18 Del. Admin. Code § 1301-5.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1301-5.0 - IHCAP Procedure

5.1 A covered person or his authorized representative may request review of a final coverage decision based, in whole or in part, on medical necessity or appropriateness of services by filing an appeal with the carrier within four months of receipt of the final coverage decision.

5.2 Upon receipt of an appeal, the carrier shall transmit the appeal electronically to the Department as soon as possible, but within no more than three business days.

5.3 Within five calendar days of receipt of an appeal, the Department shall assign an approved, impartial Independent Utilization Review Organization to review the final coverage decision and shall notify the carrier.

5.4 The assigned IURO shall, within five calendar days of assignment, notify the covered person or his authorized representative in writing by certified or registered mail that the appeal has been accepted for external review.

5.4.1 The notice shall include a provision stating that the covered person or his authorized representative may submit additional written information and supporting documentation that the IURO shall consider when conducting the external review.

5.4.2 The covered person or his authorized representative shall submit such written documentation to the IURO within seven calendar days following the date of receipt of the notice.

5.4.3 Upon receipt of any information submitted by the covered person or his authorized representative, the assigned IURO shall as soon as possible, but within no more than two business days, forward the information to the carrier.

5.4.4 The IURO must accept additional documentation submitted by the carrier in response to additional written information and supporting documentation from the covered person or his authorized representative.

5.5 Within seven calendar days after the receipt of the notification required in subsection 5.3 of this regulation, the carrier shall provide to the assigned IURO the documents and any information considered in making the final coverage decision.

5.5.1 If the carrier fails to submit documentation and information or fails to participate within the time specified, the assigned IURO may terminate the external review and make a decision, with the approval of the Department, to reverse the final coverage decision.

5.6 The external review may be terminated if the carrier decides to reverse its final coverage decision and provide coverage or payment for the health care service that is the subject of the appeal.

5.6.1 Immediately upon making the decision to reverse its final coverage decision, the carrier shall notify the covered person or his authorized representative, the assigned IURO, and the Department in writing of its decision. The assigned IURO shall terminate the external review upon receipt of the written notice from the carrier.

5.7 Within 45 days after the IURO's receipt of an appeal, the assigned IURO shall provide written notice of its decision to uphold or reverse the final coverage decision to the covered person or his authorized representative, the carrier and the Department, which notice shall include the following information:

5.7.1 The qualifications of the members of the review panel;

5.7.2 A general description of the reason for the request for external review;

5.7.3 The date the IURO received the assignment from the Department to conduct the external review;

5.7.4 The date(s) the external review was conducted;

5.7.5 The date of its decision;

5.7.6 The principal reason(s) for its decision; and

5.7.7 References to the evidence or documentation, including practice guidelines and clinical review criteria, considered in reaching its decision.

5.8 The decision of the IURO is binding upon the carrier except as provided in 18 Del.C. § 6416(b).

18 Del. Admin. Code § 1301-5.0

19 DE Reg. 923 (4/1/2016)
21 DE Reg. 580 (1/1/2018)
26 DE Reg. 873 (4/1/2023) (Final)