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Delaware DMAP Prior Authorization Request Form

Delaware Medicaid's fee-for-service program uses this request for prior authorization of durable medical equipment, home health care, private duty nursing, skilled nursing visits, therapies, surgery and diagnostic testing. Although the PDF is fillable, the request must be entered through the DMAP Provider Portal with supporting documentation, at least two weeks before the scheduled date of service.

Who completes it

The ordering provider's office completes sections A through F: member and other insurance details, ordering provider, primary physician, the DME or home health agency, service dates with ICD-10 and CPT or HCPCS codes, and the place of service.

Submitting and payment

How to submit it
Submit electronically through the DMAP Provider Portal, which starts the authorization process, with documentation for the requested services, at least 2 weeks before the date of service.

Good to know

  • Sections E and F ask whether the request continues an existing service and whether the place of service is an out-of-state provider, so check both boxes.
  • Home health aide services appear on the checklist for prior authorization when they exceed two hours per day.
  • The companion Practitioner's Medical Necessity Letter for DME requests is in Appendix D of the DMAP DME provider manual.
  • Only fee-for-service members use this form; most Delaware Medicaid members are enrolled in Diamond State Health Plan managed care organizations, which have their own prior authorization forms.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Request Form

Official pagePDF

Get the note ready with Vero

Delaware Division of Medicaid and Medical Assistance (DMMA), Delaware Medical Assistance Program (DMAP) takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can the Delaware DMAP prior authorization form be faxed?

The form's instructions say prior authorization requests must be submitted electronically through the DMAP Provider Portal to start the process. The PDF lays out the information the request needs, and documentation for the requested services should be sent with the portal submission.

How far in advance should a DMAP prior authorization be requested?

Submit requests at least two weeks before the scheduled date of service. Incomplete forms can delay the authorization, so include the ICD-10 diagnosis codes, CPT or HCPCS codes, service dates and the ordering provider's NPI and taxonomy.

Does this form apply to Diamond State Health Plan members?

No. It covers the fee-for-service Delaware Medical Assistance Program. Members enrolled in Diamond State Health Plan managed care organizations follow their plan's own prior authorization process and forms, so check the member's enrollment before starting a DMAP portal request.