Provider Complaint Form

At Delaware First Health, we value provider feedback and are committed to addressing provider concerns in a fair, timely, and respectful manner. Providers may use the form below to submit a complaint regarding Delaware First Health policies, procedures, claims, payments, service authorizations, or other administrative matters.

All complaints are reviewed and handled in accordance with our established provider complaint process. For more information, please visit our Provider Complaints, Claim Appeals, Corrections and Reconsiderations page.

PROVIDER IDENTIFIERS

Provider's First Name *

Provider's Last Name *

Provider's Specialty *

Tax ID Number (TIN) *

NPI Number

Are you contracted with Delaware First Health (Medicaid)? * Yes No Unsure

PROVIDER CONTACT INFORMATION

Practice/Clinic/Facility Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address

Preferred Contact Method * Phone Email

COMPLAINT DETAILS

Date of Incident * Use Date Format: MM/DD/YYYY

Is this related to a specific claim? * Yes No

Claim Number(s) (if applicable) Claims detail and / or examples are required for a full review of the complaint to be completed.

Date(s) of Service (if applicable)

Description of Complaint * Please provide a detailed description of the issue, including any relevant dates, claim numbers, authorization numbers, individuals contacted, and previous attempts to resolve the matter.

RESOLUTION REQUEST

Requested Resolution * Please describe the outcome or resolution you are seeking.

SUPPORTING DOCUMENTATION

Attachments

Examples: claim remittance advice, authorization letters, correspondence, screenshots, supporting documentation, etc.

ATTESTATION

I certify that the information provided is accurate and complete to the best of my knowledge.

Name of Individual Completing Form *

First and Last Name

Professional Title *

Professional Title in Relation to Provider's Office

ACKNOWLEDGMENT STATEMENT

Upon receipt, Delaware First Health will acknowledge provider complaints within three (3) calendar days. Complaints are generally resolved within ninety (90) calendar days in accordance with Delaware First Health's Provider Complaint and Appeal Process.