Payments to Non-Network Providers of Emergency Services

TRINIDAD NAVARRO COMMISSIONER [LOGO] STATE OF DELAWARE DEPARTMENT OF INSURANCE # DOMESTIC/FOREIGN INSURERS BULLETIN NO. 71 (Revised) TO: ALL INSURANCE COMPANIES THAT WRITE HEALTH INSURANCE COVERAGE IN DELAWARE RE: Payments to Non-Network Providers of Emergency Services DATED: June 23, 2014 REVISED: March 28, 2017 February 7th 2023 The purpose of the original and the latest version of this bulletin¹ is to remind carriers of their statutory obligation to fully reimburse non-network emergency services as required by 18 Del. C. §§ 3349(c) and 3565(c) by paying the provider: - Directly; - At an amount that is the highest allowable charge for each emergency care service allowed by the insurer for any other network or non-network provider during the full 12-month period immediately prior to the date of emergency care service performed by the non-network provider; and - Within 30 days of receipt of each clean claim for each emergency care service. The Department is very concerned with complaints from representatives of emergency medical service providers who report that carriers are terminating contracts or reducing reimbursement under contracts between carriers and these providers, resulting in several hundred outstanding, unpaid claims. The above-cited sections require carriers to pay emergency service providers within 30 days of a clean claim and require payment of the highest allowable charge during the prior 12-month period. Failure to comply is a violation of those provisions and the Unfair Claims Settlement Act. If the amount due for the emergency service under the policy is disputed, either the carrier or the provider may file for arbitration of these claims as is provided at 18 DE Admin. Code 1316, but either party's decision to pursue arbitration does not negate the carrier's responsibility to pay the claim in the required amount within 30 days of presentment of a clean claim. Any questions, comments, or requests for clarification about this bulletin should be emailed to Compliance@delaware.gov. the provider may file for arbitration of these claims as is provided at 18 DE Admin. Code 1316, but either party's decision to pursue arbitration does not negate the carrier's responsibility to pay the claim in the required amount within 30 days of presentment of a clean claim. Any questions, comments, or requests for clarification about this bulletin should be emailed to Compliance@delaware.gov. NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Delaware Department of Insurance if additional information is needed. ♦INSURANCE.DELAWARE.GOV♦ 1351 W. NORTH ST., SUITE 101, DOVER, DELAWARE 19904-2465 (302) 674-7300 DOVER♦ (302) 259-7554 GEORGETOWN♦ (302) 577-5280 WILMINGTON This Bulletin shall be effective immediately and shall remain in effect unless withdrawn or superseded by subsequent law, regulation, or bulletin. Trinidad Navarro Trinidad Navarro Delaware Insurance Commissioner ¹ The purpose of the March 28, 2017 revision to this bulletin was to inform carriers that the Department recodified 18 DE Admin. Code 1301-7.61 and 7.62 to 18 DE Admin. Code 1316-3.6.1 and 3.6.2. See 19 DE Reg. 923 and 926 (April 1, 2016). 2