What is independent review?
Independent review (external review) is a second look at certain denials by a TDI-certified independent review organization (IRO)—not your insurance company or its utilization review agent.
For eligible TDI-regulated cases, the IRO decision is generally binding on the plan. TDI assigns the IRO after the denying company forwards your request.
General overview: Appeals roadmap. Complete Texas internal appeals first unless a skip-internal exception applies.
Who can use Texas review?
Independent review under Insurance Code Chapter 4201, Subchapter I, generally applies when:
- You have a TDI-regulated health plan (check your card for TDI or DOI)
- A utilization review agent, HMO, or carrier denied care as not medically necessary, not appropriate, or experimental / investigational
- You exhausted internal UR appeal—or qualify to skip it (life-threatening, Rx/IV, or other statutory exceptions)
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review through DOL/HHS may still apply)
- Medicare and Medicare Advantage (federal Medicare appeals)
- Texas Medicaid managed care (HHSC state fair hearing—not commercial IRO review)
- Workers' compensation networks (separate TDI/MCQA rules and deadlines)
TDI notes that many ACA plans also have a federal external review process overseen by HHS or DOL; fully insured Texas plans may use TDI's IRO system, federal review, or both depending on plan type—follow your denial notice.
Deadlines & exhaustion
Exhaust internal appeal first (most cases)
In most cases you must receive an adverse determination on your internal UR appeal before requesting IRO review. Exceptions include:
- Life-threatening conditions — immediate IRO appeal, no internal review required (§ 4201.360)
- Prescription drugs or IV infusions for ongoing covered benefits — immediate IRO appeal (§ 4201.3601)
Filing your IRO request
Complete TDI Form LHL009 (How to file an IRO request) and return it to the company or URA that issued the denial—not directly to TDI. The company forwards the request to TDI for IRO assignment.
Submit as soon as possible after your final internal denial. For federally regulated plans, external review is generally available within four months of a final adverse benefit determination (HealthCare.gov — external review).
Preauthorization exemption disputes
Denial or rescission of a gold card PA exemption may be reviewed by an IRO within 30 days of the request (§ 4201.656).
How to file
- Complete internal appeal when required and obtain a final adverse determination.
- Download and complete Form LHL009(English or Spanish PDF on TDI's site).
- Sign the form so the IRO can access medical records (authorization on the form).
- Submit LHL009 to the denying carrier or URA using the address or fax on your denial letter.
- After TDI assigns an IRO, submit any supplemental records within 3 working days of the assignment notice (per TDI IRO FAQ).
TDI consumer guide: How to file an appeal or ask for external review · Help Line: 800-252-3439
Links hub: Texas external appeals links.
How long it takes
TDI-published IRO timeframes for regulated health plans (after TDI assigns the case):
- Life-threatening: IRO decision within 3 days
- Rx/IV concurrent or step therapy preauth denials: within 3 days
- Non-life-threatening preauthorization / concurrent: within 20 days
- Retrospective medical necessity: within 20 days (health plans)
- PA exemption (gold card) disputes: within 30 days (§ 4201.656)
Is the decision binding?
For eligible medical-necessity disputes, the IRO decision is binding on the health carrier or URA and the enrollee. If the IRO overturns the denial, the plan must provide coverage consistent with the decision.
TDI can help with complaints about fully insured plans but generally cannot overturn an IRO decision.
Medicaid & Medicare
Texas Medicaid (STAR / STAR+PLUS / STAR Kids): Appeal through your MCO, then request an HHSC state fair hearing (Fair hearings FAQs)—not TDI IRO review under Chapter 4201.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS.
More: Medicaid managed care · Medicare appeals.