Texas health insurance appeal rights
Denied in Texas? You have a two-step path: an internal appeal to your plan, then an independent external review by an IRO overseen by the Texas Department of Insurance. Here’s how it works and the deadlines to watch.
How appeals work in Texas
Texas gives you a two-step path after a denial. First you appeal to your health plan (the internal appeal). If the plan still says no, you can ask for an independent external review by an Independent Review Organization (IRO) — a reviewer outside your insurer. The Texas Department of Insurance (TDI) certifies and assigns IROs, and the IRO’s decision is binding on your plan.
External review generally applies when a plan denies care as not medically necessary, experimental or investigational, or otherwise clinically inappropriate. Some plans — for example large-employer self-funded plans governed by federal ERISA rules — follow the federal external review process instead; your denial letter will tell you which applies.
Step 1 — your internal appeal
Start by appealing to your plan in writing. Include your denial notice and the records that support your case. Federal rules generally give you at least 180 days from the denial to file — but check the deadline printed on your own notice. If your situation is urgent, ask for an expedited appeal.
Step 2 — request an IRO (external review)
Once the plan upholds its denial, you can request an IRO review. You ask through your plan, which must forward the request to TDI for assignment to an independent reviewer. The review is free to you. A standard IRO decision generally comes within 45 days of the reviewer receiving a complete file; an expedited review for urgent cases is decided within 72 hours.
For ACA-regulated plans the external-review request is due within four months of your final internal denial. Deadlines vary by plan, so calendar the date on your denial letter as soon as it arrives and don’t wait.
Where to file and get help
- Texas Department of Insurance — consumer help line 1-800-252-3439; how to file an appeal or ask for external review.
- IRO process details — TDI Independent Review Organizations.
Putting it together
Read the denial, file your internal appeal, then request an IRO review if you’re turned down. Our step-by-step guide covers each stage, external review explains independent review generally, and our appeal-deadline guide helps you track your dates. In another state? See Florida or California appeal rights.
Frequently asked questions
How long do I have to request an external review in Texas?
For ACA-regulated plans the federal deadline is four months from your final internal denial. Deadlines can differ by plan type, so check the date printed on your own denial letter and act promptly.
What is an IRO in Texas?
An Independent Review Organization (IRO) is an independent body that reviews your denial after your internal appeal. The Texas Department of Insurance certifies and assigns IROs, and the IRO’s decision is binding on your health plan.
Does the external review cost me anything?
No. The external / IRO review is free to you.
How fast is a decision?
A standard external review is generally decided within about 45 days after the reviewer receives a complete request; an expedited (urgent) review is decided within 72 hours.
Denied in Texas? Build your appeal free
IntelClaim helps you assemble a clear, evidence-backed internal appeal or IRO request — free, purpose-built, and self-help. You stay in control.
IntelClaim is a self-help tool — not legal, medical, or insurance advice — and does not guarantee any particular outcome. Information on this site is general and may not reflect the rules of your specific plan or state. Always read your own denial letter, plan documents, and the deadlines that apply to you, and consider professional advice for your situation. No PHI is collected on this marketing site.