Pick your issue from the list to learn how we can help:
- My insurance company denied a service my doctor says I need.
- My insurance company stopped paying for one of my prescriptions.
- I got a bill from an out-of-network provider.
- I’m a provider and the insurance company didn’t pay me on time or only partially paid the claim.
- I need help with a mental health condition or substance use disorder.
- I have another issue.
If your health plan denied a treatment, procedure, or medicine, you have several options.
Step 1: Tell the insurance company you want to appeal its decision.
You or your doctor can appeal treatment decisions with most health plans if you disagree with them. For example, your plan might deny a preauthorization request if they think the care is not medically necessary or appropriate.
The notice you got from the health plan telling you that it denied your treatment or service should tell you how to appeal.
Your plan booklet will explain your appeal rights and how to request an appeal. You must usually ask for an appeal within a certain time period. Don’t delay or you might miss your right to appeal.
Step 2: Ask for an external review.
If you aren't happy with your appeal or were denied care for a life-threatening condition, you can ask for an external review. Someone who doesn’t work at the insurance company or for your provider (an independent reviewer) will decide if the insurance company must pay for the service. External reviews are free to you.
The Affordable Care Act requires plans to have an external review process. The U.S. Department of Labor or the U.S. Department of Health and Human Services (HHS) oversees the external review process for most plans in Texas.
TDI can help if you have a fully insured plan.
TDI can’t overturn an independent reviewer’s decision.
Step 3: File a complaint.
If you’re not happy with the outcome of your appeal, you can file a complaint. Learn how by going to our webpage, How to file a health insurance complaint.
File a complaint with TDI if:
- Your insurance card has “TDI” or “DOI” on it. See example cards
- You have a Medicare supplement policy.
- You have a long-term care insurance or disability plan.
- You have short-term insurance or another limited benefit plan.
TDI doesn’t regulate:
- Medicare, Medicaid.
- CHIP plans that aren’t HMOs.
- Military plans.
- City, county, state, and federal employee plans.
- Teacher plans.
Visit our page to learn where to get help with these plans.
Not sure? If you’re not sure what type of plan you have, call us at 800-252-3439.
Step 4: Talk to an attorney about your legal options.
If you’re not satisfied with the outcome of your dispute, you may have the option to sue the insurance company. Use our Getting legal help page to learn about resources that might help.