Provider Complaints, Claim Appeals, Corrections and Reconsiderations

A provider may submit a corrected claim to correct a billing error in the initial claim submission. Corrected claims must be received within 90 days of the date of the EOP or as defined in the provider’s contract with Delaware First Health. A claim correction or adjustment is not considered an appeal.

• CMS-1500 should be submitted with the appropriate resubmission code (value of 7) in field 22 of the paper claim with the original claim number of the corrected claim. For the EDI 837P, the data should be sent in the 2300 Loop, segment CLM0S (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted.
• UB-04 should be submitted with the appropriate resubmission code in the 3rd digit of the bill type (for corrected claim this will be 7) and the original claim number in field 64 of the paper claim. For the EDI 8371, the data should be sent in the 2300 Loop, segment CLM0S (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted.

Omission of these data elements may cause inappropriate denials, delays in processing and payment or may result in the claim being denied as a duplicate, or for exceeding the filing limit deadline.

Corrected or adjusted claims submission can be submitted via our provider portal. To access this function, provider representatives must become a registered user at: delawarefirsthealth.com

Corrected or adjusted paper claims can be mailed to:

Delaware First Health
ATTN: Claims Department
P.O. Box 8001
Farmington, MO 63640-8001

For Behavioral Health corrected or adjusted paper claims mail to:

Delaware First Health
ATTN: BH Claims Department
P.O. Box 8001
Farmington, MO 63640-3001

A provider may receive more payment for a claim than is expected resulting in an overpayment of products or services. Providers are required to report and return any overpayments received within 60 days of the discovery of the overpayment, and must notify Delaware First Health in writing of the reason for the overpayment. Delaware First Health will recoup the amount of the overpayment as outlined below. If the claim involves COB, a copy of other insurance EOP must be sent to the Delaware First Health Claims Department to recoup along with the description of processing codes.

Return uncashed Delaware First Health checks to:

Delaware First Health
ATTN: Returned Checks
P.O. Box 8001
Farmington, MO 63640-3001

If you prefer to refund the overpayment by check (on your check stock), include a copy of the EOP and send to:

Delaware First Health
P.O. Box 8001
Farmington, MO 63640-3001

For Behavioral Health Claims, send to:

Delaware First Health
ATTN: Behavioral Health Claims
P.O. Box 8001
Farmington, MO 63640-3001

For claims that do not require any correction or change to the original billed claim, a provider may file a request for reconsideration of a claims payment unrelated to a medical necessity determination, including but not limited to a claims payment received being less than the payment expected.

NOTE: A request for reconsideration precedes a claims appeal.

To submit a request, a provider must make a request via Provider Services at 1-877-236-1341, via our secure provider portal (legacy), or in writing at the address below:

Delaware First Health
ATTN: Claims Department
P.O. Box 8001
Farmington, MO 63640-8001

The request must be received within 90 days of the date of the Explanation of Payment (EOP), denial, or as otherwise defined in the provider’s contract with Delaware First Health.

A representative will review the payment and, if appropriate, will either request reprocessing of the claim or indicate that the provider must resubmit the claim as a corrected claim.

Delaware First Health utilizes a claims adjudication software package, for automated claims coding verification and to ensure that Delaware First Health is processing claims in compliance with general industry standards.

A provider may request re-evaluation of claims denied by code auditing software. The most common codes are listed below but are not all-inclusive.

Providers must:

• Submit a request in writing, within 90 days of the EOP or as defined in your Delaware First Health contract.
• Include a copy of the EOP that indicates how and when the claim was processed.
• Include the patient's medical record, chart notes and/or other pertinent information to support the request for reconsideration.

These requests should be submitted to:

Delaware First Health
ATTN: Medical Review
P.O. Box 8001
Farmington, MO 63640-8001

If a provider does not agree with a claim reconsideration decision, a provider may file a formal claims appeal. Providers may request review of any post-service denial. This process allows providers to address payment-related issues only and must be initiated by the provider through a written request with supporting documentation including: 

• Provider Claim Appeal Form
• Copy of Claim
• Explanation of Payment (EOP)
• Medical Records (containing services rendered)

NOTE: Prior to submitting the claims appeal, a provider must have submitted a timely claim reconsideration request.

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.