Appeal identifier assigned by carrier
Diagnostic Category (cardiac, inpatient,
musculoskeletal, surgery, e/r, etc.)
Date appellant requested Preliminary
Date completed Preliminary Review.
Date Preliminary (or final) Decision sent
to covered person
Date appellant requested stage 2
Date stage 2 appeal occurred.
Date appellant notified of stage 2
Composition of panel (list by license
Date appellant requested External
appeal (access to IHCAP).
Date Preliminary Decision sent to DOI.
Directions for completing form:
1. Complete form/petition in its entirety.
2. Incomplete forms will be rejected.
3. Email this form/petition via secured email to: IURO@delaware.gov, subject line:
“Petition for IURO” as soon as possible, but no more than 3 business days after
appellant’s request for review under IHCAP.
4. After the Independent Utilization Review Organization (IURO) is identified, you will be
expected to forward your evidentiary material to that company.
5. Submit any additional questions via email to: IURO@delaware.gov.
***Consumers enrolled in Multi-State Plan (MSP) coverage are entitled to request an external
review from Office Personnel Management (OPM). MSP enrollees may request an external
review by calling (855) 318-0714, or e-mailing OPM at firstname.lastname@example.org. Additional information
may be found on the OPM website: http://www.opm.gov/healthcare-insurance/multi-state-
DE DOI 06/2019