Delaware DE

Delaware Medicaid (DMMA / Delaware Medical Assistance Program) publishes FFS prior-authorization requirements as a centralized, document-repository shape -- NOT a per-payer portal lookup. The classic provider-portal path medicaid.dhss.delaware.gov/medicaid/provider/prior_auth/ is now DEAD (404). The live canonical source is the Delaware Medical Assistance Portal Document Repository (a Bring2mind/DMX 'SmartCatalog' DNN module) at https://medicaidpublications.dhss.delaware.gov/docs/search. It has a top-level 'Prior Authorization' folder (Revised 3/26/2026) containing two PDFs: (1) 'Medical Items and Services PA List' -- the master FFS PA requirement list organized by Functional Area (Adult BH, Dental, DME, Home Health, Inpatient Hospital, Practitioner Services, LTC, Optical, Renal Dialysis, etc.); (2) 'Prior Authorization Annual CY2025' -- CMS-0057-style annual PA reporting. The PA List explicitly applies ONLY to Fee-for-Service members and points to General Policy Manual section 1.21 and the Practitioner Provider-Specific Policy Manual for general PA rules; MCO members (AmeriHealth Caritas DE, Highmark Health Options under Diamond State Health Plan) follow their own MCO PA rules. Pharmacy PA criteria live in a separate 'Pharmacy Corner' repository folder (state-administered FFS PDL). Authority = DMMA (state division); Gainwell operates the MMIS provider web portal but the criteria publishing lives in this DHSS document repository, not the transactional portal.

Last award: 2022-07-12. Next due: RFP for 2028+ cycle not yet released as of this snapshot. Contracts extended through: 2027-12-31 (base term; 3 optional 1-year extensions could carry through 2030-12-31).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How DE requires PA Delaware Medicaid (DMMA) requires prior authorization (PA) for a variety of medical items and services to ensure that only medically necessary treatments are covered under its program. The specific requirements are detailed in the "Medical Items and Services PA List.pdf" document, revised on March 25, 2026. Key areas where PA is required include: - **Adult Behavioral Health Services**: Authorization is needed for services such as administration of Buprenorphine in Medication-Assisted Treatment (MA-OTP) programs, crisis intervention exceeding 23 hours, DSAMH Room and Board, neuropsychological testing, psychological testing if more than six hours are provided annually, and substance abuse disorder services. - **Dental Services**: For both adults and children, PA is required for additional services that exceed annual benefit limits, deep sedation/general anesthesia, emergency/extended dental benefits, intravenous moderate sedation/analgesia, nitrous oxide, non-IV conscious sedation, periodontal scaling and root planning, prosthodontics, and specific orthodontic services. - **Durable Medical Equipment (DME)**: PA is necessary for items like airway clearance systems, breast pump replacement tubing, diabetic shoes, double-electric breast pumps if the quantity limit is exceeded, dressing supplies/wound care, equipment maintenance, external ambulatory infusion pumps, hearing aids, infusion supplies, miscellaneous supplies with specific quantity limits, orthopedic equipment, orthotics and prosthetics, out-of-region services, oxygen equipment, phototherapy blankets, specialized/custom wheelchairs, and vascular/burn specialty needs. - **Home Health Services**: PA is required for home health services exceeding certain thresholds, such as skilled nursing, therapy, or aide services for DDDS Lifespan Waiver members, in-home skilled nursing assessments exceeding two hours, multiple members requiring services from the same agency, and skilled rehabilitation visits exceeding one hour. - **Inpatient Hospital Services**: Notification of admission is required within one business day, and PA is needed for bariatric surgery, out-of-state hospital admissions (except specific neighboring states), pre-scheduled elective procedures, specialty hospitals, and transplants. - **Long Term Care Services**: Authorization is necessary if more than 23 sessions of occupational therapy, physical therapy, or speech therapy are required within one month. - **Optical/Vision Services**: PA is required for contact lenses, deluxe frames, scratch-resistant coating, specialty bifocals, and trifocals. ## 2. How DE publishes and reports PA Delaware Medicaid (DMMA) publishes its prior authorization requirements through a centralized document repository managed by Bring2mind/DMX. The primary document used to communicate these requirements is the "Medical Items and Services PA List.pdf," which was last revised on March 25, 2026. This document serves as the master list for all PA requirements within the Delaware Medicaid program. The classic provider-portal path (medicaid.dhss.delaware.gov/medicaid/provider/prior_auth/) is no longer active and results in a 404 error. Instead, providers must refer to the centralized repository for PA information. Additionally, DMMA publishes an annual report on prior authorization processes, such as "Prior Authorization Annual CY2025.pdf," which outlines general metrics and timelines for PA decisions but does not detail specific CPT/HCPCS codes or medical-necessity criteria. ## 3. DE's CMS-0057-F and PA-reform compliance posture Delaware Medicaid (DMMA) is compliant with the requirements outlined in CMS-0057-F, which pertains to prior authorization processes. The "Prior Authorization Annual CY2025.pdf" document indicates that for standard (non-urgent) requests, decisions must be made within 7 calendar days starting January 1, 2026. For expedited (urgent) requests, decisions are required within 72 hours. The state's compliance with PA reform is evident in the structured approach to publishing and reporting PA requirements through a centralized document repository. However, the annual report does not provide specific details on CPT/HCPCS codes or additional medical-necessity criteria like thresholds, step-therapy, or documentation requirements. This suggests that while DMMA adheres to CMS timelines for decision-making, there may be room for more detailed guidance in future publications. ## 4. How DE runs its own program Delaware Medicaid (DMMA) operates under a mandatory managed care organization (MCO) model, as indicated by the MCO inventory data. The current contract cycle was awarded on July 12, 2022, with contracts extending through December 31, 2027, and potentially up to December 31, 2030, with optional one-year extensions. The state has a specific 1115 waiver program called the Diamond State Health Plan (DSHP) Demonstration, which includes carve-ins for long-term services and supports (LTSS) into MCOs via DSHP Plus. This integration ensures that LTSS services are managed through the same network as other Medicaid-covered services. Delaware does not have a specific gold-card law or foster-care MCO program. The fiscal agent history shows transitions from ACS-Inc to Conduent/Gainwell, indicating changes in the administrative support for the FFS (Fee-for-Service) component of the Medicaid program. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized Document Repository**: DMMA uses a centralized document repository managed by Bring2mind/DMX to publish PA requirements, which is an efficient way to ensure all providers have access to the latest information. - **Mandatory MCO Model**: The state operates under a mandatory MCO model with specific carve-ins for LTSS services, indicating a structured approach to managing Medicaid benefits. - **1115 Waiver Program**: The Diamond State Health Plan (DSHP) Demonstration includes carve-ins for LTSS services, suggesting a focus on integrated care management. ### What's Missing/Uncertain: - **Specific PA Criteria Details**: While the "Medical Items and Services PA List.pdf" provides an overview of which services require PA, it lacks specific CPT/HCPCS codes or detailed medical-necessity criteria like thresholds, step-therapy requirements, or documentation guidelines. - **Gold Card Law Status**: The status of a gold-card law in Delaware is unspecified, leaving uncertainty about any special provisions for high-cost beneficiaries. - **WISeR**: Not applicable to Delaware. WISeR = CMS *Wasteful and Inappropriate Service Reduction* (a Medicare model covering only AZ/NJ/OH/OK/TX/WA per [[reference_wiser_model]]). The '?' in our findings is a placeholder, not a DE signal — corrected in the Claude pass. - **Provider Manual Details**: The provider manual does not contain specific PA criteria, CPT/HCPCS codes, or effective dates, suggesting a need for more detailed guidance in this document. These gaps highlight areas where additional information could enhance transparency and clarity for providers and beneficiaries within the Delaware Medicaid program.