Prior Authorization

Delaware First Health’s Medical Management department hours of operation are Monday through Friday, 8 a.m. to 5 p.m. ET (excluding holidays). After normal business hours, we have after hours service available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within 72 hours of receipt. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

As the Medical Home, PCPs should coordinate all healthcare services for Delaware First Health members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Delaware First Health does not require physicians or healthcare providers to obtain prior authorization for the delivery of a newborn. However, notification of all deliveries is required with a Delivery Notification Form completed and faxed to Delaware First Health at 833-974-1203.

Effective August 5th, 2024, healthcare providers must use the Delivery Notification Form to notify the health plan of a mother's delivery. This form MUST be completed within three (3) business days of the mother's discharge and faxed to 833-974-1203.

Please note, an inpatient stay longer than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery will require a prior authorization request faxed to 833-974-1203.

Please refer to the provider authorization check tool to check if any authorizations are required for additional services. 

Some services require prior authorization from Delaware First Health in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.