Independent Review Organizations
(February 2011)
If a health care plan refuses to pay for medical care because it considers it medically unnecessary or inappropriate, you may be able to have an independent review organization (IRO) review the decision.
IROs are independent third parties certified by the Texas Department of Insurance (TDI) to review the medical necessity and appropriateness of health care services provided or proposed to patients. The health care plan is required to comply with the IRO’s decision and pay for the review.
When an IRO Review Is Available
An independent review is available if
- Texas law requires your health care plan to participate in the IRO process
- your health care plan or its utilization review agent (URA) determines that a recommended treatment is medically unnecessary or inappropriate
- your health care plan or its URA determines that an ongoing treatment is medically unnecessary or inappropriate
- your health plan or its URA determines that a treatment already provided was medically unnecessary or inappropriate
- your health plan or its URA denies a treatment because of its experimental or investigational nature.
A health care plan must base its denial on written screening criteria developed and updated with the involvement of practicing physicians and other providers.
When an IRO Review Is Not Available
An independent review is not available if
- your plan refuses to pay for a service because it’s not covered, such as cosmetic surgery
- your health care plan is not required by law to participate in the IRO process. ERISA plans, Medicaid, Medicare (including Medicare HMO plans), and certain other health plans are not required to participate in the IRO process. Contact your health care plan to find out if it is required to participate in the IRO process.
Appeals Process
Your health care plan has an internal appeals process that allows you to challenge its decision to deny coverage of medical services, treatments, or medications.
You must typically use the appeals process before requesting an IRO review, but you can bypass the appeal process if you or your doctor believes your condition is life threatening.
You, your doctor, or another provider may file an appeal if your health care plan isn’t required to participate in the IRO process or if the plan tells you an IRO is not available because it doesn’t cover the services in question. You may also file a complaint with the plan if you’re not satisfied with the outcome of the appeal. Ask your health care plan or your employer about the process for appeals and complaints.
If you’ve gone through the plan’s appeals and complaints processes but still aren’t satisfied, you may file a complaint with TDI. Call TDI’s Consumer Help Line for more information or to file a complaint
1-800-252-3439
463-6515 in Austin
www.tdi.state.tx.us
How to Obtain an Independent Review
You, your representative, or your provider may request an independent review. There is no time limit to request an IRO review for treatment denials, but you should try to request a review as soon as possible.
To request an independent review, complete and return the independent review request form to the health care plan or URA that denied the services. Your health care plan or its URA must provide the form to you when it denies a treatment because it regarded the treatment as medically unnecessary or inappropriate or experimental or investigational in nature. The plan or its URA should send the form again if you use its internal appeals process but are denied.
If you believe your health care plan failed to inform you of your rights to an appeal or independent review, call TDI’s Consumer Help Line.
The IRO Process Time Frame
Once the health care plan or URA receives your request form, it must immediately notify TDI of your request for an IRO review. TDI will assign your case to an IRO within one business day of receiving your request and will notify all parties of the IRO assignment.
The health care plan or URA must send the IRO any information and medical records it needs for the review. Only you or your legal guardian may sign a medical records release form allowing the IRO to access the documents. The IRO must preserve the confidentiality of individual medical records and personal information.
You may also submit information and medical records to the IRO. Do not send medical records to TDI.
The IRO must receive any information it requests within three business days of the review request. The IRO must reach a decision within 15 days of receiving the information but no later than 20 days after the IRO receives its assignment. In cases involving life-threatening conditions, the IRO must reach a decision within five days of receiving the information but no later than eight days after the IRO receives its assignment.
For questions or more information about IRO’s, call TDI’s Health and Workers’ Compensation Network Certification and Quality Assurance (HWCN) Division at
1-866-554-4926
322-4266 in Austin
The IRO Decision
Your health care plan must comply with the IRO’s decision and pay for treatments the IRO decides are medically necessary or appropriate. The IRO will provide you with a notice of its decision that includes:
- 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 physician or provider reviewing the case doesn’t have a conflict of interest with the treating provider or any of the providers who previously reviewed the case
For More Information or Assistance
For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website
1-800-252-3439
463-6515 in Austin
www.tdi.state.tx.us
You can also visit HelpInsure.com to help you shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health care coverage and your options.
For printed copies of consumer publications, call the 24-hour Publications Order Line
1-800-599-SHOP (7467)
305-7211 in Austin
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1-888-327-8818
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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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