Delaware Code Title 18. Insurance Code § 3373. Utilization review entity's obligation with respect to pre-authorization

(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 using services described in § 3377 of this title.

(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 § 3377 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.

(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 § 3377 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.

(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 § 3377 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.

(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 § 3377 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.

(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 § 3377 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.