How to appeal a health insurance denial in Delaware
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Delaware lets you ask an independent reviewer to decide, through Delaware Department of Insurance. The deadline to ask: within 4 months from receiving an adverse claim decision (statute: within 4 months of the date the final decision was issued by the carrier).
Does this apply to you? State external review covers plans regulated by Delaware: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Delaware
Within 4 months from receiving an adverse claim decision (statute: within 4 months of the date the final decision was issued by the carrier)
The independent utilization review organization decides no more than 72 hours after receiving the expedited appeal, with written confirmation within 1 calendar day. You can request it when the insurer issues its final decision, or apply for expedited external review at the same time as an expedited internal appeal (emergency conditions do not need to exhaust the internal process).
Free (the insurer bears all costs of the review)
State-regulated plans (insurance bought in Delaware or through an employer that buys insurance). Self-funded employer plans use the federal process.
Under Delaware's Independent Health Care Appeals Program you file the external review request with your insurer, which must send it to the Department within 3 business days; the Department then assigns an independent reviewer. Only medical-necessity and appropriateness denials go to external review; other contract disputes go to the Department's arbitration program, which must be requested within 60 days of the insurer's notice. The statute counts the 4 months from the date the decision was issued (regulation and Department page say from receipt), so file early; 800-282-8611 works in Delaware only (main 302-674-7310).
Who to contact
- Delaware Department of Insurance
- External review information and forms
- Consumer help line: 800-282-8611
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Delaware?
Within 4 months from receiving an adverse claim decision (statute: within 4 months of the date the final decision was issued by the carrier)
Can I get a fast external review in Delaware?
The independent utilization review organization decides no more than 72 hours after receiving the expedited appeal, with written confirmation within 1 calendar day. You can request it when the insurer issues its final decision, or apply for expedited external review at the same time as an expedited internal appeal (emergency conditions do not need to exhaust the internal process).
Does external review cost anything in Delaware?
Free (the insurer bears all costs of the review)
Do Delaware’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Delaware Department of Insurance: Independent Health Care Appeals Program (IHCAP)
This section allows for a covered person or their representative to file a request for an external appeal within 4 months from receiving an adverse claim decision.
- 18 Del. C. § 6416: Independent health care appeals program
Within 4 months of the date the final decision was issued by the carrier, a covered person or the covered person’s authorized representative may file a request for an external review with the health carrier.
- 18 DE Admin. Code 1301 (Internal Review, Arbitration and Independent Utilization Review of Health Insurance Claims)
All costs for IHCAP review by an IURO, whether the review is preliminary, or partially or fully completed, shall be borne by the carrier.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.