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Delaware title xix electronic claim submission form

Delaware title 19 electronic claim submission form 2026

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The document outlines the Delaware Title XIX Electronic Claim Submission Provider Certification Agreement, which allows healthcare providers to submit Medicaid claims electronically instead of on paper. It details the certification process, requirements for compliance with federal and state laws, and responsibilities of both providers and the Department of Health and Social Services (DHSS). The agreement emphasizes the need for accurate claim submissions, potential penalties for false claims, and the necessity of notifying DHSS about any changes in billing services.

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Click ‘Get Form’ to open it in the editor.
In Section I, enter your Provider Name and review the certification statements carefully. Ensure you understand the requirements for electronic claim submission.
Proceed to Section II. Here, print or type your Provider Address, including City, State, and Zip Code. List all Medicaid provider numbers and names for which you will be submitting claims.
In Section III, sign the agreement certifying that all information is accurate. Authorize individuals who will submit claims on your behalf by providing their signatures and printed names.
Once completed, save your document. You can easily export it or share it directly from our platform for submission.

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