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Texas
General Information and Internal Plan Review:
Texas requires health plans and Utilization Review Agents (URAs)
for those plans to have an internal appeal procedure. If you have
exhausted your plan or URA’s internal appeal procedure and
are still denied coverage for care because the plan or URA regards
the care as not medically necessary or appropriate, then you may
file for independent review by an Independent Review Organization
(IRO). You cannot be required to exhaust your plan's internal appeal
process if you have a life-threatening condition and can request
the review immediately. If the IRO disagrees with the health plan
or URA’s denial, your health plan will be required to pay for
the requested care.
You are not eligible for an independent review if the denial is not based
on medical necessity (i.e., the contract does not cover the service or
treatment requested or the treatment is experimental). You may, however,
appeal to the health plan or you may file a complaint with the Department
of Insurance. You also may not request eligible for an independent review
if prospective or concurrent review was not performed by the health plan
or its utilization review agent, you have already received the services
and your health plan then determines that the treatment was not medically
necessary or appropriate (retrospective review). However, you are
entitled to appeal the denial of the claim to the health plan. In addition,
not all health plans are required to participate in the IRO process (i.e.,
Medicare plans). You should call your health plan to determine whether
the plan participates in the IRO process.
The Independent Review Process:
Whom to contact: |
Your health plan or its utilization
review agent |
Who can appeal: |
You, your provider, and your authorized
representative (although only you or your legal guardian may sign
a medical records release form). Your provider may appeal
the denial without your consent if you are not reasonably available
or competent to consent. |
What you can appeal: |
Prospective or concurrent denials of
coverage for services that the health plan or its utilization review
agent determines are not medically necessary or appropriate. |
When you can appeal: |
After denial for coverage has been
appealed through the health plan’s or its utilization review
agent’s internal process, or immediately to the IRO if you
have a life-threatening condition. There is no time limit. |
What to send: |
A completed independent review request
form (the health plan or its utilization review agent is required
to provide you with this form at the time it denies services and
again if your appeal is denied). Send to your health plan or its
utilization review agent at the address or fax number listed at
the bottom of the request form. |
What you must pay: |
No charge to you; the health plan or
its utilization review agent must pay for the IRO review. |
What will happen: |
- The health plan or its utilization review agent will immediately
notify the Department of Insurance that you have requested
an independent review.
- The Department will randomly assign your case to an independent
review organization within one business day of receiving
a complete IRO request.
- The Department will notify the health plan or its utilization
review agent, the patient and the providers, involved about
the assignment.
- The health plan or its utilization review agent will send all
pertinent information to the IRO by the 3rd day after receiving
your review request.
- The IRO will make a determination.
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When you will get a decision: |
Either 15 days after receiving necessary
information or 20 days after receiving your request for
independent review. |
In life-threateningsituations: |
Either 5 days after receiving necessary
or 8 days after receiving your request for independent review. |
How to Get More Information:
HMO/URA Division, (512) 322-4266
IRO Information Line, 888-834-2476, (322-3400 in Austin)
Consumer Help Line, 800-252-3439, (463-6515 in Austin)
www.tdi.state.tx.us|
Information updated as of 8-2-2004
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