- What is an Independent Review Organization?
- What is the LHL009 form and how do I obtain it?
- Where do I send my LHL009 form to start the IRO process?
- What happens after I submit the LHL009 form to the Utilization Review Agent or carrier?
- Where do I send medical records and related information?
- Are CPT codes required to be supplied on a LHL009 by the party requesting an IRO review?
- How much are the fees for an IRO review?
- Who pays the fee for the IRO review?
- How long does an IRO review take?
- Who gets the IRO decision?
- Do I have to request reconsideration/appeal before I can request a review by an IRO?
Q: What is an Independent Review Organization?
A: Independent Review Organizations (IROs) are organizations certified by the Texas Department of Insurance (TDI) under Insurance Code Chapter 4202. The purpose of an IRO is to provide an independent review of health care services that are denied by certain entities regulated by TDI on the basis that the services are not medically necessary or appropriate, or are experimental or investigational. These entities include Utilization Review Agents, Health Maintenance Organizations, Insurance Carriers, and Certified Workers' Compensation Networks.
Q: What is the LHL009 form and how do I obtain it?
A: The LHL009 form is the form developed by the Texas Department of Insurance for enrollees, injured employees, and providers to use to request that services denied by a Utilization Review Agent, Health Maintenance Organization, carrier, or Certified Workers' Compensation Network be reviewed by an IRO. For health cases, the LHL009 form is provided by the insurance carrier, Health Maintenance Organization, or Utilization Review Agent at the time it sends a decision denying a health care service on the basis that the service is not medically necessary or appropriate, or is experimental or investigational. For workers' compensation cases, you may obtain a copy of the LHL009 form from our website at, https://www.tdi.texas.gov/forms/form9iro.html, or you may request a copy by calling our toll free number at 866-554-4926.
Q: Where do I send my LHL009 form to start the IRO process?
A: You should send the LHL009 form to the Utilization Review Agent (URA) or the insurance carrier that actually issued the denial. The URA or carrier contact information can be found on your denial letter or explanation of benefits (EOB).
Q: What happens after I submit the LHL009 form to the Utilization Review Agent or carrier?
A: After you submit the LHL009 form, the following happens:
- The Utilization Review Agent (URA), Health Maintenance Organization, Certified Workers' Compensation Network, or carrier is required to submit your request for review by an Independent Review Organization (IRO) to the Texas Department of Insurance (TDI) within one (1) working day of receipt.
- Once TDI receives the request from the URA, Health Maintenance Organization, Certified Workers' Compensation Network, or carrier we will assign your request for an independent review to a certified IRO and send notice of assignment letters to the:
- IRO;
- Enrollee/injured employee or the enrollee's/injured employee's representative;
- Provider;
- URA;
- HMO;
- Carrier and;
- Workers' Compensation Network, if applicable.
- The URA, Health Maintenance Organization, Certified Workers' Compensation Network, or carrier then sends all medical records and related information to the assigned IRO within three (3) working days.
- The IRO selects a qualified health care provider to review the medical records related to the denied service and provide an independent opinion as whether the denied service is medically necessary or appropriate, or experimental and investigational. The IRO and the reviewer are required to certify their independence from any party that may be involved with the denial of the services.
Q: Where do I send medical records and related information?
A: Medical records and related information should go to the Independent Review Organization (IRO) that has been assigned by the Texas Department of Insurance (TDI) for the review of medical necessity.
- The Health Maintenance Organization, Certified Workers' Compensation Network, carrier or carrier's Utilization Review Agent shall submit the required documentation within three (3) working days after the receipt of the notice of assignment.
- If the provider or enrollee/injured employee has records or related information, they may fax or mail them to the IRO using the numbers or address provided on the notification letter.
- The IRO may contact you for additional records.
- Please do not send medical records to TDI, as this will only cause a delay in the IRO process.
Q: Are CPT codes required to be supplied on a LHL009 by the party requesting an IRO review?
A: CPT codes are not required to be provided on the LHL009 form. However, the requesting party is required to provide an adequate description of the services that were denied by the carrier. CPT codes are procedure codes that are helpful in providing an accurate description of the services being denied.
Q: How much are the fees for an IRO review?
A: Independent Review Organization (IRO) fees are divided into two tiers. Tier 1 is a review performed by a doctor of medicine or a doctor of osteopathy. The fee for a Tier 1 review is $650.00. Tier 2 includes all other types of health care providers. The fee for a Tier 2 review is $460.00.
Q: Who pays the fee for the IRO review?
A: Independent Review Organization (IRO) reviews are paid for by the following:
- For a health case, the carrier or the carrier's Utilization Review Agent pays for pre-authorization, concurrent, and retrospective reviews by an IRO.
- For a workers' compensation network case, the carrier pays for pre-authorization, concurrent, and retrospective reviews by an IRO.
- For workers' compensation non-network pre-authorization and concurrent reviews of medical necessity, the carrier pays the IRO fee. In workers' compensation non-network retrospective medical necessity IRO reviews, the requesting party initially pays the IRO fee. However, the carrier must pay the IRO fee for retrospective review when the review concerns reimbursement that was denied for health care paid by the employee. The IRO fee must be paid before the IRO performs its review. If the fee is not received within 15 days of the invoice, the review will be dismissed with prejudice. Upon completion of the IRO review, the IRO fee must be paid or refunded by the non-prevailing party, unless the non-prevailing party is an injured employee. In accordance with the Texas Labor Code §413.031, the injured employee may not be charged for the IRO fee.
Q: How long does an IRO review take?
A: The timeframes for an Independent Review Organization (IRO)'s decision are given below.
| Coverage Types | Health | Workers' Compensation Network (WCN) | Workers' Compensation Non-Network (WC) |
| Life Threatening | 3 days | 8 days | 8 days |
| Denial of Prescription Drugs or Intravenous Infusions - Concurrent | 3 days | NA | NA |
| Denial of an exception request to a prescription drug step therapy protocol - Preauthorization | 3 days | NA | NA |
| Non-Life-Threatening Preauthorization/Concurrent | 20 days | 20 days | 20 days |
| Retrospective | 20 days | 30 days from receipt of IRO fee* | 30 days from receipt of IRO fee** |
*Carrier pays the fee.
**Requestor pays the fee. (However, if the requestor is an injured employee, carrier pays the fee.)
- There is one exception in regards to time frames for IRO decisions in WCN and WC preauthorization/concurrent disputes- when the IRO request a Designated Doctor Examination (DDE). When a DDE has been requested by the IRO, the above time frames begin on the date of the IRO receipt of the designated doctor report.
Q: Who gets the IRO decision?
A: The Independent Review Organization is required to provide a copy of its decision to the following:
- The Texas Department of Insurance;
- Enrollee/employee or the enrollee's /employee's representative;
- Provider;
- Utilization Review Agent;
- Health Maintenance Organization;
- Carrier and
- Workers' Compensation network, if applicable.
Q: Do I have to request reconsideration/appeal before I can request a review by an IRO?
A: In most cases, you must request that a reconsideration or appeal be performed by the Health Maintenance Organization, Certified Workers' Compensation Network, carrier or the carrier's Utilization Review Agent (URA) before you can request a review by an Independent Review Organization (IRO). However, there are two exceptions to this requirement:
- If the enrollee/employee has a life-threatening condition, a request for IRO can be made after the first denial by the carrier or the carrier's URA.
- If the coverage is workers' compensation non-network and the injured employee is requesting reimbursement for out-of-pocket expenses, a request for IRO can be made after the first denial by the carrier or the carrier's URA.