Prior Authorization/Referral
Some services or medications may need approval by Delaware First Health before they can be provided. This is called Prior Authorization (PA).
Failure to get authorization may result in administrative claim denials. Delaware First Health providers cannot bill a member for any service that was administratively denied by Delaware First Health because the provider did not get authorization in time.
Check to see if a Prior Authorization is necessary. If you have any questions, call Member Services at: 1-877-236-1341 (TTY: 711).
Below is a list of some of the services that require prior authorization from Delaware First Health before your healthcare provider can proceed with treatment:
| SERVICES THAT REQUIRE A PRIOR AUTHORIZATION | PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES? |
|---|---|
| Bariatric surgery (Certain restrictions and limitations may apply) | Yes |
| Behavioral health intensive outpatient program. | Yes |
| Behavioral health partial hospitalization | Yes |
| Behavioral health residential treatment facilities | Yes |
| Care at a skilled nursing facility | Yes |
| Certain orthopedic surgeries such as joint replacement and spinal surgery | Yes |
| Chemical and substance use admissions | Yes |
| CT scans, MRIs, MRAs, nuclear cardiology, nuclear radiology, and PET scans | Yes |
| DME, orthotics, and prosthetics | Yes |
| Electroconvulsive therapy (ECT) | Yes |
| Facility-based sleep studies | Yes |
| Genetic and molecular diagnostic testing | Yes |
| Habilitation services | Yes |
| Home healthcare | Yes |
| Implantable hearing devices | Yes |
| Inpatient hospital care | Yes |
| Inpatient psychiatric admissions. | Yes |
| Pain management procedures | Yes |
| Physical therapy, occupational therapy, or speech therapy | Yes |
| Potentially cosmetic or plastic surgeries | Yes |
| Psychological and neuropsychological testing | Yes |
| Quantitative drug testing | Yes |
| Services received through an out-of-network provider (except for emergency care, post-stabilization, and some family planning services) | Yes |
| Transcranial magnetic stimulations (TMS) | Yes |
| Transplants | Yes |
Non-Covered Services
Some services are not covered by the Delaware Medicaid state
plan or Diamond State Health Plan. These include:
- Services that are not medically necessary.
- Abortions, except for certain circumstances.
- Infertility treatments.
- Cosmetic services (unless medically necessary)
- Services outside of the continental United States.
Specialist Care
If you need specialized care that your PCP cannot give, your PCP will refer you to a specialist. A specialist is a provider who is trained and practices in a specific area of medicine (like a cardiologist).
To make a referral, your PCP can:
- Call 1-877-236-1341 (TTY: 711).
- Fill out a form at DelawareFirstHealth.com.
If your PCP refers you to a specialist, we will pay for your care. Most specialists are Delaware First Health providers. Talk to your PCP about how referrals work.
Receiving Care Outside of Your Network
There may be times when you need to get services outside of our network. If Delaware First Health does not have a provider who can treat your covered condition or give you a covered service, you may ask to see a provider who is not in the Delaware First Health network. You should talk to your PCP about this. Prior authorization is required for out-of network providers.