How to appeal a health insurance denial in Texas
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Depending on your plan, external review in Texas runs through the state’s process or the federal one; your final denial letter says which. The deadline to ask: within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process).
Does this apply to you? State external review covers plans regulated by Texas: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Texas
Within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process)
Expedited external reviews are decided no later than 72 hours after the request is received. TDI says that if your condition is life-threatening, or your plan stops covering a prescription you already take, you can ask for external review right away without appealing to the plan first.
Free
Fully insured plans bought in Texas or through an employer that buys insurance (the card shows "TDI" or "DOI"). Most of these use the federal external review process. TDI's own IRO process covers plans outside the ACA rules, such as disease-specified (cancer) plans. Self-funded employer plans use the federal process.
Texas stopped running external review for ACA plans on June 30, 2018. Your final denial letter says whether your insurer uses the HHS process run by MAXIMUS (request online, by fax at 888-866-6190, or call 888-866-6205) or an IRO the insurer contracts with, in which case you send the request to the insurer. For disease-specified plans, TDI's IRO process uses form LHL009, which goes to the insurer (not TDI), and TDI then assigns an IRO. TDI does not regulate Medicare, Medicaid, city/county/state/federal employee plans or teacher plans.
Who to contact
- Texas Department of Insurance
- External review information and forms
- Consumer help line: 800-252-3439
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Texas?
Within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied (federal process)
Can I get a fast external review in Texas?
Expedited external reviews are decided no later than 72 hours after the request is received. TDI says that if your condition is life-threatening, or your plan stops covering a prescription you already take, you can ask for external review right away without appealing to the plan first.
Does external review cost anything in Texas?
Free
Do Texas’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- TDI: How to file an appeal or ask for an external review
The U.S. Department of Labor or the U.S. Department of Health and Human Services (HHS) oversees the external review process for most plans in Texas.
- TDI: Request for review by an IRO
For workers’ compensation and disease-specified plans (like cancer plans), you can ask for a review by an independent review organization (IRO).
- HealthCare.gov: External Review
You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.