How appeals work in Delaware
When a Delaware-regulated carrier denies or reduces coverage, you receive an adverse determination notice. The carrier must maintain an internal review process (IRP) under 18 Del. C. § 332 and 18 Del. Admin. Code § 1301-3.0.
You file a grievance with the carrier first. If you receive a final coverage decision upholding the denial, you may request IHCAP external review through the Insurance Department.
Universal how-to: Appeals roadmap and Building a strong appeal packet.
The usual steps
- Adverse determination — read denial reasons and IRP rights on the notice.
- Internal grievance — submit orally or in writing within 30 days of the denial (§ 332(c)(2)). Use the carrier's form if provided; you may have 10 days to complete an oral grievance in writing.
- Carrier acknowledgement — often within 5 business days of receiving your written grievance.
- Final coverage decision— carrier's final written disposition with external review rights.
- IHCAP external review — see Delaware external review.
CID offers free informal mediation in addition to external review—but mediation does not extend IHCAP filing deadlines (18 Del. Admin. Code § 1301-4.0).
How long the carrier has to answer
After the carrier has all information needed, grievances must be decided within:
- 72 hours — emergency reviews
- 30 days — referrals and whether a benefit is covered under the contract
- 45 days — most other grievances (§ 332(c)(5))
Written notice of the decision is generally mailed within 5 days after the grievance is decided. Medical-necessity denials must be reviewed by qualified clinical staff who did not make the initial denial.
If the carrier is late
If a utilization review entity misses PA deadlines under Chapter 33, Subchapter II, services may be deemed preauthorized—you may also be able to move toward external review (§ 3378).
Keep proof of when you filed the grievance and calendar the carrier's response deadlines on your denial letter.
What comes next?
After a final coverage decision, request external review by filing an appeal with your carrier within 4 months. The carrier forwards the case to the Insurance Department for IHCAP (18 Del. Admin. Code § 1301-5.0).
Delaware also offers arbitration for some disputes (often 60 days from the final grievance letter, up to $75 fee)—an alternative to IHCAP for eligible cases (§ 332(e)).
Key takeaway
File the internal grievance within 30 days, track the 30- or 45-day answer window, and read the final letter for IHCAP rights. You have 4 months from that final decision to start external review—do not rely on mediation alone to pause the clock.