Medical Billing Services in Delaware
Billing, coding, credentialing and denial management for Delaware practices, with Medicare claims through Novitas Solutions (Jurisdiction JL) and Delaware Medicaid handled by people who know the rules.
Medical billing for Delaware practices
Delaware is a small state with a concentrated payer market. Highmark Blue Cross Blue Shield Delaware holds a large share of commercial coverage, most Medicaid members are in one of three Diamond State Health Plan managed care organizations, and Medicare Part B is processed by Novitas Solutions in Jurisdiction L. Many patients cross state lines into Pennsylvania, Maryland and New Jersey for care, which adds out-of-state coverage to the mix.
Practices in Wilmington, Dover and the Sussex County beach towns often juggle seasonal volume and a growing retiree population. SFA Solutions works with practices across Delaware remotely. Our team works inside your current EHR, submits most clean claims within 24 hours and keeps Highmark, Medicaid plan and Medicare claims on a steady follow-up cycle.
Delaware at a glance
| Medicare contractor | Novitas Solutions, Jurisdiction JL |
|---|---|
| Medicaid timely filing | 12 months from the date of service for DMAP claims, with listed exceptions; managed care organizations set their own limits in provider contracts |
| NP practice authority | Full |
| Cities we serve | Wilmington, Dover, Newark, Middletown, Smyrna, Milford, Georgetown, Seaford, Lewes, Rehoboth Beach |
What Delaware billing involves
These are the programs and rules our team works with for Delaware claims.
Medicare
Novitas Solutions · JLDelaware Part B claims are processed by Novitas Solutions in Jurisdiction JL. Medicare's filing limit is 12 months from the date of service, and appeals start with a redetermination within 120 days of the initial decision.
Delaware Medicaid
Delaware Medical Assistance Program (DMAP), including the Diamond State Health Plan and Diamond State Health Plan Plus; Delaware Healthy Children Program for CHIP
Portal: Delaware Medical Assistance Portal for providers, operated by the fiscal agent Gainwell Technologies, for enrollment and fee-for-service claims
Medicaid managed care
Most members are enrolled in one of three managed care organizations: AmeriHealth Caritas Delaware, Highmark Health Options and Delaware First Health.
Timely filing
12 months from the date of service for DMAP claims, with listed exceptions; managed care organizations set their own limits in provider contracts.
Commercial and Medicare Advantage
Highmark Blue Cross Blue Shield Delaware is the largest commercial carrier, with Aetna, Cigna and UnitedHealthcare also active. Medicare Advantage is growing in Kent and Sussex counties.
Prompt pay law
Delaware regulation 18 Del. Admin. Code 1310 requires carriers to pay, partially pay or deny a clean claim within 30 days of receipt, and to act within 15 days after receiving requested additional information.
Nurse practitioners
Full practiceDelaware APRNs have full practice authority. New APRNs work under a collaborative agreement for two years and at least 4,000 hours before they can practice independently, so payers may request that agreement during credentialing.
Credentialing
Providers enroll with DMAP through Gainwell, then credential separately with AmeriHealth Caritas Delaware, Highmark Health Options and Delaware First Health. Highmark and the national carriers use CAQH ProView. Medicare enrollment goes through PECOS with Novitas JL.
Billing challenges Delaware practices face
Three Medicaid MCOs
Each Diamond State Health Plan MCO has its own prior authorization list, claim submission rules and appeal timeline. Billing the wrong plan after a member switches causes denials that are slow to fix. We verify the current plan before each visit.
Cross-border patients
Delaware practices see many patients covered by Pennsylvania, Maryland and New Jersey employers or Medicaid programs. Out-of-state Medicaid usually requires separate enrollment before you can be paid. Identifying these patients early avoids unpaid visits.
Highmark concentration
With one carrier holding much of the commercial market, Highmark's medical policies and coding edits have a large effect on revenue. Claims that do not match current policy get denied in volume. Regular review of denial trends shows where changes are needed.
Our services in Delaware
Medical Billing
Learn moreCredentialing & Payer Enrollment
Learn moreMedical Coding
Learn moreDenial Management
Learn moreA/R Recovery
Learn moreEligibility Verification & Prior Authorization
Learn moreMedical Billing Audit
Learn moreRevenue Cycle Management
Learn moreSpecialties we bill in Delaware
Delaware medical billing questions
What is the timely filing limit for Delaware Medicaid?
DMAP requires claims to be submitted within 12 months of the date of service, with exceptions such as retroactive eligibility. Claims submitted on time but not paid can be considered within 24 months of the date of service if you can document the original submission. Managed care organizations set their own limits.
Which Medicaid managed care plans operate in Delaware?
Delaware's Diamond State Health Plan members are enrolled with AmeriHealth Caritas Delaware, Highmark Health Options or Delaware First Health. Each plan credentials providers and processes claims separately.
How fast must Delaware insurers pay clean claims?
Under 18 Del. Admin. Code 1310, carriers must act on a clean claim within 30 days of receipt. If they request more information, they have 15 days after receiving it to pay or deny.
Who is the Medicare contractor for Delaware?
Novitas Solutions processes Medicare Part B claims for Delaware under Jurisdiction L, which also covers Washington, DC, Maryland, New Jersey and Pennsylvania.
Get a free billing audit for your Delaware practice
We will review your recent claims and denials against Delaware payer rules and show you what can be recovered.
Nearby states
Primary sources
- CMS: Who are the MACs, A/B MAC Jurisdiction L (JL)
- DMAP General Policy Manual (timely filing, section 1.19)
- DHSS announces Medicaid managed care organizations
- 18 Del. Admin. Code 1310 (standards for prompt, fair and equitable settlement of claims for health care services)
- Laws of Delaware, Volume 83, Chapter 111 (APRN practice, HB 141)
Payer rules change. Last reviewed against the primary sources above on . Confirm current rules with the payer before relying on them.
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