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Delaware
General Information and Internal Plan Review:
For managed care organizations, regulated by both the Department
of Health and Social Service and the Department of Insurance,
Delaware specifies 2 stages of internal review for health plans.
Stage 1 must be completed within 5 days, and stage 2 must be
completed within 30 days. For conditions that cause an imminent,
emergent, or serious threat to the health of the enrollee, each
stage may take no more than 72 hours. If the appeal concerns
an “Emergency Medical Condition” (which is defined
by health department regulations), both stages must be concluded
within 72 hours. If you receive an adverse determination after
the internal reviews, then you can apply for the independent
health care appeals program.
Enrollees of commercial plans regulated by the Delaware Department of
Insurance (excluding self-funded ERISA and governmental plans) can also
access the Independent Health Care Appeals Process after an internal
review procedure by the carrier.
The Independent Health Care Appeals Process:
Whom to contact: |
Your health plan |
Who can appeal: |
You or your authorized
representative |
What you can appeal: |
Denial, reduction,
or termination of health care benefits that
deprive the covered person of medically necessary
covered services. |
When you can appeal: |
You must file within
60 days after you receive notice of an adverse
determination from your health plan. |
What to send: |
A written request:
- Your name & address
- Your health plan information
- A brief request for review by IHCAP (Independent
Health Care Appeals Program)
There is no restriction on the amount of
material you may supply to the Independent
Utilization Review Organization (IURO), but
it must be supplied within 7 days of the
IURO’s notification of acceptance. |
What you must pay: |
No charge |
What will happen: |
- Your health plan will notify the Department
of Health and Social Services (DHSS)
- DHSS will assign an Independent Utilization
Review Organization (IURO).
- The IURO will review the case and make
its determination as appropriate.
- The IURO will make a decision and notify
you.
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When you will get
a decision: |
45 days after receipt
of a completed application for appeal review |
In urgent situations: |
If your case involves
an imminent, emergent, or serious threat to
the health of the enrollee or if immediate
medical attention is required, the appeal process
will not exceed 72 hours. |
How to Get More Information:
Delaware Office of Health Facilities Licensing and Certification,
800-942-7373 or 302-995-8521
Information updated as of 7-16-2004
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