health care and charges. The intended purpose of utilization review services shall be the prompt resolution of issues related to treatment
and/or compliance with the health-care payment system or practice guidelines for those claims which have been acknowledged to be
compensable. An employer or insurance carrier may engage in utilization review to evaluate the quality, reasonableness and/or necessity of
proposed or provided health-care services for acknowledged compensable claims. Any person conducting a utilization review program for
workers' compensation shall be required to contract with the Office of Workers' Compensation once every 2 years and certify compliance
with Workers' Compensation Utilization Management Standards or Health Utilization Management Standards of Utilization Review
Accreditation Council ("URAC") sufficient to achieve URAC accreditation or submit evidence of accreditation by URAC. If a party
disagrees with the findings following utilization review, a petition may be filed with the Industrial Accident Board for de novo review.
Complete rules and regulations relating to utilization review shall be approved, proposed and maintained by the Workers' Compensation
Oversight Panel. Rules recommended by the Panel shall be adopted by regulation of the Department of Labor pursuant to Chapter 101
of Title 29.
(k) Coordination of health care payments. — (1) Upon notification to an employer that an employee is exercising that employee's
rights under § 2304 of this title with respect to an injury or condition, the employer shall be exclusively responsible for treatment of that
injury or condition to the extent that the employer is obliged to provide treatment under this chapter.
(2) An employee, as part of a notification that an employee will exercise rights under § 2304 of this title, shall notify the employer of
all health insurance benefits that could compensate the employee for treatment of the injury or condition in question in the absence of
coverage under this chapter. Such notification to the employer is intended to facilitate the notice provided for in paragraph (k)(4) of this
section; the failure of an employee to provide such notice shall not waive or defeat any rights the employee may have under this chapter.
(3) An employee whose health care treatment for an injury or condition is being paid for pursuant to this chapter shall not be entitled
to seek compensation from any other health insurance carrier for the same treatment. A health care provider who is being paid for
treating an injury or condition pursuant to this chapter shall not seek compensation from any other health insurance carrier for the
same treatment.
(4) At any time that a final determination is made that an employee is not entitled to health care treatment pursuant to this chapter,
the employer shall notify any health insurance carrier of which it is aware pursuant to paragraph (k)(2) of this section of such a final
determination.
(5) Notwithstanding any other provision of this chapter, if a final determination is made that an employee is not entitled to health care
treatment pursuant to this chapter, the employee and/or the health care provider who provided said treatment may seek payment for
such treatment from a health insurance carrier from which the employee had coverage applicable at the time of the injury or condition.
(6) Any time restrictions imposed upon an employee with respect to making claims against that employee's health insurance coverage
for an injury or condition for which that employee initially sought treatment under this chapter shall be tolled until notification of the
health insurance carrier under paragraph (k)(4) of this section.
(7) No requirements for preauthorization of treatment in any health insurance policy shall be the basis for denying payment of a
claim submitted under paragraph (k)(5) of this section.
(8) With respect to claims submitted by an employee pursuant to paragraph (k)(5) of this section for treatment provided by a health-
care provider that had a contract with the health insurance carrier at the time of the treatment, reimbursement shall be at the contract rate.
(9) With respect to claims submitted by an employee pursuant to paragraph (k)(5) of this section for treatment provided by a health
care provider that did not have a contract with the health insurance carrier at the time of the treatment, reimbursement shall be at the
health insurance carrier's average contract rate for the same treatment with health-care providers with whom it does have a contract.
(10) All claims submitted pursuant to paragraph (k)(5) of this section shall be entitled to treatment under Insurance Department
Regulation 1310 [18 DE Admin Code 1310] or any successor regulation relating to the prompt payment of health-care claims by health
insurance carriers.
(11) A health insurance carrier may deny payment of claims submitted under paragraph (k)(5) of this section for health care that
it determines was not reasonable or necessary. However, an employee shall have the right to immediate appeal to an Independent
Utilization Review organization under § 6416 of Title 18 for all such denials of treatment, with the cost of such appeal being borne
by the health insurance carrier.
(12) A health-care provider may not balance bill an employee for treatment for which the health care provider has been compensated
under paragraph (k)(8) or (9) of this section.
(l) Balance billing prohibited. — (1) Any health-care provider rendering services under this chapter shall be prohibited from billing or
invoicing an employee, employer or insurance carrier for charges or expenses other than those authorized by this chapter and the health-
care payment system provided for herein. No health-care provider rendering treatment or services under this chapter shall seek payment
for charges from an employee except as authorized by this section.
(2) Billing procedures where compensability under this chapter is contested.
a. A provider may seek payment of the actual charges from the employee if the employer or insurance carrier notifies the provider
that it does not consider the illness or injury to be compensable. If an employer notifies a provider that it will pay only a portion of
a bill, the provider may seek payment of the unpaid portion from the employee up to the lesser of the actual charge, the negotiated
rate, or the rate authorized by the payment system.
b. If an employee informs the health-care provider that a claim is on file at the Department, the provider shall cease all efforts
to collect payment from the employee.
c. While a claim concerning compensability is pending with the Department, a provider may notify an employee that the employee
will be responsible for payment of unpaid invoices when the claim has been determined not to be compensable and the provider is
able to resume collection efforts. Any such notice or reminder made under this subsection shall not be disclosed or otherwise provided
to any credit agency. The provider may request information about the Department claim, and if the employee fails to respond or
provide the information within 90 days, the provider shall be entitled to resume collection efforts directly and the employee may be
determined liable for invoices as otherwise provided by law.
(3) Upon final award or settlement, a provider may resume efforts to collect payment from the employee and the employee shall
be responsible for payment of any outstanding bills without regard to this section and as otherwise provided or authorized by law. If
the service is found compensable, the provider shall not require a payment rate, excluding interest, greater than the lesser of the actual
charge or payment level set by the payment system. The employee shall be responsible for payment for services found not covered
or compensable unless agreed otherwise by the provider and employee. Services not covered or not compensable shall not be subject
to the payment system.‹ Prev All Delaware sections Next ›
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