Form B "Response to Petition for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

What Is Form B?

This is a legal form that was released by the Delaware Department of Insurance - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form B "Response to Petition for Non-network Providers of Emergency Care Services Health Care Reimbursement for Emergency Care Arbitration" - Delaware

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Regulation 1316 – Form B
Response to Petition for Non-Network Providers of Emergency Care Services Health Care
Reimbursement for Emergency Care Arbitration
Arbitration Case # _______________
(Office use only)
Respondent Company Name
Respondent Address
Respondent Phone #
Claimant Name
Claimant Practice Group
Claimant Address
Claimant Phone #
Name of Policyholder
Policyholder Address
Was the policyholder: _____ Patient _____ Spouse ______ Parent or guardian ____ Power of attorney ____ Other
Date of determination of denial of claim
Dates of Service
From:
To:
Amount of claim admitted by Respondent
$
Briefly describe the basis for your
response/objection to the Petition indicating
each CPT Code in dispute and attach the
notification or explanation that you sent to
the claimant. (If needed, attach separate
sheet)
Prior to the hearing, it is necessary that you submit the appropriate documents to support your Response to Petition to the
Delaware Department of Insurance and to the Claimant.
Parties may present witnesses on their behalf at the hearing provided that due notice is given. Please list the name, address, and
telephone number of all witnesses you expect to appear on your behalf on a separate sheet and attach it to this form.
If you have made a settlement offer, how much was it? $___________________
Who will represent you at the hearing? _______ Self ________ Attorney
If an attorney will represent you, please provide the following:
Name: _________________________________ Address:
____________________________________________________________
Phone #: _______________________________
Under Delaware law, any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement
or claim containing false, incomplete, or misleading information is guilty of a felony.
___________________________________________________
__________________________________
Signature of Respondent’s Representative
Date
Return the original and one (1) copy of this
Arbitration Secretary
Response to Petition to:
Delaware Department of Insurance
1351 West North St., Suite 101 Dover, DE 19904
Note: You must also send a copy of this Response to Petition to the Complainant by first class mail, postage prepaid. Use Form C
to provide confirmation to the Department that a copy of this Petition was sent to the Complainant. (Forms are available at
www.insurance.delaware.gov.)
Regulation 1316 – Form B
Response to Petition for Non-Network Providers of Emergency Care Services Health Care
Reimbursement for Emergency Care Arbitration
Arbitration Case # _______________
(Office use only)
Respondent Company Name
Respondent Address
Respondent Phone #
Claimant Name
Claimant Practice Group
Claimant Address
Claimant Phone #
Name of Policyholder
Policyholder Address
Was the policyholder: _____ Patient _____ Spouse ______ Parent or guardian ____ Power of attorney ____ Other
Date of determination of denial of claim
Dates of Service
From:
To:
Amount of claim admitted by Respondent
$
Briefly describe the basis for your
response/objection to the Petition indicating
each CPT Code in dispute and attach the
notification or explanation that you sent to
the claimant. (If needed, attach separate
sheet)
Prior to the hearing, it is necessary that you submit the appropriate documents to support your Response to Petition to the
Delaware Department of Insurance and to the Claimant.
Parties may present witnesses on their behalf at the hearing provided that due notice is given. Please list the name, address, and
telephone number of all witnesses you expect to appear on your behalf on a separate sheet and attach it to this form.
If you have made a settlement offer, how much was it? $___________________
Who will represent you at the hearing? _______ Self ________ Attorney
If an attorney will represent you, please provide the following:
Name: _________________________________ Address:
____________________________________________________________
Phone #: _______________________________
Under Delaware law, any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement
or claim containing false, incomplete, or misleading information is guilty of a felony.
___________________________________________________
__________________________________
Signature of Respondent’s Representative
Date
Return the original and one (1) copy of this
Arbitration Secretary
Response to Petition to:
Delaware Department of Insurance
1351 West North St., Suite 101 Dover, DE 19904
Note: You must also send a copy of this Response to Petition to the Complainant by first class mail, postage prepaid. Use Form C
to provide confirmation to the Department that a copy of this Petition was sent to the Complainant. (Forms are available at
www.insurance.delaware.gov.)