A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
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Texas General Information and Internal Plan Review: Texas requires health plans and Utilization Review Agents (URAs) for those plans to have an internal appeal procedure. If you have exhausted your plan or URA’s internal appeal procedure and are still denied coverage for care because the plan or URA regards the care as not medically necessary or appropriate, then you may file for independent review by an Independent Review Organization (IRO). You cannot be required to exhaust your plan's internal appeal process if you have a life-threatening condition and can request the review immediately. If the IRO disagrees with the health plan or URA’s denial, your health plan will be required to pay for the requested care.
You are not eligible for an independent review if the denial is not based on medical necessity (i.e., the contract does not cover the service or treatment requested or the treatment is experimental). You may, however, appeal to the health plan or you may file a complaint with the Department of Insurance. You also may not request eligible for an independent review if prospective or concurrent review was not performed by the health plan or its utilization review agent, you have already received the services and your health plan then determines that the treatment was not medically necessary or appropriate (retrospective review). However, you are entitled to appeal the denial of the claim to the health plan. In addition, not all health plans are required to participate in the IRO process (i.e., Medicare plans). You should call your health plan to determine whether the plan participates in the IRO process.
The Independent Review Process:
Whom to contact: | Your health plan or its utilization review agent | Who can appeal: | You, your provider, and your authorized representative (although only you or your legal guardian may sign a medical records release form). Your provider may appeal the denial without your consent if you are not reasonably available or competent to consent. | What you can appeal: | Prospective or concurrent denials of coverage for services that the health plan or its utilization review agent determines are not medically necessary or appropriate. | When you can appeal: | After denial for coverage has been appealed through the health plan’s or its utilization review agent’s internal process, or immediately to the IRO if you have a life-threatening condition. There is no time limit. | What to send: | A completed independent review request form (the health plan or its utilization review agent is required to provide you with this form at the time it denies services and again if your appeal is denied). Send to your health plan or its utilization review agent at the address or fax number listed at the bottom of the request form. | What you must pay: | No charge to you; the health plan or its utilization review agent must pay for the IRO review. | What will happen: | - The health plan or its utilization review agent will immediately notify the Department of Insurance that you have requested an independent review.
- The Department will randomly assign your case to an independent review organization within one business day of receiving a complete IRO request.
- The Department will notify the health plan or its utilization review agent, the patient and the providers, involved about the assignment.
- The health plan or its utilization review agent will send all pertinent information to the IRO by the 3rd day after receiving your review request.
- The IRO will make a determination.
| When you will get a decision: | Either 15 days after receiving necessary information or 20 days after receiving your request for independent review. | In life-threateningsituations: | Either 5 days after receiving necessary or 8 days after receiving your request for independent review. |
How to Get More Information: HMO/URA Division, (512) 322-4266
IRO Information Line, 888-834-2476, (322-3400 in Austin)
Consumer Help Line, 800-252-3439, (463-6515 in Austin)
www.tdi.state.tx.us Information updated as of 8-2-2004 |
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