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Independent Review Organizations

(January 2016)

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 certified by the Texas Department of Insurance, and health care plans must comply with their decisions.

Asking for a 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, someone acting on your behalf, or your doctor may file the appeal. You can bypass your plan's appeal process if you or your doctor believes your condition is life-threatening. You may also bypass the appeal if your plan denies a claim for prescription drugs or intravenous infusions that you’re currently getting benefits for.

After you’ve been through your plan’s appeals process, you may ask for an independent review if

  • your health plan denies a treatment because it considers the treatment to be experimental, investigational, medically unnecessary, or inappropriate; and
  • Texas law requires your health care plan to participate in the IRO process.

You can’t ask for an IRO review if

  • your policy doesn't cover the denied service, or
  • Texas law doesn't require your plan to participate in the IRO process. ERISA plans, Medicaid, Medicare, and certain other health plans don’t have to participate. Contact your health care plan to find out if it’s required to participate.

There isn't a deadline for requesting an IRO review, but it’s best to ask for a review as soon as possible. Your health care plan will pay for the cost of the review.

To get a review, fill out the IRO request form and send it to your health plan. Your plan must give you the form when it denies a treatment.

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 Review Process

Your health plan will notify TDI of the request for a review. TDI will then assign your case to an IRO. If the IRO needs to see your medical records, you or your legal guardian will have to sign a consent form. You may give the IRO the records yourself or have your health plan do it.  The health plan must send any medical records or information requested by the IRO within three days of the request. The IRO must keep your medical records and personal information confidential.

Don’t send your medical records to TDI.

The IRO has 20 days from the date TDI assigned your case to decide whether your plan must pay for the denied treatment. In cases involving life-threatening conditions, the IRO has three days to decide.

For more information about IROs, call TDI's Managed Care Quality Assurance Office at 1-866-554-4926 or visit www.tdi.texas.gov/wc/wcnet/index.html.

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.

You can also visit www.HelpInsure.com to help you shop for automobile, homeowners, condo, and renters insurance, and www.TexasHealthOptions.com to learn more about health care coverage and your options.

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: 02/11/2016

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