Texas insurance appeal rights
Texas administers appeals through the Texas Department of Insurance (TDI) for most commercial plans, with separate routes for ERISA self-funded employer plans.
Internal appeal rights
Internal appeals must be filed within 180 days. Texas requires carriers to respond to standard internal appeals within 30 days; urgent appeals within 72 hours.
External review
Texas Independent Review Organization (IRO) review is available after exhaustion of internal appeals. The IRO decision binds the carrier.
TX regulator
Texas Department of Insurance (TDI). official site
Notable
- Texas requires carriers to disclose clinical review criteria on request.
- TDI Consumer Help: 800-252-3439.
- Texas has aggressive surprise-billing protections; out-of-network denials should be cross-checked against state rules.
How to file an external review in Texas
In Texas, external review is handled by the state itself through the Texas Department of Insurance (TDI), which assigns an Independent Review Organization (IRO) certified under Insurance Code Chapter 4202. After your final internal appeal denial on a medical-necessity, experimental, or investigational basis, you generally have four months to request review by submitting TDI form LHL009 to the insurer or its utilization review agent, which must forward it to TDI within one working day. A standard IRO decision is due within about 20 days, and life-threatening cases qualify for expedited review in roughly three days. The IRO decision is binding on the insurer, and the carrier, not you, pays the review fee.
Texas appeal questions
How do I file for an independent review in Texas?
You request an Independent Review Organization (IRO) by completing the Texas Department of Insurance form LHL009 and sending it to the insurer or utilization review agent that issued your denial, not directly to TDI. That entity must forward your request to TDI within one working day, and TDI then randomly assigns a certified IRO to decide your case. Your denial letter or explanation of benefits should list the contact and instructions for submitting the form.
What is the deadline to request an IRO review in Texas?
For state-regulated health plans, you generally have four months from the date of your final internal appeal denial to ask for an Independent Review Organization review. Do not wait, because missing the window can forfeit your right to external review. If your situation is life-threatening, you can request an expedited review and the IRO must decide much faster, typically within a few days.
Does an IRO review in Texas cost me anything?
No. The Texas IRO process is free to you as the patient. By law the insurance carrier, not the patient, pays the IRO's fee, so cost should never be a reason to skip external review. This keeps the independent review accessible regardless of your ability to pay.
Is the IRO decision binding, and what about self-funded ERISA plans?
Yes. An IRO weighs whether the denied care is medically necessary, appropriate, or experimental, and its decision is binding on the insurer in Texas. If the IRO overturns the denial, the plan must provide or pay for the service. Note that self-funded employer (ERISA) plans usually fall outside TDI's authority and instead use the federal HHS-administered external review process, so check whether your plan is fully insured or self-funded.
Filed a denial in Texas?
We work under TX rules and structure the appeal under the strongest available state and federal protections.
Start Your AppealState law information is provided for general guidance and is not legal advice. Confirm with your state regulator or a licensed attorney for your specific case.