(And How Banjo Health Helps You Automate Compliance and Performance)
Delaware’s prior authorization (PA) rules—outlined in HB 381 (2016)—are designed to improve transparency, reduce delays, and streamline care delivery across the state.
For payers and PBMs, these laws come with clear obligations for timelines, data reporting, and clinical review. If your processes aren’t optimized for speed and compliance, you could be risking more than just administrativeinefficiency.
At Banjo Health, we help modernize your prior authorization workflow to meet Delaware’s rules effortlessly.
Delaware PA Response Time Requirements
Delaware’s law breaks down response timelines by service type:
● Prescription Drugs (Rx):
○ Response required within 2 business days of receiving all necessary information
● Medical Services:
○ Response required within 5 business days (non-urgent)
○ 8 business days allowed in specific, justified cases
Banjo Health’s intelligent routing and automation ensures no deadline is missed—reducing friction, improving accuracy, and maintaining compliance automatically.
ePA Standards and Submission Guidelines
Delaware mandates that health insurers and PBMs support electronic prior authorization (ePA) for both prescription and medical services. While the state does not enforce a specific standard, NCPDP SCRIPT and interoperable digital portals are expected best practice.
Banjo’s ePA engine integrates with provider systems and adjudicates requests in real time—helping you stay ahead of ePA expectations while reducing provider abrasion.
Data Transparency and Reporting in Delaware
Payers are required to report key metrics to the Delaware Health Information Network (DHIN) twice a year, including:
● Number of PA requests
● Approval/denial rates
● Average turnaround times
● Most frequently denied services or drugs
With Banjo Health, these metrics are automatically tracked and visualized, so your compliance reporting is always audit-ready—and never a last-minute scramble.
Delaware’s Clinical Criteria and Decision Integrity
Delaware’s statute requires PA decisions be based on clear, written clinical criteria that:
● Are evidence-based
● Are easily understood by practicing providers
● Are made available to both patients and providers on request
Banjo Health embeds these criteria into its decisioning engine—ensuring consistency across cases and full transparency when sharing rationale with providers or regulators.
Delaware’s Prior Authorization Appeals, Peer Review & Reviewer Qualifications
Delaware encourages peer-level appeals and clinical oversight:
● Reviews must be conducted by a licensed healthcare professional with similar or relevant clinical expertise
● Communication should be clear and include contact information for their viewer
With Banjo, peer-matching is automated, and every denial or escalation includes complete reviewer info—removing manual steps and maintaining full compliance.
Why This Matters
Failing to meet Delaware’s PA rules can result in:
● Regulatory violations
● Provider friction and appeals
● Loss of trust from members and networks
Banjo Health eliminates these risks by automating your end-to-end PA workflow and surfacing everything you need to stay compliant and competitive in Delaware.
Automate Compliance with Banjo Health
From timeline management and clinical rule enforcement to automated DHIN reporting, Banjo Health helps payers and PBMs stay compliant with Delaware’s PA regulations—while reducing cost, delay, and error.
● Automated response times
● Built-in peer review workflows
● Real-time reporting and dashboard visibility
● Scalable ePA infrastructure
● Fully auditable logs
