18 Del. Admin. Code § 1319-4.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1319-4.0 - Arbitration Procedures

4.1 Provider Petition for Arbitration.

4.1.1 A provider or a provider's authorized representative may request that the Department review a carrier's final reimbursement decision through arbitration by complying with the following requirements:

4.1.1.1 Complete in full the Department's standard Petition for Arbitration form, which may be downloaded from the Department's website;

4.1.1.2 Attach to the completed Petition for Arbitration all supporting documentation;

4.1.1.3 Include a filing fee in the form of a check that is made payable to the Department of Insurance, which shall be in the amount of $75 and which shall be maintained by the Department in a special fund identified as the "Arbitration Fund";

4.1.1.4 File the original and one copy of the Petition for Arbitration and the appropriate filing fee with the Department, at the following address:

Delaware Department of Insurance

ATTN: Arbitration Secretary

1351 West North Street, Suite 101

Dover, DE 19904

4.1.1.5 Ensure that the Petition for Arbitration is timely submitted so that it is received by the Department no later than 60 days after the provider received the carrier's final reimbursement decision.

4.1.2 A provider who requests Department review under subsection 4.1.1 shall also:

4.1.2.1 Send a copy of the petition and supporting documentation to the carrier by certified mail, return receipt requested; and

4.1.2.2 Deliver to the Department a proof of service confirming that a copy of the petition was sent to the carrier by certified mail, return receipt requested.

4.1.3 The Department may refuse to accept any petition that is not timely filed or does not otherwise meet the criteria for arbitration.

4.2 Carrier Response to Petition for Arbitration

4.2.1 Within 20 days of receipt of the Petition for Arbitration, the carrier shall deliver to the Department an original and one copy of a response to the Petition for Arbitration, to which it shall attach all supporting documents or other evidence.

4.2.2 At the time of delivering the response to the Department, the carrier shall also:

4.2.2.1 Send a copy of the response and supporting documentation to the provider or the provider's authorized representative by first class U.S. mail, postage prepaid;

4.2.2.2 Deliver to the Department a proof of service confirming that a copy of the response was mailed to the health care provider or the health care provider's authorized representative; and

4.2.2.3 Deliver to the Department a $75.00 filing fee, which shall be maintained by the Department in the Arbitration Fund.

4.2.3 The Department may return any non-conforming response to the carrier.

4.3 Appointment of Arbitrator

4.3.1 Upon receipt of a petition filed in proper form, the Department shall assign an arbitrator.

4.3.2 The arbitrator shall be of suitable background and experience to decide the matter in dispute and shall not be affiliated with any of the parties or with the patient whose care is at issue in the dispute.

4.4 Summary Disposition of Petition by the Arbitrator

4.4.1 An arbitrator may summarily dispose of a petition if:

4.4.1.1 The carrier fails to timely deliver a response; or

4.4.1.2 The arbitrator determines that the petition is meritless on its face or that the subject of the petition is not appropriate for arbitration under this regulation.

4.4.2 If the carrier fails to timely respond to a Petition for Arbitration, the Department may, after verifying proper service and with written notice to the parties, assign the matter to the next scheduled arbitrator for summary disposition.

4.4.2.1 The arbitrator may determine the matter by issuing a default judgment after establishing that the petition is properly supported and was properly served on the carrier.

4.4.2.2 The arbitrator may allow the re-opening of the matter to prevent a manifest injustice. A carrier must make a request for re-opening no later than fifteen days after notice of the default judgment.

4.4.3 If the arbitrator determines that the subject of the petition is not appropriate for arbitration under this regulation or is meritless on its face, the arbitrator may summarily dismiss the petition and provide notice of such dismissal to the parties.

4.5 Arbitration Hearing

4.5.1 The arbitrator shall schedule the matter for a hearing in a timeframe that will allow the arbitrator to render a written decision within 45 days after the delivery to the Department of the Petition for Arbitration. The arbitrator shall give notice of the arbitration hearing date to the parties at least 10 days prior to the hearing. The parties are not required to appear and may rely on the papers delivered to the Department.

4.5.2 Testimony at the arbitration hearing is to be limited, to the maximum extent possible, to statements by each party in which they are afforded the opportunity to explain their view of the previously submitted evidence and to answer any questions posed by the arbitrator.

4.5.3 If the arbitrator allows any testimony in addition to that provided for in subsection 4.5.2 of this regulation, the arbitrator shall allow brief cross-examination or other response by the opposing party.

4.5.4 The "Delaware Uniform Rules of Evidence" will be used for general guidance but will not be strictly applied.

4.5.5 Because the testimony may involve evidence relating to personal health information that is confidential and protected by state or federal laws from public disclosure, the arbitration hearing shall be closed to the public.

4.5.6 The arbitrator may contact, with the parties' consent, individuals or entities identified in the papers by telephone, in or outside of the parties' presence, for information the arbitrator deems necessary to resolve the matter.

4.5.7 The arbitrator shall consider the matter based on the submissions of the parties and information otherwise obtained by the arbitrator in accordance with this regulation. The arbitrator shall not consider any matter not contained in the original or supplemental submissions of the parties that has not been provided to the opposing party with at least five days notice, except claims of a continuing nature that are set out in the filed papers.

4.6 Arbitrator's Written Decision

4.6.1 The arbitrator shall render the arbitrator's decision in writing and shall mail a copy of the decision to each of the parties and to the Department within 45 days of the filing of the petition.

4.6.2 If the arbitrator determines that the carrier's final reimbursement decision provides reimbursement to the provider in an insufficient amount, the carrier shall reimburse the provider in the amount that the arbitrator so determines, within 45 days from the date of the arbitrator's decision.

4.7 Arbitration Costs

4.7.1 The Department shall pay the arbitrator $100 for each arbitration, which shall be payable from the Arbitration Fund.

4.7.2 The arbitrator may award to the health care provider the filing fee, if the health care provider is the prevailing party in the arbitration.

18 Del. Admin. Code § 1319-4.0

23 DE Reg. 314 (10/1/2019)
24 DE Reg. 56 (7/1/2020) (Final)