Delaware Code Title 18. Insurance Code § 2319. Carrier post claim adjudication audit record requests

(1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.

(2) “Carrier” does not mean an entity that provides a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq.,1396 et seq. and 1397 et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.

(3) “Post-claim adjudication audit” means any audit of a claim by a carrier post payment.

(1) Based on a reasonable belief of fraud, waste, abuse or other intentional misconduct.

(2) Required by, or initiated at the request of a self-insured plan.

(3) Required by the state or federal government or a state or federal government plan.