Critical Incidents

Critical Incidents Defined


Critical Incidents (CIs) are defined by the Division of Medicaid and Medical Assistance (DMMA). They include but are not limited to:

  • Unexpected death of a member.
  • Suspected physical, mental, or sexual mistreatment; abuse; and neglect of a member.
  • Suspected theft or financial exploitation of a member.
  • Severe injury sustained by a member.
  • Inappropriate or unprofessional conduct by a provider involving a member.

Highmark Health Options will report to the state if any staff or the staff of a subcontractor has reason to believe that a member has been abused, mistreated, neglected, or financially exploited, or has knowledge of the occurrence of other critical incidents.

Reporting Critical Incidents

Critical incidents must be reported the same business day of the occurance or knowledge of the incident. Report critical incidents to Highmark Health Options by calling 1-844-325-6251.

A report should also be made to the appropriate investigative state agency:

Department of Services for Children, Youth and Their Families (DSCYF)

Division of Family Services (DFS, Child Protection)
24-hour Child Abuse and Neglect Hotline

Delaware Health and Social Services (DHSS)

Adult Protective Services

For suspected abuse, neglect, disruptive behavior, or exploitation.

Division of Health Care Quality (DHCQ)

For adult members in a long-term facility and for child members in a pediatric nursing facility.

Long-Term Care Office of the State Ombudsman (OSO)

For residents in long-term care facilities who have a complaint about their rights.

Office of Health Facilities and Certification (OHFLC)

For residents in long-term care facilities who have a complaint about their rights.