2022 Delaware Code
Title 18 - Insurance Code
Chapter 23. UNFAIR PRACTICES IN THE INSURANCE BUSINESS
§ 2319. Carrier post-claim adjudication audit record requests.
(a) For purposes of this section:
(1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.
(2) “Carrier” does not mean an entity that provides a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq. and 1397 et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
(3) “Post-claim adjudication audit” means any audit of a claim by a carrier post payment.
(b) Except as set forth in subsection (e) of this section, medical records requests for post-claim adjudication audits are limited to 400 claims for a specific episode of care in a 45-day period per provider. Any request for records pursuant to this section shall be made in writing.
(c) A provider shall have no less than 45 days and no more than 60 days from the date of the letter to submit all of the requested records.
(d) A provider shall have no less than 30 days and no more than 60 days from the receipt date of the audit result/determination letter to appeal the audit determination.
(e) This section does not apply to post-claim adjudication audits which are any of the following:
(1) Based on a reasonable belief of fraud, waste, abuse or other intentional misconduct.
(2) Required by, or initiated at the request of a self-insured plan.
(3) Required by the state or federal government or a state or federal government plan.
