Appealing Ssi Ssdi & Medicare Decisions
SSI & SSDI
You have the right to appeal both SSI and SSDI decisions. See the link below for more information on the appeals process, or contact your local Social Security Office for more information on how to appeal a decision you disagree with:
Timing is very important for appeals. Generally, your appeal must be received within 60 days of the date on your notice. Legal assistance for your appeal may be available. However, you should apply for legal assistance as soon as possible as it can take time for your case to be evaluated.
Medicare
Learn how to appeal your Medicare Income-Related Premium:
Information on how to appeal coverage or payment decisions made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan can be found at .
The medical eligibility criteria for SSI and SSDI are the same.
Required Documents For Those Applying For New Submitter Ids
The following enrollment process is required and must be completed, signed and submitted to the Delaware Medicaid office prior to initiation of electronic claims submission or inquiry.
Please click the following link to begin their online Trading Partner Enrollment Process:
If the above link does not work properly please click this link to go to their Home Page:
Next click the link on the left for “Trading Partner Enrollment” then “Enrollment Application” on the following page.
If you have any questions regarding any of the options on their online portal, please call the Delaware Medicaid EDI Technology Support Center at 1-800-999-3371.
We can now process 276/277 requests . If this is a transaction you would like to utilize please make sure to enroll with the payer.
Electronic Visit Verification Launch Postponed
The launch of Electronic Visit Verification on Jan. 1, 2021, has been postponed.
Highmark Health Options will notify you of the new go-live date. While the overall system implementation will be delayed, please continue with your efforts towards implementation. If you are using a third-party EVV system, please move forward with collecting EVV data as of Jan. 1, 2021. This will enable you to upload your visit data to the AuthentiCare aggregator when AuthentiCare is implemented. If you are planning to use AuthentiCare as your EVV solution, it is not necessary for you to collect visit data during this delay. If you have received state-issued devices, please ensure they are safely stored.
Electronic Visit Verification is an electronic system that records the time your personal care, nursing, and home health services begin and end. Highmark Health Options uses EVV as required by the federal government.
Read Also: Eye Place That Takes Medicaid
Billing For Home Delivered Meals
10/26/2020
The purpose of this information letter is to clarify the claim submission guidelines for Delaware Health Options Home Delivered Meal Benefit.
Delaware Division of Medicaid and Medical Assistance Electronic Visit Verification Provider Overview Training
10/16/2020
The Division of Medical Medicaid & Medical Assistance has partnered with Fiserv in the implementation of Electronic Visit Verification effective January 2021.
Services Available In Delaware In 202:
1. Nursing Facility Program
2. Long Term Care Community Services Elderly and Disabled/Assisted Living/Acquired Brain InjuryAIDS/HIV Community-Based Services
3. Developmental Disabilities Services Waiver
4. Program of All-Inclusive Care for the Elderly
The majority of the Medicaid population receiving Medicaid services will be enrolled into the Diamond State Health Plan, or Diamond State Health Plan Plus. Individuals that are eligible for the Nursing Facility Program, the Long Term Care Community Services Program must enroll in Diamond State Health Plan Plus. This managed care initiative will provide improved access to community-based long-term care services, increased flexibility to more effectively address individual needs, and to better control rising long-term care costs significantly impacting Medicaid.
Individuals that opt for enrollment in the Program of All-Inclusive Care for the Elderly are not eligible to enroll in a Managed Care.
Delaware long term care insurance partnership in 2022:
Apply for programs here:
Medicaid contact information:
You May Like: High Risk Ob Gyn That Accepts Medicaid
Delaware Sb 109 Reminder
In August 2020, Highmark Health Options shared a provider update regarding SB 109. The following serves as a reminder that, in cooperation with the State of Delaware, HHO continues to abide by SB 109, amending 18 Del.C. §§ 3343 and 3578 and 31 Del.C. §524, to increase access and decrease barriers to needed substance use disorder treatments.
May 1, 2021
Reminder From Dmma: Providers Must Enroll With Dmap
A message from Stephen M. Groff, Medicaid Director, DMMA:
In compliance with 42 CFR 438.602 and 42 CFR Part 455, subparts B and E, and the 21st Century Cures Act, the Delaware Medical Assistance Program has developed processes to screen current and prospective Managed Care Organization providers according to the Centers for Medicare & Medicaid Services guidelines.
Effective March 1, 2022, providers who wish to participate with a Delaware Medicaid MCO are required to enroll with DMAP. These requirements align with the Division of Medicaid & Medical Assistance provider screening and enrollment with fee-for-service requirements. DMMA has sent providers a letter containing information about the steps providers need to take to enroll in DMAP. It is vital that providers respond to this letter and follow the necessary steps to ensure enrollment. For those providers who have completed the process, I thank you. For those who have not, please do so as soon as possible. Failure to comply with these requirements will result in the MCOs inability to contract with you for Medicaid services.
If you have questions regarding this process, please contact DMMA by:⢠Calling Provider Services at 1-800-999-3371 Option 0, then Option 4⢠Emailing
Reminder: Do not send any correspondence that has protected health information to this mailbox.
You May Like: Give Me The Number To Medicaid
Delaware Division Of Social Services And Division Of Medicaid And Medical Assistance
You can apply for certain benefits through the Division of Social Services which is a state agency. The Delaware ASSIST website acts as a one-stop shop to make it easy for you to find if you are eligible for lots of different programs, and to also apply. You can use Delaware Assist to apply for:
- Long Term Care Medicaid
- Health Care Coverage through Medicaid
- Food Supplement Program
- Cash Assistance
- Low Income Home Energy Assistance Program
You can also apply for benefits at your local DSS office.
- You can call the DSS helpline at 211 to find your DSS office.
- If you cannot apply on-line or by visiting the DSS office in-person, you can request that DSS assist you through the application and other processes via mail and telephone.
You should be aware that you have a right to file an application even if DSS staff tell you that they think you will be denied.
Electronic Claim Submission Provider Agreement
-
Please press “Continue” once done reading their welcome page
Profile Information
-
Please enter your Provider or Business name as the Trading Parnter Name
-
Please enter your address
-
For Type of Business enter Provider if you are billing on your own behalf or Billing Company if you are a billing service billing on behalf of the provider
-
Please enter enrollment and EDI contact information
-
Please press “Continue”
-
Please select “837I Health Care Claim: Institutional” if you send institutional claims
-
Please select “837P Health Care Claim: Professional” if you send professional claims
-
Please select “835 Health Care Claim Payment/Advice” if you wish to receive electronic remits
-
Press “Continue” once done
-
Enter your Name in the box to electronically sign the document
-
Please press “Submit” to submit your application
Summary Page
-
Please print out this page for your records
Also Check: Does Medicaid Pay For Hospital Bills
New Provider Portal Launching In 2022
The new provider portal launches this winter, replacing NaviNet, the Enhanced Provider Portal, and parts of Highmarkâs Provider Resource Center. Starting Oct. 22, 2021, authorization submissions will no longer be accepted through NaviNet. While the new provider portal is being developed, temporary manual processes will be in place for authorizations and appeals and claims disputes. Here’s what to expect.
Delaware Long Term Care In 202:
Delaware is an income cap state, meaning that in order to be eligible for Medicaid long term care benefits there is a hard income limit. The income limit for an applicant is set at 250% of the Supplemental Security Income standard, which changes annually. Non income cap states allow applicants to spend down money for their care, whereas income cap states require the amount to be no higher than their limit at time of application.
Applicants must meet medical and financial eligibility requirements. A nurse may visit the applicant to decide whether he/she needs skilled or intermediate levels of care as determined by Delaware Medicaid criteria.
When applying in 2022, the Delaware Division of Medicaid and Medical Assistance will mail an application packet to the applicant or their family. Financial eligibility is then determined by the information submitted plus an evaluation by a financial eligibility social worker.
Spousal Rules in 2022:
If the community spouses total assets are less than $25,000.00, an amount may be taken from the applicant spouses portion to bring it up to $25,000.00. The maximum amount of resources the community spouse may retain is $137,400.
If the community spouses monthly income is less than $2,177.50/month then he or she may keep part of the institutionalized spouses income to meet the minimum. Depending on documented shelter expenses, the community spouse may be able to bring their monthly income up to $3,435.00.
Don’t Miss: Does Medicaid Pay For Hospice Room And Board
Appeals Of Decisions About Dss And Dmma Benefits Including Decisions By Your Medicaid Managed Care Organization
If your application for Division of Social Services benefits is denied, you have a right to receive a written denial, and you also have a right to appeal that decision. If you are receiving benefits from the Division of Social Services and you find out that your benefits are being reduced, suspended, or terminated, you also have the right to appeal.
You have the right to appeal decisions about your medical assistance, including Medicaid. This includes decisions made by your Medicaid Managed Care Organization MCO , or the Division of Medicaid and Medical Assistance. Examples of decisions you can appeal include: a decision to deny coverage for something, to decide not to cover as much of a service as your healthcare provider is requesting, or to reduce or terminate a service you already receiving. For example, if your doctor requests that you receive 16 hours of home health aide services and you are only approved for 8, you can appeal that decision. Or, if your doctor prescribes you a medical device and that device is not covered, you can appeal that decision.
To request a Fair Hearing, you can complete and return the form that is typically on the last page of your notice, or, you can send a written request to:
Fair Hearing Office
P.O. Box 906, Lewis Bldg.
New Castle, DE 19720
You’re Invited: Virtual Provider Education And Demo
Join Highmark Health Options for a virtual info session on our quality program, pharmacy, provider network, and new risk adjustment platform.
Date: Monday, May 17, 2021
Times: 11 a.m. to noon or 2 p.m. to 3 p.m.
Register for your session by emailing Provider Relations at . Include your practice name, participant name, participant email address, and choice of session.
Also Check: Who Qualifies For Medicaid In New Jersey
Delaware Healthy Children Program
The Delaware Health Program is a partnership between the federal and state governments that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.
CHOOSE HEALTH
REQUEST FOR PROFESSIONAL SERVICES The State of Delaware Department of Health and Social Services , Division of Medicaid and Medical Assistance has released a Request for Professional Services for Managed Care Medicaid Service Delivery. The release date was December 15, 2021, with responses due March 15, 2022. The estimated notification of award is June 1, 2022, with implementation and readiness review June through December 2022. Click here for more information.
Delaware Diamond State Health Plan 1115 Demonstration Waiver 2021 Annual Report
In compliance with the Special Terms and Conditions of the Diamond State Health Plan , Section 1115 Demonstration, the State of Delaware ) publishes this most recently approved Annual Report.
Delaware Diamond State Health Plan 1115 Demonstration Waiver Evaluation Design
In compliance with the Special Terms and Conditions of the Diamond State Health Plan , Section 1115 Demonstration, the State of Delaware ) publishes this Approved Evaluation Design.
Don’t Miss: Is Nebraska Total Care Medicaid
Find Out If A Service Requires Prior Authorization
Review the latest Highmark Health Options Prior Authorization List. Updated quarterly, this document lists codes and prior authorization requirements for medical procedures and services. The contents of this document are subject to change in accordance with plan policies and procedures and the Provider Manual.
As a reminder, prior authorizations are required for:
⢠All non-par providers.⢠Out-of-state providers.⢠All inpatient admissions, including organ transplants.⢠Durable medical equipment over $500.⢠Elective surgeries.⢠Any services that require coordination of benefits.⢠When the primary payer requires an authorization for the service.
Questions? Contact your provider account liaison or call Provider Services at 1-855-401-8251, MondayâFriday, 8 a.m. to 5 p.m.
May 11, 2022
Medicaid Provider Enrollment Requirements By State
The following information includes state-specific provider enrollment requirements for states where BCBS Plans offer Medicaid products. Please refer to the table below for state-specific Medicaid provider enrollment requirements if your claim has been denied and you have received notice from a BCBS Plan that the state where the member is enrolled in Medicaid requires that providers enroll in that states Medicaid program before the BCBS Plan can issue payment.
Products and services are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon Healthcare of New Jersey, and/or Horizon Healthcare Dental, Inc., each an independent licensee of the Blue Cross Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.
Recommended Reading: Does Medicaid Cover Breast Lift
Supporting Individuals With Substance Use Disorder
Highmark Health Options, in collaboration with Wayspring, has launched a data-driven Recovery Support Program that focuses exclusively on supplementing existing services, filling gaps in care, and meeting the complex physical, behavioral, and social needs of individuals with substance use disorder. This no-cost program is available for members and participating providers. Read the overview.
Diamond State Health Plan
The majority of people receiving Medicaid must choose a family doctor who, along with a managed care organization , will provide or arrange for all your preventive care and medical needs. The following individuals are not enrolled with a MCO:
- Individuals entitled to or eligible to enroll in Medicare
- Individuals residing in a nursing facility or intermediate care facility for the mentally retarded .
- Individuals covered under the Medicaid home and community based waiver programs.
- Non lawful and non qualified non citizens .
- Individuals who have military health insurance for active duty, retired military, and their dependents.
- Individuals eligible for the Medicaid Breast and Cervical Cancer program.
- Presumptively eligible pregnant women.
Also Check: Ob Gyn In Orlando That Accept Medicaid
Waiting For A Response
Once the complete provider enrollment application has been submitted it will be processed. Processing will take approximately two weeks from the date of receipt.After processing, a confirmation will be sent to you as notification to begin filing claims electronically. If confirmation is not received after two weeks, contact the Technology Support Center toll-free at 1-800-999-3371.
Evolve Emod For Minor Home Modification Services
Highmark Health Options is transitioning our minor home modification benefit management service to Evolve Emod. As of Dec. 31, 2021, Evolve Emodâs all-inclusive benefit management solution will help enhance MHM processes for providers by streamlining:
⢠Intake requests⢠Medical necessity review requests⢠Project close out reviews⢠Proposal reviews⢠Provider bid requests
This partnership will create a seamless continuation of service to Highmark Health Options LTSS members by providing safe and accessible MHM solutions.
Also Check: How Can I Get Medicaid In Nc
Delaware Diamond State Health Plan 1115 Demonstration Waiver
Delaware’s Diamond State Health Plan 1115 Demonstration Waiver was initially approved in 1995 and implemented beginning January 1, 1996. The DSHP 1115 Demonstration was designed to mandatorily enroll eligible Medicaid recipients into managed care organizations and create cost efficiencies in the Medicaid program that could be used to expand coverage.
Electronic Visit Verification New Start Date
The new Electronic Visit Verification go-live date is July 1, 2021. As the system implementation moves forward, please continue with your efforts towards implementation. If you are using a third-party EVV system, please continue to collect EVV visit data. This will enable you to upload your visit data to the AuthentiCare aggregator when AuthentiCare is implemented.
DMMA will communicate additional updates going forward. For questions regarding EVV, email [email protected].
You May Like: Wv Medicaid Monthly Income Guidelines
Medicaid Programs For Persons With Disabilities
Medicaid Waiver Programs
In Delaware, we have two Medicaid waiver programs to assist people with higher level of care needs. One, the DD Waiver is operated by the Division of Developmental Disabilities Services . DD Waiver services may include residential services , day habilitation, prevocational services, supported employment, nursing, and behavioral services. To be eligible for the DD Waiver you must be eligible for DDDS services . You can contact DDDSs Applicant Services at 744-9700 or Toll Free 1-866-552-5758.
Another waiver, called Diamond State Health Plan Plus , operated by the Division of Medicaid and Medical Assistance, is for individuals with disabilities who require a higher level of care, but can be served in the community, including family homes and apartments or assisted living facilities, with the correct services. Services can include home modifications, nursing services, attendant care services, cognitive services, day habilitation, home delivered meals and more. To apply, individuals may contact the Division of Medicaid and Medical Assistances Long Term Care Programs office at 368-6610 or 424-7172 .
Medicaid for Workers with Disabilities
Delaware also has a program called Medicaid for Workers with Disabilities. This program helps individuals with disabilities by allowing them to work without losing their Medicaid. To find out more or to apply, contact 857-5045 or 1-800-464-4357.
Pathways to Employment
