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New Prior Authorization Requirements Effective August 1st, 2025
Date: 05/06/25
Delaware First Health is committed to delivering cost-effective, quality care to our members. This requires us to ensure that our members only receive treatments that are medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
Delaware First Health requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements.
The following service will require prior authorization effective August 1, 2025:
- J1439 – Injection, ferric carboxymaltose, 1 mg
The following service will no longer require prior authorization effective August 1, 2025:
- A7039 – Filter, nondisposable, used with positive airway pressure device
- 81257 – HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)
- K0001 – Standard wheelchair
- A7046 – Water chamber for humidifier, used with positive airway pressure device, replacement, each
- E0601 – Continuous positive airway pressure (CPAP) device
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization. Please verify every member’s eligibility and benefits prior to rendering services to them. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. Non-Par Providers and facilities require authorization for all services except where indicated.
For a complete list of CPT/HCPCS codes, please use the Pre-Auth Check Tool.
If you have any questions, please call Provider Services at 1-877-236-1341. You may also locate your Provider Engagement Administrator Manager to confirm the individual supporting your specialty and region.
We encourage you stay up to date on Delaware First Health provider announcements by Signing up for Provider Updates and visiting the Provider News section of our website.