Delaware External Review (IHCAP)

What is IHCAP external review?

Delaware's Independent Health Care Appeals Program (IHCAP)provides binding external review when a carrier's final coverage decision denies care based on medical necessity or appropriateness (18 Del. C. § 6416; § 6417).

The Insurance Department assigns an Independent Utilization Review Organization (IURO) that does not work for your insurer. The IURO decision is generally binding on the carrier.

Start with Delaware internal appeals. Background: Appeals roadmap.

When you can use it

Eligible disputes often include:

• Medical necessity or appropriateness of services
• Experimental or investigational treatment
• Continued treatment or stay denials
• Some eligibility and rescission of coverage issues

Pure plan exclusions (benefits never covered) usually cannot be overturned unless clinical evidence shows the exclusion may not apply.

You can generally request external review when:

• You completed the carrier's internal review and got a final coverage decision upholding the denial, or
• The carrier missed required UR or grievance deadlines (see internal appeals guide), or
• You qualify for urgent external review (see below)

File with your carrier within 4 months of the final coverage decision (18 Del. Admin. Code § 1301-5.0(5.1)). Coverage must be a fully insured plan issued in Delaware (or the state employee plan).

How to request it (step by step)

1. Complete internal grievance unless an urgent-care exception applies.
2. Read your final coverage decision letter — it must explain IHCAP and the 4-month deadline (§ 1301-4.0).
3. Gather records: denial letters, clinical notes, treating provider letter.
4. File a request for external review with your carrier within 4 months. The carrier submits the appeal to the Insurance Department using IHCAP procedures (insurance.delaware.gov — IHCAP).
5. DOI assigns an IURO (often within about 5 days). You may submit additional documents within about 7 days of IURO acceptance notice.
6. Receive binding decision. If reversed, the carrier must provide coverage (§ 1301-5.0).

Help: 800-282-8611 (Delaware) or 302-674-7310.

How long it takes

• Standard review: IURO decision within 45 days after IURO receives the appeal
• Experimental/investigational (standard): 20 days
• Expedited (serious threat to health): no later than 72 hours (§ 6417(b))
• Expedited experimental/investigational: about 5 days (CID materials)

If the carrier fails to send records to the IURO on time, the IURO may reverse the denial with Department approval (§ 1301-5.0(5.5.1)).

When it does not apply

• Self-funded ERISA employer plans
• Medicare / Medicare Advantage — CMS appeals
• Medicaid (Diamond State Health Plan) — MCO appeal then DSS fair hearing (Delaware First Health — appeals)
• Plans not regulated by Delaware (federal exemption)

Some disputes may use arbitration instead of IHCAP (§ 332(e))—read your final denial letter carefully.

Urgent cases

For urgent care requests, you may be able to submit for external review immediately after a carrier denial—without completing full internal review first (CID — IHCAP).

Your treating provider should document an imminent, emergent, or serious threat to health. Expedited IURO timelines apply.

For urgent PA, see Delaware prior authorization law and expedited appeals.