What is prior authorization?
Prior authorization (PA) means the carrier must approve certain care before it happens. A PA denial is different from a claim denial after care was provided.
Overview for any state: Prior authorizations. This page is Delaware-only.
Confirm plan type: Delaware: Start Here.
Delaware PA deadlines
Delaware's Pre-Authorization Reform Act of 2025 (Title 18, Chapter 33, Subchapter II) sets timelines for utilization review entities. Key provisions are in 18 Del. C. §§ 3371–3378.
Non-urgent health-care services
- Standard submission: approve or deny within 5 business daysof a complete ("clean") request
- Electronic submission (§ 3377 platform): within 3 business days
Urgent health-care services
- Electronic urgent: within 24 hours of a clean request
- Non-electronic urgent: within 48 hours
- Urgent patient transfers: often 24 hours (electronic) or 48 hours
Prescription drugs
Pharmaceuticals using the electronic platform: generally within 2 business days of a clean request.
If the plan misses deadlines
Failure to meet Subchapter II deadlines can result in services being automatically deemed preauthorized (§ 3378). Document submission dates and every carrier response.
After a PA denial
Appeals of adverse PA determinations: carrier must decide within 15 days (another 15 days if more records are needed). PA approvals are generally valid at least 90 days under recent reforms.
Other protections
- Step therapy exception requests: often 2 business days (deemed granted if late)
- Carriers must accept electronic PA on the same platform by January 1, 2027
Where to look up PA rules
Match tools to the exact plan on the ID card. Major 2026 Marketplace carriers:
- Highmark Blue Cross Blue Shield Delaware: highmarkbcbsde.com
- AmeriHealth Caritas: amerihealthcaritasde.com
- Ambetter (Celtic): ambetterhealth.com
Delaware Medicaid
Medicaid PA follows MCO and DSS rules—not commercial Subchapter II. For pharmacy PA under DSS programs, deemed granted rules may apply within 24 hours in some situations (17 Del. C. § 17b-491a— Medicaid only).
Service denials: appeal to your MCO, then state fair hearing—see Delaware First Health — appeals.
If PA is denied
- Get the adverse determination in writing with clinical reasons and IRP instructions.
- Ask the treating clinician for records and a medical-necessity letter.
- File an internal grievance within 30 days of the denial— Delaware internal appeals.
- If care cannot wait, request expedited review.
Building a strong appeal packet has a checklist.
Urgent care
Use the 24- or 48-hour PA rules above. For urgent denials, internal grievances must be decided within 72 hours after the carrier has needed information (18 Del. C. § 332(c)(5)(a)). See Delaware external review for urgent IHCAP options.