Independent Review Organizations
If a health care plan refuses to pay for your medical care, you might be able to have an independent review organization (IRO) review the decision. IROs are independent third parties certified by the Texas Department of Insurance to review health care services that plans deny because they consider them medically unnecessary, inappropriate, or experimental. The health care plan must comply with the IRO's decision and pay for the review.
Asking for an IRO Review
Before you ask for an IRO review, you must go through your health care plan’s internal appeals process. Every plan has an appeals process that you may use if the plan denies a medical treatment or service. You, your doctor, or another doctor may file the appeal. You can bypass your plan's appeal process if you or your doctor believes your condition is life-threatening.
After you’ve been through the appeals process, you may ask for an independent review if
- Texas law requires your health care plan to participate in the IRO process, and
- your health plan or its utilization review agent (URA) denies a treatment because it considers the treatment to be experimental, investigational, medically unnecessary, or inappropriate.
A health care plan must base its denial on written screening criteria.
An independent review isn’t available if
- your policy doesn't cover the service (cosmetic surgery, for instance), or
- Texas law doesn't require your plan to participate in the IRO process. ERISA plans, Medicaid, Medicare (including Medicare HMO plans), and certain other health plans don't have to participate in the IRO process. Contact your health care plan to find out if it is required to participate.
How to Get an IRO Review
You, your representative, or your doctor may ask for an IRO review. There isn't a deadline for requesting an review, but you should try to ask for a review as soon as possible.
To get a review, complete and return the IRO request form to the plan or URA that denied the services. Your plan or its URA must give you the form when it denies a treatment. If you appeal the decision and lose, the plan or URA should send you the form again.
If your plan didn't tell you about your rights to an appeal or independent review, call TDI's Consumer Help Line at 1-800-252-3439.
The IRO Process Time Frame
Once the plan or URA gets your completed request form, it must notify TDI. TDI will assign your case to an IRO within one business day.
If the IRO needs your medical records or other information to review your case, the health plan or URA must send them within three days of the IRO's request. You or your legal guardian might have to sign a release form to let the IRO see your medical records. You may also give your medical records to the IRO yourself. The IRO must keep your medical records and personal information confidential.
Don't send your medical records to TDI.
The IRO must decide whether your health plan will pay for the denied treatment within 15 days of receiving your information, or no later than 20 days after TDI assigns the case. In cases involving life-threatening conditions, the IRO must decide no later than three days after TDI assigns the case.
For more information about IRO's, call TDI's Managed Care Quality Assurance Office at 1-866-554-4926
The IRO Decision
Your plan must comply with the IRO's decision and pay for treatments the IRO decides are medically necessary or appropriate. The IRO's decision will include
- the clinical basis for the decision
- the screening criteria used to make the decision
- a list of qualifications of the IRO staff who reviewed your case
- a written certification stating that the doctor reviewing the case doesn't have a conflict of interest with the treating doctor or any of the doctors who previously reviewed the case.
For More Information or Assistance
For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line at 1-800-252-3439 between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.
For printed copies of consumer publications, call the Consumer Help Line.
To report suspected arson or suspicious activity involving fires, call the State Fire Marshal's 24-hour Arson Hotline at 1-877-4FIRE45 (434-7345).
The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.
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Last updated: 12/02/2014