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SPONSOR: Sen. Townsend & Sen. Poore & Rep. Griffith &
Rep. Minor-Brown
Sens. Hoffner, Huxtable, Richardson, Seigfried, Sokola,
Walsh; Reps. Carson, Gorman, Morrison, Romer,
Ross Levin
DELAWARE STATE SENATE
153rd GENERAL ASSEMBLY
SENATE BILL NO. 12
AN ACT TO AMEND TITLE 18 AND TITLE 29 OF THE DELAWARE CODE RELATING TO THE DELAWARE
PRE AUTHORIZATION ACT OF 2025.
1 WHEREAS, according to a 2023 survey of physicians conducted by the American Medical Association, physician
2 offices spend approximately 2 business days per week dealing with insurance pre-authorization requirements and on
3 average complete 45 pre-authorizations per physician each week; and
4 WHEREAS, in this same survey: (i) 94% of physicians reported that pre-authorization requirements have delayed
5 necessary care for patients; (ii) 89% of physicians reported that pre-authorization requirements had a “somewhat or
6 significant negative impact” on patient clinical outcomes; (iii) 80% of physicians reported that pre-authorization
7 requirements can lead to patients abandoning treatments; (iv) more than 60% of physicians reported that pre-authorization
8 requirements have led to ineffective initial treatments or additional office visits; and (v) 33% of physicians reported that
9 pre-authorization requirements have led to a serious adverse event (death, hospitalization, disability/permanent bodily
10 damage, or other life-threatening event); and
11 WHEREAS, the General Assembly believes that reforming the laws relating to insurance pre-authorization
12 practices is an important part of keeping Delaware residents healthy and assuring that patients can access necessary medical
13 care in a timely manner.
14 NOW, THEREFORE:
15 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:
16 Section 1. Amend Chapter 33, Title 18 of the Delaware Code by making deletions as shown by strike through and
17 insertions as shown by underline as follows and by redesignating accordingly:
18 § 3371. Definitions.
19 In this section, the following words have the meanings indicated:
20 ( ) "Episode of Care" means care that meets all of the following:
2 1 a. Is for a specific medical problem, condition, or illness being managed by a health-care provider,
22 including tests, procedures, and rehabilitation initially requested by the health-care provider.
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23 b. Is performed at the site of service.
24 c. Is not out-of-network care.
25 ( ) "Urgent health-care service" means a covered health-care service subject to prior authorization that is delivered
26 on an expedited basis for the treatment of an acute condition with symptoms of sufficient severity pursuant to a
27 determination by a licensed treating physician, operating within the physician's scope of practice and professional expertise,
28 that the failure to provide the service is likely to result in serious, long-term health complications or a material deterioration
29 in the covered person's or enrollee's condition and prognosis.
30 § 3372.. §3372. Disclosure and review of preauthorization requirements. requirements; adverse
31 determinations.
32 (c) (1) If an insurer, health-benefit plan, or health-service corporation, or utilization review entity intends
33 either to implement a new preauthorization requirement or restriction, either to implement a new preauthorization requi
34 rement or restriction, or amend an existing requirement or restriction, they shall provide covered persons who are
35 currently authorized by the utilization review entity for coverage of the affected health-care service care service
36 and all contracted health-care providers who provide the affected health-care service or services of written
37 notice of the new or amended requirement or amendment no less than 60 days before the requirement or
38 restriction is implemented. Such notice may be delivered electronically or by other means.
39 (2) Notwithstanding the provisions of paragraph (c)(1) of this section, if an insurer, health benefit plan, health-
40 service corporation, or utilization review entity changes utilization review terms, such as clinical criteria, for a health-care
41 service, the change in utilization review terms does not apply to covered persons with an existing authorization for the
42 health-care service, and will apply only upon re-authorization of the health-care service. An insurer, health benefit plan,
43 health-service corporation, or utilization review entity must provide notice to covered persons at least 6 months before any
44 changes to utilization review terms for a health-care service, unless those changes were due to clinical guideline status
45 changes, recalls, market withdrawals or relevant FDA published safety information.
46 (d) Insurers, health-benefit plans and health-service corporations utilizing pre-authorization shall report de-identified
47 statistics regarding pre-authorization approvals, denials, and appeals to the Delaware Health Information Network in a
48 format and frequency, no less than twice annually, of the Delaware Health Information Network’s request. The Department
49 may also request this data at any time. The statistics shall include, but may be expanded upon or further delineated by
50 regulation, categories for all of the following:
51 (1) For denials, the aggregated reasons for denials such as as, but not limited to, medical necessity or
52 incomplete pre-authorization submission.
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53 (2) For appeals:
54 a. 1. Practitioner specialty; specialty.
55 b. 2. Medication, diagnostic test, or diagnostic procedure; procedure.
56 c. 3. Indication offered; offered.
57 d. 4. Reason for underlying denial; and denial.
58 e. 5. Number of denials overturned upon appeal.
59 (e) Utilization review; specific requirements related to adverse determinations –
60 (1) When a clean pre-authorization request is submitted by a physician or representative of a physician, an insurer,
61 health-benefit plan, health-service corporation, or utilization review entity must ensure that any adverse determination is
62 made by a physician who meets all of the following requirements:
63 a. Any compensation paid to the physician is not contingent upon the outcome of the review.
64 b. At least one of the following requirements is satisfied:
65 1. The physician is licensed in any United States jurisdiction with appropriate training, knowledge, or
66 experience in the same or similar specialty that typically manages or consults on the health-care service in
67 question.
68 2. The physician is licensed in any United States jurisdiction, in consultation with an appropriately
69 qualified third-party health-care provider licensed in the same or similar medical specialty as the requesting
70 physician, or a health-care provider with experience related to the covered person’s associated condition. Any
71 compensation paid to the consulting health-care provider may not be contingent upon the outcome of the review.
72 (2) An insurer, health-benefit plan, health-service corporation, or utilization review entity must ensure that all
73 appeals of an adverse determination related to a clean pre-authorization request submitted by a physician or representative
74 of a physician are reviewed and determined by a physician who meets all of the following requirements, in addition to the
75 requirements set forth in paragraph (e)(1) of this section:
76 a. Possesses a current, unrestricted license in good standing to practice medicine in any United States
77 jurisdiction.
78 b. Was not directly involved in making the adverse determination under appeal.
79 c. Reviews and considers all clinical aspects of the health-care service under appeal, including all
80 medical records of the covered person submitted as part of the pre-authorization process.
81 (3) When a clean pre-authorization request is submitted by a health-care provider other than a physician, an
82 adverse determination or review in an appeal from an adverse determination must be made by a health-care provider
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83 licensed in the same or similar profession as the health-care provider submitting the request for pre-authorization, or a
84 licensed health-care provider in consultation with an appropriately qualified third-party health-care provider licensed in the
85 same or similar medical specialty as the requesting health-care provider.
86 (4) A utilization review entity must, within 15 days of the receipt of an appeal of an adverse determination, notify
87 the covered person and health-care provider submitting the request for pre-authorization of determination on the appeal. If
88 the utilization review entity cannot make a determination within the 15-day period because additional information,
89 documentation, or medical records are required to complete a review of the health-care service under appeal, the utilization
90 review entity must notify the covered person and health-care provider submitting the request for pre-authorization in
91 writing within the 15-day period specifying the additional information, documentation, or medical records required to
92 complete the determination on appeal and shall have 15 days from the receipt thereof to make a determination on the appeal
93 and notify the covered person and health-care provider. The written notification required by this paragraph must include all
94 of the following:
95 a. A summary of the findings supporting the determination made in the appeal.
96 b. The qualifications of any reviewer involved in making the determination in the appeal,
97 including any license, certification, or specialty designation of any reviewer.
98 c. The relationship between the covered person’s diagnosis or disease being treated and the review
99 criteria used as the basis for the determination in the appeal, including the specific basis for the determination
100 made.
101 (5) An insurer, health-benefit plan, or health-service corporation must ensure that any utilization
102 review entity used to perform utilization review complies with all of the following:
103 a. Performs utilization review on weekends.
104 b. Provides access to a medical director or other clinical decision maker Monday through Friday
105 between the hours of 7:00 AM and 7:00 PM and during reasonable business hours Saturday through Sunday.
106 c. Has established procedures for the submission of appeals in writing, electronically, or by
107 telephone.
108 d. Provides a minimum of 30 days from the date of an adverse determination for the submission of an
109 appeal.
110 §3373. . Utilization review entity’s obligation with respect to pre-authorization in non-emergency
111 circumstances.
112 (a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review
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113 entity must complete its process or render an adverse determination and notify the covered person’s health-care provider
114 within 2 business days of obtaining a clean pre-authorization or of using services described in § 3377 of this title.
115 (b) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity
116 must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider of the
117 determination within 8 business 5 business days of receipt of a clean pre-authorization not submitted through electronic
118 pre-authorization. using services described in § 3377 of this title. For purposes of this subsection, a clean preauthorization
119 includes the results of any face-to-face clinical evaluation or second opinion that may be required.
120 (c) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity
121 must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the
122 determination within 5 3 business days of receipt of a clean pre-authorization through electronic pre-authorization
123 submitted using services described in § 3377 of this title. For purposes of this subsection, a clean pre-authorization
124 includes the results of any face-to-face clinical evaluation or second opinion that may be required.
125 (d) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review
126 entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider
127 of the determination within 24 hours of receipt of a clean pre-authorization submitted using services described in § 3377 of
128 this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical
129 evaluation or second opinion that may be required.
130 (e)(1) If a utilization review entity requires pre-authorization of a patient transfer, the utilization review entity
131 must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of
132 the determination within 24 hours of receipt of a clean pre-authorization submitted using services described in § 3377 of
133 this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical
134 evaluation or second opinion that may be required.
135 (2) Notwithstanding the provisions in paragraph (e)(1) of this section, when an insurer, health-benefit plan, or
136 health-service corporation has determined that a lower level of care at a health-care facility is clinically appropriate, the
137 insurer, health benefit plan, or health-service corporation may not require pre-authorization for medically necessary
138 interfacility transport of the covered person.
139 (f) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review
140 entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider
141 of the determination within 48 hours of receipt of a clean pre-authorization submitted not using services described in §
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142 3377 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical
143 evaluation or second opinion that may be required.
144 (g) If a utilization review entity requires pre-authorization of a patient transfer, the review entity must grant a pre-
145 authorization or issue an adverse determination and notify the covered person's health-care provider of the determination
146 within 48 hours of receipt of a clean pre-authorization not submitted using services described in § 3377 of this title. For
147 purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second
148 opinion that may be required.
149 § 3376. Effect and Length length of pre-authorization. authorization; limitation per episode of care.
150 (b) A pre-authorization for a health-care service shall be valid for a period of time that is reasonable and
151 customary for the specific service, but no less than 60 days 90 days, from the date the health-care provider
152 receives the pre-authorization, subject to confirmation of continued coverage and eligibility and to policy changes
153 validly delivered as per § 3372 of this title.
154 (c) Limitation per episode of care – An insurer, health-benefit plan, or health-service corporation may not
155 require more than 1 pre-authorization for an episode of care. Any new treatment or additional testing or procedures related
156 o r unrelated to the specific medical problem, condition, or illness being managed may require a separate pre-authorization.
157 (d) Pre-authorization of other covered services in-network - If a utilization review entity gives pre-
158 authorization of a health-care service as part of a group of services for which a bundled payment is charged, pre-
159 authorization of all other covered health-care services provided by in-network providers included in the group is deemed to
160 be approved.
161 § 3377. Electronic standards for pharmaceutical pre-authorization.
162 (a) No later than January 1, 2018, the insurer must accept and respond to pre-authorization requests under the
163 pharmacy benefit through a secure electronic transmission using the NCPDP SCRIPT standard ePA transactions. Facsimile,
164 proprietary payer portals, and electronic forms shall not be considered electronic transmission.
165 (b) No later than January 1, 2027, an insurer, health-benefit plan, health-service corporation, or utilization
166 review entity must allow for and accept electronic pre-authorization requests and must respond to electronic pre-
167 authorization requests through the same website, mobile application, digital platform, or other method as the electronic
168 pre-authorization request was submitted.
169 (c) No later than January 1, 2027, an insurer, health-benefit plan, health-service corporation, or utilization review
170 entity must establish a provider portal that includes all of the following features:
171 (1) Electronic submission of pre-authorization requests.
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172 (2) Access to the insurer’s, health-benefit plan’s, health-service corporation’s, or utilization review
173 entity’s applicable medical policies.
174 (3) Information necessary to request a peer-to-peer review.
175 (4) Contact information for the insurer’s, health-benefit plan’s, health-service corporation’s, or utilization
176 review entity’s relevant clinical or administrative staff.
177 (5) For any health-care service that requires pre-authorization that is not subject to electronic submission
178 via the provider portal, copies of applicable forms.
179 (6) Instructions for the submission of pre-authorization requests if the insurer’s, health-benefit plan’s,
180 health-service corporation’s, or utilization review entity’s provider portal is unavailable for any reason.
181 (d) Within 12 months following establishment of a provider portal under subsection (c) of this section, the insurer,
182 health-benefit plan, health-service corporation, or utilization review entity may require a health-care provider seeking pre-
183 authorization to submit the request via the provider portal unless one of the following exemptions applies:
184 (i) The portal is not available and operational at the time of attempted submission.
185 (ii) The health-care provider does not have access to the insurer’s, health-benefit plan’s, health-
186 service corporation’s, or utilization review entity’s operational provider portal.
187 (iii) The health-care provider satisfies an allowance by the insurer, health benefit plan, health service
188 corporation, or utilization review entity for submission other than through the provider portal.
189 Section 2. Amend Chapter 35, Title 18 of the Delaware Code by making deletions as shown by strike through and
190 insertions as shown by underline as follows and by redesignating accordingly:
191 § 3581. Definitions. [For application of this section, see 82 Del. Laws, c. 44, § 3].
192 For purposes of this subchapter, the following definitions apply:
193 ( ) "Episode of Care" means care that meets all of the following:
194 a. Is for a specific medical problem, condition, or illness being managed by a health-care provider,
195 including tests, procedures, and rehabilitation initially requested by the health-care provider.
196 b. Is performed at the site of service.
197 c. Is not out-of-network care.
198 ( ) "Urgent health-care service" means a covered health-care service subject to prior authorization that is delivered
199 on an expedited basis for the treatment of an acute condition with symptoms of sufficient severity pursuant to a
200 determination by a licensed treating physician, operating within the physician's scope of practice and professional expertise,
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201 that the failure to provide the service is likely to result in serious, long-term health complications or a material deterioration
202 in the covered person's or enrollee's condition and prognosis.
203 § 3582. Disclosure and review of pre-authorization requirements; requirements; adverse determinations.
204 (c) (1) If an insurer, health-benefit plan, or health-service corporation, or utilization review entity intends
205 either to implement a new pre- authorization requirement or restriction, or amend an existing requirement or restriction,
206 they shall provide covered persons who are currently authorized by the utilization review entity for coverage of the
207 affected health-care service and all contracted health-care providers who provide the affected health care service or
208 services of written notice of the new or amended requirement or amendment no less than 60 days before the requirement or
209 restriction is implemented. Such notice may be delivered electronically or by other means.
210 (2) Notwithstanding the provisions of paragraph (c)(1) of this section, if an insurer, health benefit plan, health-
211 service corporation, or utilization review entity changes utilization review terms, such as clinical criteria, for a health-care
212 service, the change in utilization review terms does not apply to covered persons with an existing authorization for the
213 health-care service, and will apply only upon re-authorization of the health-care service. An insurer, health benefit plan,
214 health-service corporation, or utilization review entity must provide notice to covered persons at least 6 months before any
215 changes to utilization review terms for a health-care service, unless those changes were due to clinical guideline status
216 changes, recalls, market withdrawals or relevant FDA published safety information.
217 (d) Insurers, health-benefit plans, and health-service corporations utilizing pre-authorization shall report de-
218 identified statistics regarding pre-authorization approvals, denials, and appeals to the Delaware Health Information Network
219 in a format and frequency, no less than twice annually, of the Delaware Health Information Network’s request. The
220 Department may also request this data at any time. The statistics shall include, but may be expanded upon or further
221 delineated by regulation, categories for all of the following:
222 (1) For denials, the aggregated reasons for denials such as, but not limited to as medical necessity or incomplete
223 pre-authorization submission.
224 (2) For appeals:
225 1. Practitioner specialty; specialty.
226 2. Medication, diagnostic test, or diagnostic procedure; procedure.
227 3. Indication offered; offered.
228 4. Reason for underlying denial; and denial.
229 5. Number of denials overturned upon appeal.
230 (e) Utilization review; Specific requirements related to adverse determinations –
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231 (1) When a clean pre-authorization request is submitted by a physician or representative of a physician, an insurer,
232 health-benefit plan, health-service corporation, or utilization review entity must ensure that any adverse determination is
233 made by a physician who meets all of the following requirements:
234 a. Any compensation paid to the physician is not contingent upon the outcome of the review.
235 b. At least one of the following requirements is satisfied:
236 1. The physician is licensed in any United States jurisdiction with appropriate training,
237 knowledge, or experience in the same or similar specialty that typically manages or consults on the
238 health-care service in question.
239 2. The physician is licensed in any United States jurisdiction, in consultation with an
240 appropriately qualified third-party health-care provider licensed in the same or similar medical specialty
241 as the requesting physician, or a health-care provider with experience related to the covered person’s
242 associated condition. Any compensation paid to the consulting health-care provider may not be
243 contingent upon the outcome of the review.
244 (2) An insurer, health-benefit plan, health-service corporation, or utilization review entity must ensure that all
245 appeals of an adverse determination related to a clean pre-authorization request submitted by a physician or representative
246 of a physician are reviewed and determined by a physician who meets all the following requirements, in addition to the
247 requirements set forth in paragraph (e)(1) of this section:
248 a. Possesses a current, unrestricted license in good standing to practice medicine in any United States
249 jurisdiction.
250 b. Was not directly involved in making the adverse determination under appeal.
251 c. Reviews and considers all clinical aspects of the health-care service under appeal, including all
252 medical records of the covered person submitted as part of the pre-authorization process.
253 (3) When a clean pre-authorization request is submitted by a health-care provider other than a physician, an
254 adverse determination or review in an appeal from an adverse determination must be made by a health-care provider
255 licensed in the same or similar profession as the health-care provider submitting the request for pre-authorization, or a
256 licensed health-care provider in consultation with an appropriately qualified third-party health-care provider licensed in the
257 same or similar medical specialty as the requesting health-care provider.
258 (4) A utilization review entity must, within 15 days of the receipt of an appeal of an adverse determination,
259 notify the covered person and health-care provider submitting the request for pre-authorization of the determination on the
260 appeal. If the utilization review entity cannot make a determination within the 15-day period because additional
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261 information, documentation, or medical records are required to complete a review of the health-care service under appeal,
262 the utilization review entity must notify the covered person and health-care provider submitting the request for pre-
263 authorization in writing within the 15-day period specifying the additional information, documents, or medical records
264 required to complete the determination on appeal and shall have 15 days from the receipt thereof to make a determination
265 on the appeal and notify the covered person and health-care provider. The written notification required by this paragraph
266 must include all of the following:
267 a. A summary of the findings supporting the determination made in the appeal.
268 b. The qualifications of any reviewer involved in making the determination in the appeal, including any
269 license, certification, or specialty designation of any reviewer.
270 c. The relationship between the covered person’s diagnosis or disease being treated and the review
271 criteria used as the basis for the determination in the appeal, including the specific basis for the determination
272 made.
273 (5) An insurer, health-benefit plan, or health-service corporation must ensure then that any utilization
274 review entity used to perform utilization review complies with all of the following:
275 a. Performs utilization review on weekends.
276 b. Provides access to a medical director or other clinical decision-maker Monday through Frida y
277 between the hours of 7:00 AM to 7:00 PM and during reasonable business hours Saturday through
278 Sunday.
279 c. Has established procedures for the submission of appeals in writing, electronically, or by
280 telephone.
281 d. Provides a minimum of 30 days from the date of an adverse determination for the submission
282 of an appeal.
283 § 3583. Utilization review entity’s obligations with respect to pre-authorizations in non-emergency circumstances.
284 (a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review entity must
285 complete its process or render an adverse determination and notify the covered person’s health-care provider within 2
286 business days of obtaining a clean pre-authorization or of using services described in § 3377 § 3587 of this title.
287 (b) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity
288 must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the
289 determination within 8 business 5 business days of receipt of a clean pre-authorization through electronic pre-
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290 authorization not submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-
291 authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.
292 (c) If A utilization review entity requires pre-authorization of a health-care service, the utilization review entity
293 must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the
294 determination within 5 3 business days of receipt of a clean pre-authorization through electronic pre-
295 authorization. submitted using services described in § 3587 of this title. For purposes of this subsection, a clean pre-
296 authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.
297 (d) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review
298 entity must grant a pre-authorization or issue an adverse determination and notify the covered person’s health-
299 care provider of the determination within 24 hours of receipt of a clean pre-authorization submitted using services
300 described in § 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-
301 to-face clinical evaluation or second opinion that may be required.
302 (e)(1) If a utilization review entity requires pre-authorization of a patient transfer, the utilization review entity must
303 grant a pre-authorization or issue an adverse determination and notify the covered person’s health-care provider of the
304 determination within 24 hours of receipt of a clean pre-authorization submitted using services described in § 3587 of this
305 title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or
306 second opinion that may be required.
307 (2) Notwithstanding the provisions in paragraph (e)(1) of this section, when an insurer, health-benefit
308 plan or health-service corporation has determined that a lower level of care at a health-care facility is clinically
309 appropriate, the insurer, health benefit plan, or health-service corporation may not require pre-authorization for medically
310 necessary interfacility transport of the covered person.
311 (f) If a utilization review entity requires pre-authorization of an urgent health-care service, the utilization review
312 entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider
313 of the determination within 48 hours of receipt of a clean pre-authorization submitted not using services described in §
314 3587 of this title. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical
315 evaluation or second opinion that may be required.
316 (g) If a utilization review entity requires pre-authorization of a patient transfer, the review entity must grant a pre-
317 authorization or issue an adverse determination and notify the covered person's health-care provider of the determination
318 within 48 hours of receipt of a clean pre-authorization not submitted using services described in § 3387 of this title. For
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319 purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second
320 opinion that may be required.
321 § 3586. Length Effect and length of pre- authorization. authorization; limitation per episode of care.
322 (b) A pre-authorization for a health-care service shall be valid for a period of time that is reasonable and customary
323 for the specific service, but no less than 60 days 90 days, from the date the health-care provider receives the pre-
324 authorization, subject to confirmation of continued coverage and eligibility and to policy changes validly delivered as per
325 § 3582 of this title.
326 (c) Limitation per episode of care – An insurer, health-benefit plan, or health-service corporation may not require
327 more than 1 pre-authorization for an episode of care. Any new treatment or additional testing or procedures related or
328 unrelated to the specific medical problem, condition, or illness being managed may require a separate pre-authorization.
329 (d) Pre-authorization of other covered services in-network - If a utilization review entity gives pre-authorization of
330 a health-care service as part of a group of services for which a bundled payment is charged, pre-authorization of all other
331 covered health-care services provided by in-network providers included in the group is deemed to be approved.
332 § 3587. Electronic standards for pharmaceutical pre-authorization.
333 (a) No later than January 1, 2018, the insurer must accept and respond to pre-authorization requests under the
334 pharmacy benefit through a secure electronic transmission using the NCPDP SCRIPT standard ePA transactions. Facsimile,
335 proprietary payer portals, and electronic forms shall not be considered electronic transmission.
336 (b) No later than January 1, 2027, an insurer, health-benefit plan, health-service corporation, or utilization review
337 entity must allow for and accept electronic pre-authorization requests and must respond to electronic pre-authorization
338 requests through the same website, mobile application, digital platform, or other method as the electronic pre-authorization
339 request was submitted.
340 (c) No later than January 1, 2027, an insurer, health-benefit plan, health-service corporation, or utilization review
341 entity must establish a provider portal that includes all of the following features:
342 (1) Electronic submission of pre-authorization requests.
343 (2) Access to the insurer’s, health-benefit plan’s, health-service corporation’s, or utilization review
344 entity’s applicable medical policies.
345 (3) Information necessary to request a peer-to-peer review.
346 (4) Contact information for the insurer’s, health-benefit plan’s, health-service corporation’s, or utilization
347 review entity’s relevant clinical or administrative staff.
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348 (5) For any health-care service that requires pre-authorization that is not subject to electronic submission
349 via the provider portal, copies of applicable forms.
350 (6) Instructions for the submission of pre-authorization requests if the insurer’s, health-benefit plan’s,
351 health-service corporation’s, or utilization review entity’s provider portal is unavailable for any reason.
352 (d) Within 12 months following establishment of a provider portal under subsection (c) of this section, the insurer,
353 health-benefit plan, health-service corporation, or utilization review entity may require a health-care provider seeking pre-
354 authorization to submit the request via the provider portal unless one of the following exemptions applies:
355 (i) The portal is not available and operational at the time of attempted submission.
356 (ii) The health-care provider does not have access to the insurer’s, health-benefit plan’s, health service
357 corporation’s, or utilization review entity’s operational provider portal.
358 (iii) The health-care provider satisfies an allowance by the insurer, health benefit plan, health service
359 corporation, or utilization review entity for submission other than through the provider portal.
360 Section 3. Amend § 5210, Title 29 of the Delaware Code by making deletions as shown by strikethrough and
361 insertions as shown by underline as follows:
362 § 5210. Authority and duties of the State Employee Benefits Committee.
363 The State Employee Benefits Committee established under § 9602 of this title has the following powers, duties,
364 and functions under this chapter:
365 ( ) Ensure that carriers administering plans for group health insurance under this chapter comply with all
366 requirements and provisions concerning pre-authorization set forth in Chapter 33, Subchapter II, and Chapter 35,
367 Subchapter V of Title 18.
368 Section 4. Effective Date. This Act shall apply to all health insurance policies, contracts, or certificates issued,
369 renewed, modified, altered, amended or reissued in this state after December 31, 2026.
370 Section 5. The Department of Health and Social Services must, to the extent feasible, assure that contracts
371 awarded to carriers providing health insurance under § 505(3) of Title 31 after the effective date of this Act include the
372 requirements and provisions concerning pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter
373 V of Title 18.
374 Section 6. This Act shall be known as and may be referred to as the “Delaware Pre-Authorization Reform Act of
375 2025”.
SYNOPSIS
This Legislation is the Delaware Pre-Authorization Reform Act of 2025.
Section 1 of the Act applies to health Insurance Contracts regulated under Chapter 33 of Title 18.
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Section 1 provides that changes in utilization review terms for a health-care service, such as the clinical criteria
used to conduct utilization reviews for a health-care service, will apply only upon re-authorization of the health-care
service. Covered persons must be notified at least 6 months before any changes to utilization review terms, except in certain
circumstances such as changes in clinical guideline status
In addition, Section 1 sets qualifications for who may make determinations with regard to requests for pre-
authorization of health-care services and appeals of adverse determinations; a timeline and required contents for the
notification of an outcome of appeal of an adverse determination or a notification that additional information is necessary to
make the determination of appeal; and requirements for any utilization review entity used to perform utilization review by
an insurer, health-benefit plan, or health-service corporation.
Section 1 also shortens the timelines for the determination of pre-authorization requests and notification to the
health-care provider of the determination. For requests for pre-authorization of non-urgent health-care services not
submitted electronically, the utilization review entity must notify the health-care provider within 5 business days of receipt
of the request; for requests submitted electronically, notification must be given within 3 business days of receipt. For
requests for pre-authorization for urgent health-care services submitted electronically, notification must be given within 24
hours of receipt.
By January 1, 2027, insurers, health-benefit plans, health-service corporations, and utilization review entities must
accept and respond to electronic pre-authorization requests through the same platform as the electronic request was
submitted.
In addition, Section 1 extends the time period that a pre-authorization is valid for from 60 days to 90 days. Finally,
Section 1 provides that no more than 1 pre-authorization may be required for a single episode of care, and that if pre-
authorization is granted as to a health-care service that is part of a group of services for which a bundled payment is
charged, pre-authorization for the other health-care services included in the group is deemed to be approved as well.
Section 2 of the Act applies to Group and Blanket Health Insurance under Chapter 35 of Title 18 and makes the
same changes to pre-authorization standards and procedures that Section 1 of the Act makes to Health Insurance Contracts
regulated under Chapter 33 of Title 18.
Section 3 of the Act provides that the State Employee Benefits Committee established under § 9602 of the Title 29
of the Delaware Code must ensure that carriers administering plans for group health insurance comply with the
requirements and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of
Title 18.
Section 4 of the Act provides that the Act will apply to health insurance policies, contracts, or certificates issued,
modified, or renewed after December 31, 2026.
Section 5 of the Act provides that the Department of Health and Social Services must, to the extent feasible, assure
that contracts awarded to carriers providing health insurance relating to Medicaid assistance comply with the requirements
and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of Title 18.
Section 6 provides that this Act is known as the "Delaware Pre-Authorization Reform Act of 2025."
Author: Senator Townsend
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4761530097Every fact on this page links to its source, starting with the official bill record.