Appeals

What is an appeal?

If you do not agree with a decision to deny or limit your medical care, you can file an appeal. You may file an appeal if you are not satisfied with:

  • Denial of or limits on a service.
  • Reduction or termination of a service that had been authorized.
  • Denial in whole or in part of payment for a service.
  • Failure to provide services in a timely manner.
  • Failure of AmeriHealth Caritas Delaware to act within required time frames.

You may file an appeal directly with AmeriHealth Caritas Delaware. If you are not happy with the outcome of the appeal, you may request a State Fair Hearing with the Department of Health and Social Services (DHSS).

We will send you a written adverse benefit determination if your health care services are:

  • Denied.
  • Reduced.
  • Limited.
  • Suspended.

How to file an appeal

You must file your appeal within 60 days after the date on the adverse benefit determination. If you get a adverse benefit determination and do not agree with our decisions, you may file an appeal. You can file the appeal by phone or in writing.

  • By phone: call AmeriHealth Caritas Delaware Member Services, 24 hours a day, seven days a week, at:
    • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
    • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).
    • If you file your appeal by phone, you will also need to send a written letter afterward that confirms your appeal.
  • In writing: You or your authorized representative can send the letter to:

AmeriHealth Caritas Delaware
Christiana Executive Campus
220 Continental Drive, Suite 300
Newark, DE 19713

We will start to review your appeal the day we get it. We will send you a written notice of the decision within 30 days. This can change if we need more information. We may extend the time up to 14 calendar days. If you didn’t ask for the extension, we will send you a letter to explain the delay.

Your doctor can appeal for you. You will need to give your written consent. You may choose someone else to represent you to request an appeal. If the appeal is expedited, you do not need to take this step.

We will send you or your representative a letter with the decision. The letter will tell you how we made our decision.

Expedited appeals

Appeals are expedited when a decision needs to be made in less than 30 days. We will expedite an appeal when your life or health is at risk. Expedited appeals are for health care services. They are not for denied claims.

How to file an expedited appeal

Request an expedited appeal by phone. Call AmeriHealth Caritas Delaware Member Services, 24 hours a day, seven days a week, at:

  • Diamond State Health Plan: 1-844-211-0966 (TTY 1-855-349-6281).
  • Diamond State Health Plan-Plus: 1-855-777-6617 (TTY 1-855-362-5769).

AmeriHealth Caritas Delaware will start to review your appeal request the day we get it. We will make a decision within 72 hours of getting your request. We will let you know by phone and mail about our decision.

AmeriHealth Caritas Delaware may extend the 72-hour time period by up to 14 calendar days if:

  • You request an extension.
  • If AmeriHealth Caritas Delaware shows a need for additional information and how the delay is in your interest.

If you ask for an expedited appeal and we do not believe it needs a faster decision, it will be reviewed within the standard time frame. We will inform you by phone and writing within two calendar days if the time frame for your appeal has changed.

We will let you or your representative know how long you have to submit information for an expedited review.

Members