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.
| 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 |
