Texas external review for health insurance denials
After the final internal appeal in Texas, an independent organization can re-decide your claim. Texas Department of Insurance oversees the process.
- Regulator
- Texas Department of Insurance
- Program type
- State-administered external review
- Filing window
- Federal default: 4 months after the final internal denial (45 CFR 147.136(d)). Confirm the Texas deadline at the official page below.
- Official page
- https://www.tdi.texas.gov/consumer/cpmiro.html
- Department site
- https://www.tdi.texas.gov/
What external review covers
External review applies to adverse benefit determinations involving medical judgment — denials based on medical necessity, appropriateness, level of care, effectiveness of a covered benefit, or whether a treatment is experimental or investigational. It also covers rescissions of coverage. It does not apply when the denial is based on an explicit benefit exclusion in your plan document.
For an expedited request (when the standard timeframe would seriously jeopardize life, health, or ability to regain maximum function), the reviewer must decide as soon as possible and no later than 72 hours.
How to file in Texas
- Exhaust the insurer's internal appeals process. Keep the final adverse benefit determination letter — you'll need it.
- Open the Texas external review page at https://www.tdi.texas.gov/consumer/cpmiro.html and use the request form posted there.
- Submit the final denial letter, your provider's medical necessity letter, supporting medical records, and any relevant guideline or peer-reviewed citations. The state-assigned IRO will review the full record.
- The standard decision is typically issued within 45 days. The insurer is bound by the decision if the IRO reverses the denial.
Texas notes
Texas administers Independent Review Organization (IRO) review through TDI under Tex. Ins. Code Chapter 4202. Requests are filed with the insurer and forwarded to a TDI-assigned IRO.
Upload the final denial letter. The free analysis builds the IRO submission packet: medical necessity letter, evidence list, and policy citations.