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You are here: Home . wc . wcnet . injureddenied

Were you denied a medical service?

The purpose of this webpage is to provide information to help you understand your options if you were denied a medical service.

If your request for health care services has been denied as not medically necessary, you can now request that your case be reviewed by a health care provider who is totally independent of your insurance carrier. This is called an independent review by an independent review organization or "IRO."

You, your health care provider, or someone acting on your behalf may file a request for an independent review by completing the form LHL009, Request for a Review by an Independent Review Organization.

Before you request an independent review you must first requested reconsideration of the denial. Below are the time frames in which you must file for reconsideration:

  • For Workers' Compensation Non-Network cases, you must request reconsideration by the workers' compensation insurance carrier or Utilization Review Agent (URA) that made the decision within 15 working days after you received the first denial.
  • For Workers' Compensation Network cases, you must request reconsideration by the workers' compensation insurance carrier or URA that made the decision within 30 calendar days.

Exceptions

  • If you have a life threatening condition and services have not been received, you do not have to request an appeal or reconsideration before requesting an independent review.
  • If you are an injured employee and have paid for services out of pocket, you do not have to request reconsideration before requesting an independent review.
  • If you are an injured employee and services have been provided, you cannot request an independent review unless you have paid for the services.

Here is what you must do to request an independent review of your case

  • Complete the form LHL009, Request for a Review by an Independent Review Organization.
  • Return the completed form to the company that sent you the denial letter as soon as possible. (For Workers' Compensation cases, you must return this form - requesting an IRO - within 45 calendar days). The company's address and/or fax number are either listed on page four of the form or on the denial letters. DO NOT SEND THIS FORM TO THE TEXAS DEPARTMENT OF INSURANCE .

The company will forward your request for an IRO to the Texas Department of Insurance. Once the Texas Department of Insurance receives the request from the company, we will assign your case to an IRO. You will receive a letter from the Texas Department of Insurance identifying the IRO to whom your case has been assigned.

The IRO has 20 days to make a decision for non life threatening cases and 8 days to make a decision for life threatening cases. The IRO will notify you of its decision.

There is no cost to you for the independent review.



For more information, contact:

Last updated: 10/16/2015

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