Delaware Administrative Code
Title 18 - Insurance
1300 - Health Insurance General Provisions
1301 - Internal Review and Independent Utilization Review of Health Insurance Claims
Section 1301-7.0 - Refusal or Dismissal of IHCAP Appeal

Universal Citation: 18 DE Admin Code 1301-7.0

Current through Register Vol. 28, No. 3, September 1, 2024

7.1The Department may refuse to accept any appeal that is not timely filed or does not otherwise meet the criteria for IHCAP review. If the subject of the appeal is appropriate for arbitration, the Department shall advise the covered person or his authorized representative of the arbitration procedure. If the subject of the appeal is appropriate for arbitration, the appeal shall be treated as a petition for arbitration.

7.2 Carrier's motion to dismiss an IHCAP appeal.

7.2.1 A carrier may move to dismiss an IHCAP appeal if the carrier believes the appeal:
7.2.1.1 Concerns a benefit that is the subject of an express written exclusion from the covered person's health insurance;

7.2.1.2 Is appropriate for arbitration; or

7.2.1.3 Should be dismissed because it is inappropriate for IHCAP review as explained in a sworn statement by an officer of the carrier.

7.2.2 The carrier's motion to dismiss must be made in writing at the time the carrier transmits the appeal to the Department and must include any necessary supporting documentation.

7.2.3 The Department shall review the appeal and motion for dismissal and may, in its discretion:
7.2.3.1 Dismiss the appeal and notify the covered person or his authorized representative in writing that the appeal is inappropriate for the IHCAP; or

7.2.3.2 Appoint an IURO to conduct a full external review.

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