2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3564. Referrals.

§ 3564. Referrals.
(a) This section applies to every group or blanket policy or contract of health insurance, including each policy or contract issued by a health service corporation, which is delivered or issued for delivery in this State and which designates network physicians or providers or preferred physicians or providers (hereinafter referred to collectively as “network providers”).
(b) All individual and group health insurance policies shall provide that if medically necessary covered services are not available through network providers, or the network providers are not available within a reasonable period of time, the insurer, on the request of a network provider, within a reasonable period, shall allow referral to a non-network physician or provider and shall reimburse the non-network physician or provider at a previously agreed-upon or negotiated rate. In such circumstances, the non-network physician or provider may not balance bill the insured. Such a referral shall not be refused by the insurer absent a decision by a physician in the same or a similar specialty as the physician to whom a referral is sought that the referral is not reasonably related to the provision of medically necessary services.
(c) All individual and group health insurance policies which do not allow insureds to have direct access to health-care specialists shall establish and implement a procedure by which insureds can obtain a standing referral to a health-care specialist.
(d) The procedure established under subsection (c) of this section:
(1) Shall provide for a standing referral to a specialist if the insured's network provider determines that the insured needs continuing care from the specialist; and
(2) May require the insurer's approval of an initial treatment plan designed by the specialist containing:
a. A limit on the number of visits to the specialist;
b. A time limit on the duration of the referral; and
c. Mandatory updates on the insured's condition.
Such approval shall not be withheld absent a decision by a qualified physician that the treatment sought in the treatment plan is not reasonably related to the appropriate treatment of the insured's condition.
Within the treatment period referred to in paragraph (d)(2) of this section, the specialist shall be permitted to treat the insured without a further referral from the insured's network provider and may authorize such further referrals, procedures, tests and other medical services as the individual's network provider would otherwise be permitted to provide or authorize, provided that such further referrals, procedures, tests and other medical services are part of treating the patient for the condition for which the patient was referred to the specialist. Referrals, procedures, tests and other medical services referred to in this subsection shall be provided by network providers unless such services are not available through network providers, or the network providers are not available within a reasonable period of time. If services are not available through network providers, or the network providers are not available within a reasonable period of time, the out-of-network provider shall be reimbursed at an agreed-upon or negotiated rate. In such circumstances, the non-network provider may not balance bill the insured.
(e) Nothing in this section shall prevent the operation of policy provisions involving deductibles or copayments.
73 Del. Laws, c. 96, §  8;  73 Del. Laws, c. 315, §  8;