{"data":{"id":"us-de/18-del.-c.-3583","jurisdiction":"us-de","citation":"18 Del. C. § 3583","heading":"Utilization review entity’s obligations with respect to pre-authorizations [For application of this section, see 85 Del. Laws, c. 176, § 4].","body":"(a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review entity must complete its process or render an adverse determination and notify the covered person’s health-care provider within 2 business days of obtaining a clean pre-authorization or of using services described in § 3587 of this title.\n(b) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 5 business days of receipt of a clean pre-authorization not submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.\n(c) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 3 business days of receipt of a clean pre-authorization submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.\n(d) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 24 hours of receipt of a clean pre-authorization submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.\n(e) (1) If a utilization review entity requires pre-authorization of a patient transfer, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 24 hours of receipt of a clean pre-authorization submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.\n(2) Notwithstanding the provisions in paragraph (e)(1) of this section, when an insurer, health-benefit plan or health-service corporation has determined that a lower level of care at a health-care facility is clinically appropriate, the insurer, health-benefit plan, or health-service corporation may not require pre-authorization for medically necessary interfacility transport of the covered person.\n(f) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 48 hours of receipt of a clean pre-authorization submitted not using services described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.\n(g) If a utilization review entity requires pre-authorization of a patient transfer, the review entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the determination within 48 hours of receipt of a clean pre-authorization not submitted using services described in § 3387 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.","path":["Title 18. Insurance Code","Insurance","CHAPTER 35. Group and Blanket Health Insurance","Subchapter V. Pre-Authorization Transparency"],"source_url":"https://delcode.delaware.gov/title18/c035/sc05/index.html#3583","current_through":"2026-08-10 (85 Del. Laws, c. 421, 424)","vintage":"","retrieved_at":"2026-09-05T23:02:24Z","sha256":"be8085328736553057d909301674806a565506c67652d9fe633192d35d489f00","source_id":"us-de","stale":true,"prev":"us-de/18-del.-c.-3582","next":"us-de/18-del.-c.-3584"},"notice":"GroundRules: Original legal text. Not legal advice."}