Delaware: fighting a health insurance denial

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

Delaware usually cannot help with these plans. Call the Employee Benefits Security Administration.

Call 1-866-444-3272
Insurance you buy, or an employer plan bought from an insurer

Call Delaware Department of Insurance (Office of the Insurance Commissioner), Consumer Services Division. See the at-a-glance box.

Call 1-800-282-8611
Medicaid or children's coverage

Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Delaware.

Medicaid in Delaware
Medicare

Delaware Medicare Assistance Bureau (DMAB), Delaware's State Health Insurance Assistance Program (SHIP) gives free counseling. Or call 1-800-MEDICARE.

Call 1-800-336-9500 1-800-633-4227

The short version for Delaware

Delaware runs its own external review, called the Independent Health Care Appeals Program (IHCAP). You ask your insurance company for it (not the state), the Delaware Department of Insurance assigns an independent reviewer, and the insurer pays the full cost. It only covers denials based on medical necessity or appropriateness of care; other denials go to a separate Department of Insurance arbitration program that has a 60-day deadline and a $75 fee. The Department's Consumer Services Division also offers free informal mediation and help with appeals.

At a glance: independent review for plans Delaware regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator: Delaware Department of Insurance (Office of the Insurance Commissioner), Consumer Services Division · 1-800-282-8611 (toll-free in Delaware) or (302) 674-7310
Independent review: A state process (Independent Health Care Appeals Program (IHCAP))
Deadline to request it: 4 months after the insurer's final coverage decision. Official sources differ on whether the clock starts on the date of the letter or the date you receive it, so count from the date printed on the final denial letter to be safe.
Cost: None for you. The insurer must pay all costs of the review, whatever the outcome.
Decision time: 45 days after the independent review organization receives the appeal; fast track: 72 hours after the independent review organization receives the expedited appeal

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Delaware Department of Insurance says the easiest way to find out whether you have a self-funded plan (one paid for by your employer rather than an insurance company) is to ask your human resources department, or to call the phone number on your health benefits card and ask customer service. Self-funded employer plans are overseen by the U.S. Department of Labor's Employee Benefits Security Administration (EBSA), 1-866-444-3272, not by the state. The Department also cannot intervene when a policy was issued and delivered to the policyholder in another state.

Delaware Department of Insurance (Office of the Insurance Commissioner), Consumer Services Division
Health insurance policies issued in Delaware by insurance companies, health service corporations and managed care organizations, including plans you buy yourself and fully insured employer plans. It cannot step in when the policy was issued and delivered in another state, and it does not regulate self-funded employer plans.

Phone: 1-800-282-8611 (toll-free in Delaware) or (302) 674-7310. File a complaint online
Delaware Department of Health and Social Services (DHSS), Division of Medicaid and Medical Assistance (DMMA)
Delaware Medicaid (the Diamond State Health Plan) and the Delaware Healthy Children Program, including the private managed care plans that run Medicaid benefits under contract with the state.

Phone: 302-571-4900 or 866-843-7212 (Medicaid Customer Relations).

Independent (external) review

Process: A state process. Run by Delaware Department of Insurance, which assigns an approved Independent Utilization Review Organization (IURO) to decide each case.
Where you file: insurer
How: After your insurer's internal appeal ends in a final denial, send your request for external review to the insurance company, following the instructions in the final denial letter. The insurer must forward it electronically to the Delaware Department of Insurance within 3 business days, and the Department assigns an independent review organization within 5 calendar days. The reviewer will notify you in writing; you then have 7 calendar days from receiving that notice to send any extra records or letters you want considered.
Which denials qualify: Final decisions that deny, reduce or end coverage for a covered service based in whole or in part on medical necessity or appropriateness of services. That includes denials saying a treatment is cosmetic, experimental or investigational, or not the appropriate treatment or setting. It does not cover services your policy expressly excludes or benefit limits you have used up. Denials on other grounds go to the Department of Insurance's health insurance arbitration program instead (petition must reach the Department within 60 days of receiving the final decision; $75 non-refundable filing fee). If it is unclear which route applies, the law sends the case to independent review.
Appeal to the plan first?: Yes. You must finish the insurer's internal appeal first. Exceptions stated in the regulation: for an emergency medical condition you may ask for expedited external review without finishing the internal appeal; and you do not have to finish it if the insurer waives the requirement, if the insurer failed to follow the internal appeal rules, or if you ask for expedited external review at the same time as an expedited internal appeal.

Official page

General rules and what to send: how external review works, how to request it.

Free help in Delaware

Delaware Department of Insurance, Consumer Services Division
Listed by the federal Centers for Medicare & Medicaid Services as Delaware's consumer assistance resource; staff investigate complaints, get explanations from your insurer, offer free informal mediation and help with filing appeals of medical claims for Delaware-issued policies (email consumer@delaware.gov).

Phone: 1-800-282-8611 (toll-free in Delaware) or (302) 674-7310
Community Legal Aid Society, Inc. (CLASI)
Free legal help for low-income Delaware residents facing denials, reductions or terminations of Medicaid and Medicare benefits; its Disability Rights Delaware program also helps people with disabilities with Medicaid, Medicare and Medicaid waiver services.

Phone: New Castle County 302-575-0660 or 800-292-7980; Kent County 302-674-8500 or 800-537-8383; Sussex County 302-856-0038 or 800-462-7070
U.S. Department of Labor, Employee Benefits Security Administration (EBSA)
Where the Delaware Department of Insurance sends people with self-funded employer plans, union group plans and COBRA questions, because the state does not regulate those plans.

Phone: 1-866-444-3272

Medicare and Medicaid in Delaware

Medicare counseling: Delaware Medicare Assistance Bureau (DMAB), Delaware's State Health Insurance Assistance Program (SHIP) · 1-800-336-9500 or (302) 674-7364 . Free help with Medicare appeals.
Medicaid agency: Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance (DMMA); the Medicaid program is called the Diamond State Health Plan
Fair hearing deadline: 90 days from the date the notice of action is mailed, for decisions made by the Medicaid agency. If you are in a Medicaid managed care plan, 120 calendar days from the date of the plan's notice of its appeal decision. Your notice states the deadline that applies to you.
Good to know: Most Delaware Medicaid members are in a managed care plan (AmeriHealth Caritas, Delaware First Health or Highmark Health Options). You must appeal to the plan first, then ask the state for a fair hearing; if the plan misses its own appeal deadlines you can go straight to a fair hearing. The plan must decide an expedited appeal within 72 hours. You can ask for a hearing in person at a DHSS office, by mail, fax, phone (302-255-9500 or 1-800-372-2022) or email (DHSS_DSS_FHRequest@delaware.gov). To keep your benefits during the appeal, your request must arrive before the change takes effect (within the 10-day notice period); the state may recover the cost if you lose. A hearing decision is due within 90 days of the request.

Medicaid appeals page How Medicaid appeals work

State laws that can help

External review. The independent reviewer's decision binds the insurer, the insurer pays all review costs, and if the insurer appeals a decision in your favor to Superior Court, the court appoints an independent attorney to defend the decision at the insurer's expense.

18 Del. C. §§ 6416 and 6417; 18 Del. Admin. Code 1301
Denial notice. A final denial letter must explain how to appeal and must tell you about the Department of Insurance's free mediation, the 4-month external review deadline and the 60-day arbitration deadline; insurers also may not drop or penalize you for filing a grievance or appeal.

18 Del. Admin. Code 1301, sections 4.0 and 11.0
Prior authorization. Insurers must answer a complete pre-authorization request for a drug within 2 business days; a missed deadline means the service is automatically treated as pre-authorized, and an approval cannot later be taken back on medical necessity grounds. Under the Delaware Pre-Authorization Reform Act of 2025, for policies issued or renewed after December 31, 2026, other services must be answered within 3 business days (electronic) or 5 business days, urgent care within 24 or 48 hours, denials must be made by a physician in the same or a similar specialty, and appeals must be decided within 15 days.

18 Del. C. §§ 3371 to 3380 (group plans: Chapter 35, Subchapter V); Senate Bill 12 of 2025, 85 Del. Laws, c. 176
Step therapy. When a plan makes you try other drugs first, your prescriber can request an exception that must be granted in listed situations (for example the required drug is likely to harm you, is expected not to work, you already tried it, or you are stable on your current drug); the plan must answer within 2 business days (24 hours in an emergency) or the request is treated as granted, and a denial can be appealed.

18 Del. C. § 3381 (individual policies) and § 3591 (group policies)
Surprise billing. For emergency care from an out-of-network provider, the provider may not balance bill you; payment disputes are settled between the provider and insurer through Department of Insurance arbitration. For planned care, an out-of-network provider who did not give you a written disclosure and get your signed consent beforehand may not balance bill you.

18 Del. C. § 3349 (emergency care) and § 3370A (network disclosure and transparency)
Mental health parity. Plans may not put a greater financial burden or tighter limits on treatment for serious mental illness or drug and alcohol dependency than on other illnesses, may not require prior authorization for medically necessary drug and alcohol dependency treatment, and may not do concurrent review during the first 14 days of an inpatient admission, 30 days of intensive outpatient treatment or 5 days of inpatient withdrawal management.

18 Del. C. § 3343
AI in utilization review. This is regulator guidance rather than a statute: the Department of Insurance has told all insurers that decisions made or supported by artificial intelligence must still comply with Delaware insurance law, including the unfair claims settlement practices rules, and that insurers are expected to keep a written program for responsible use of artificial intelligence.

Delaware Department of Insurance, Domestic and Foreign Insurers Bulletin No. 148 (February 5, 2025)

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on 2026-11-11. Phone numbers and deadlines change; check the official page before you rely on one.

Not confirmed (14)

The deadline to request independent review. official sources disagree on when the 4 months start: Regulation 1301 section 5.1 says within 4 months of receipt of the final coverage decision; 18 Del. C. § 6416(c) says within 4 months of the date the final decision was issued; the Department's 2019 procedure sheet says 4 months from the date of the appeal denial letter, 'not received date but letter date'. The record advises the stricter reading.
The cost of independent review. no official page says in so many words that external review is free to the consumer; the value rests on Regulation 1301 section 8.1 and 18 Del. C. § 6417(b), which make the insurer responsible for all costs.
The independent review request form. the only form published on the Department's page is the 'Insurer's Petition for External Appeals Program', which the insurance company completes; no consumer request form was found.
Published results of independent review. the Department does not appear to publish external review outcomes on its own site. A Department letter hosted by a third party (aimedalliance.org) reports 29 external reviews in 2024, 21 denied and 8 overturned; this was seen only in a search excerpt, not on an official page, so it is left null.
A searchable list of past decisions. no searchable database of past external review decisions was found on the Department of Insurance site.
The state regulators. the Department prints two different local numbers with the same toll-free number: (302) 674-7310 on the Consumer Services, complaint and external review pages, and (302) 674-7300 on its Contact Us page and on the federal Centers for Medicare & Medicaid Services Delaware page. The external review questions sheet also shows an older street address (841 Silver Lake Blvd) than the current 1351 West North Street, Suite 101, Dover.
The state regulators. no online complaint page for Medicaid plans was found on the Department of Health and Social Services site; the Department of Insurance page lists 800-996-9969 for Medicaid complaints.
The Medicaid fair hearing page. no consumer-facing state web page explaining how to request a Medicaid fair hearing was found; the link is to the official fair hearing rules. The phone numbers 302-255-9500 and 1-800-372-2022 for requesting a hearing come from Medicaid plan member pages (AmeriHealth Caritas Delaware, Delaware First Health) and match the Division of Medicaid and Medical Assistance director's office numbers on the state contact page.
The Medicaid fair hearing deadline. the state's rules (16 Del. Admin. Code 5305) count the 90 days from the 'effective date of action', while the November 2025 state notice to staff says 90 days from the date the notice of action is mailed, with a 5-day mail grace period. The record uses the mailing-date wording, which is the earlier deadline.
Notes on Medicaid appeals. the deadline for the first appeal to a Medicaid managed care plan was not confirmed on a state page; use the deadline printed on the plan's denial notice.
Not confirmed. stateLaws (prior-authorization) — the code text loaded reflects Senate Bill 12 of 2025, which applies to policies issued, renewed or modified after December 31, 2026; the response deadlines for non-drug services under policies still on the earlier rules were not confirmed.
Not confirmed. stateLaws (step-therapy) — Department Bulletin No. 165 (March 24, 2026) says the generic-first exception in subsection (e) does not reach biologic drugs and biosimilars, but the current online code text of §§ 3381(e) and 3591(e) expressly lets plans require an interchangeable biologic or biosimilar first (citing 85 Del. Laws, c. 401); the effective date of that amendment was not confirmed.
Not confirmed. stateLaws (ai-in-utilization-review) — no Delaware statute limiting artificial intelligence in coverage decisions was found; the entry is a Department bulletin (guidance), not a law.
Free consumer help programs. the address is as printed in the Department of Insurance health guide (www.dol.gov/ebsa); the U.S. Department of Labor site returned an access-denied response to an automated check, so the page itself was not loaded in this session. The phone number is as printed on the Department of Insurance pages.

Delaware

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

Insurance you buy, or an employer plan bought from an insurer

Medicaid or children's coverage

Medicare