New to helping someone in Texas?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Check whether the card shows TDI or DOI (Texas-regulated fully insured plan) or whether the plan is likely self-funded ERISA (no TDI marking).
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (HealthCare.gov, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
For many Texas-regulated plans, you have an internal appeal with the insurer or utilization review agent first, then a right to independent review through a TDI-certified independent review organization (IRO) under Insurance Code Chapter 4201.
For steps that work in every state, read these general guides first, then return here for Texas rules:
What is different in Texas?
- HealthCare.gov: Texas uses the federal Marketplace at HealthCare.gov. Major 2026 carriers include Blue Cross Blue Shield of Texas, Ambetter, Molina, Oscar, Cigna, UnitedHealthcare, and regional plans such as Community Health Choice and Sendero (availability varies by county).
- Prior authorization: § 4201.653 — gold carding (90%+ approval over a 12-month evaluation period, effective Sept. 1, 2025 under HB 3812); adverse notices often within 3 working days (§ 4201.304).
- Internal appeals: Ch. 4201 — typically 30 calendar days for standard UR appeals; expedited appeals within 1 working day after all information is received for urgent Rx/IV or emergency care disputes.
- Independent review (IRO): TDI-certified IRO after internal appeal in most cases—skip internal review for life-threatening conditions (§ 4201.360) and many prescription drug / IV infusion denials (§ 4201.3601); 20-day standard / 3-day urgent IRO decisions for many health plans.
- Medicaid (STAR / STAR+PLUS): MCO process, then HHSC fair hearing—90 days (or 120 days after MCO final action)—not commercial IRO review.
Who is in charge of your plan?
- TDI (Texas Department of Insurance): Utilization review, IRO certification, fully insured commercial plans — tdi.texas.gov. Help Line: 800-252-3439
- U.S. Department of Labor / HHS: Many self-funded ERISA plans and federal external review for some ACA plans.
- HHSC fair hearings: Medicaid managed care — Fair hearings FAQs
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.