's contract with Delaware First Health.

Submission Requirements

For CMS-1500 (Professional Claims):

• Use resubmission code "7" in Field 22 of the paper claim.
• Include the original claim number.
• For EDI 837P submissions:
  • Use Loop 2300, Segment CLM05 with a value of "7".
  • Include Loop 2300, Segment REFF8 with the original claim number.

For UB-04 (Institutional Claims):

• Use resubmission code "7" in the third digit of the bill type.
• Include the original claim number in Field 64 of the paper claim.
• For EDI 837I submissions:
  • Use Loop 2300, Segment CLM05 with a value of "7".
  • Include Loop 2300, Segment REFF8 with the original claim number.

Important: Missing or incorrect data elements may result in:

• Denial as a duplicate claim
• Processing delays
• Denial for exceeding the filing limit

Submission Methods

Online Submission:

Corrected or adjusted claims can be submitted via the provider portal.

To access this feature, providers must register by accessing the Secure Provider Portal Login page on the Delaware First Health website.

Paper Submission:

Send corrected or adjusted paper claims to:

If a provider disagrees with a reconsideration decision, they may submit a formal claim appeal. A timely claim reconsideration request must be submitted before initiating an appeal.

Adverse Benefit Determination Denials

If an emergency service is denied based on medical necessity but the member received care, the provider may submit a Formal Claim Appeal. 

To submit a formal claims appeal, the provider must:

Complete the Claim Appeal Form, available on the Delaware First Health website on the Manuals, Forms and Resources page. The form is located under the Provider Forms menu.

• Submit the completed form and supporting documentation in writing to the address below.
• Ensure the appeal is received within 120 days of the date of service, or within 60 calendar days after the reconsideration decision—whichever is later.
• Clearly mark the request as an “Appeal.”
• Provide a specific explanation of why the claim or issue merits reconsideration.
• Include a copy of the claim in question and the EOP showing how and when the claim was processed.
• All relevant medical records, chart notes, and other supporting documentation important to submission requirements.

Please see the table below for further instruction on mailing or faxing claims appeals.

Adverse Benefit Determination appeals are reviewed by a Delaware First Health Medical Director who was not involved in the original adverse determination. This ensures an independent and impartial evaluation of the appeal

• Appeals sent to any address other than the one listed for appropriate claims appeals (example – Adverse Benefit Determination denials must be sent to the Adverse Benefit Determination Address), will not be accepted and will be returned to the sender.
• Electronic media such as USB flash drives, CDs, or similar devices are not accepted. These items are restricted from use with Delaware First Health’s authorized systems and will also be returned to the sender.

A final determination regarding the appeal will be communicated within 45 calendar days of Delaware First Health receiving the appeal.

Delaware First Health maintains written policies and procedures for the submission and resolution of provider complaints. Providers have the right to file a complaint, which is defined as a written expression of dissatisfaction.

Providers may submit complaints regarding Delaware First Health policies, procedures, or any aspect of administrative functions, including but not limited to claims, payments, and service authorizations. Delaware First Health is committed to addressing and resolving provider concerns. Providers will not be penalized or treated differently for filing a complaint.

Non–claims-related complaints must be submitted in writing within forty-five (45) calendar days from the date of the dissatisfaction. Complaints related to claims must be submitted in writing within twelve (12) months from the date of service or within sixty (60) calendar days following the payment or denial of a timely submitted claim.

All provider complaints will be acknowledged within three (3) calendar days of receipt and resolved within ninety (90) calendar days. If a complaint cannot be resolved within thirty (30) calendar days, Delaware First Health will provide written documentation explaining the delay and will issue a status update to the provider every thirty (30) calendar days thereafter until resolution is achieved.

Submit your complaint via four different channels: 

• Mail

• Fax: 1-844-273-2671
• Secure Provider Portal (legacy)
• *New Effective September 2026* Provider Complaint Form - This form will allow users to submit a complaint using the form, which will route directly to the dedicated Delaware First Health complaint team.

Requests for retrospective review must be submitted within 120 days of the service date and must include the extenuating circumstance. If requested DOS exceeds 120 days from the service date when enrollment discrepancies are identified, providers can submit a claims appeal noting the enrollment discrepancy and request consideration during review.

For further instructions for submitting an authorization request, please see the Prior Authorization section of this website.