Dispute& Appeal Process

Highmark Delaware members have the right to a fair review of all claim decisions.

For members:

To appeal, you or your authorized representative must contact Highmark Delaware Customer Service within 180 days from the date you received the claim decision. You may call us, or download the Appeal Form available on our website, highmarkbcbsde.com , and return it to us by mail. There is no cost to file an appeal.

Please explain why you are appealing and provide all relevant information. Please note: If you do not submit your appeal within the 180-day timeframe, your appeal will not be considered.

  • Pre-service decision: If your appeal relates to a Highmark Delaware denial of authorization and you have not received the service or treatment, you will be notified of the appeal decision within 30 days. You may request an expedited appeal for a denial relating to an emergency or a life-threatening illness; we will notify you and your provider within 72 hours of our decision.
  • Post-service decision: For appeals relating to a Highmark Delaware denial of coverage for a service you have already received, you will be notified of the decision within 30 to 60 days.

Upon request and free of charge, Highmark Delaware will provide copies of all records relevant to the claim decision.

PLEASE NOTE: If your health plan is subject to the Employee Retirement Income Security Act (ERISA), you have the right to file a civil action under Section 502 (A) of ERISA when you have completed the Highmark Delaware appeal process.

MEDIATION SERVICES AVAILABLE: The Delaware Department of Insurance (DOI) provides free, informal mediation services that are in addition to, but do not replace, your right to a review. For information about mediation, call the DOI Consumer Services Division at 302.674.7300 or 800.282.8611, email them at consumer@state.de.us or visit the DOI office Monday through Friday, 8:00 AM - 4:30 PM at: 841 Silver Lake Boulevard, Dover, Delaware, 19904. Please note that the 180-day appeal deadline will still apply if you choose mediation services.

Last updated on 6/15/2017

 

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