Denial Reply appeal paperwork for denied back and neck surgery and scans, for adults in Texas

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Federal external review for self-funded job-based plans in Texas

In short

The Texas Department of Insurance (TDI) says most people with a health plan in Texas have a self-funded plan, usually through an employer. Those plans fall under federal law and the U.S. Department of Labor, not TDI. When such a plan keeps a denial that turns on medical judgment, federal rules provide an outside review by an independent review organization (IRO). This page sets out those rules.

How to tell a plan is self-funded

Which denials qualify

The federal process covers a denial that "involves medical judgment", including the plan's requirements for "medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit", and denials of care as experimental or investigational, "as determined by the external reviewer" (45 CFR 147.136(d)(1)(i)(A)). A denial about whether someone is eligible for the plan does not qualify ((d)(2)(ii)(A)(2)). Older "grandfathered" plans are generally outside these rules ((a)(1)(ii)).

The steps in the federal rule

  1. Ask within four months. The request is filed with the plan within four months after receipt of the final internal denial. If there is no matching date, the deadline is the first day of the fifth month ((d)(2)(i)).
  2. The plan checks it. Within five business days, the plan confirms coverage, that internal appeals are finished (unless not required), and that the forms are complete. Its written notice follows within one business day. If the request is not eligible, the notice must give the reasons and the Labor Department's contact details ((d)(2)(ii)).
  3. An IRO is assigned. It must be accredited (by URAC or a similar body), and the plan rotates cases among at least three IROs. The claimant pays no costs, including filing fees ((d)(2)(iii)(A)).
  4. More papers. The claimant may send the IRO more information in writing within ten business days of its notice. The plan sends its file to the IRO within five business days of assignment ((d)(2)(iii)(B)(2)-(3)).
  5. A fresh look. The IRO reviews the claim "de novo". It considers the records, the attending health care professional's recommendation, practice guidelines, and the plan's clinical review criteria unless they conflict with the plan terms or the law ((B)(5)).
  6. A decision in 45 days. The IRO sends written notice within 45 days of receiving the request ((B)(6)). If it reverses the denial, the plan "immediately must provide coverage or payment" ((d)(2)(iv)).

When waiting could seriously harm health

An expedited outside review can be asked for at the same time as an expedited internal appeal. The IRO then decides in no more than 72 hours (45 CFR 147.136(d)(3)). A separate page covers urgent appeals.

Where the request goes

HealthCare.gov says a plan outside a state process and outside the HHS-run federal process "must contract with an independent review organization". It also says the Explanation of Benefits, or the final internal denial, gives contact details for the organization that handles the review.

What can be gathered

Free public help

What Denial Reply prepares

Denial Reply prepares appeal paperwork for Texas adults from the denial letter and records, with a calendar that carries the four-month outside-review deadline. The free decoder at /decode needs no upload.

Related guides: which kind of plan you have · Texas outside review · the 72-hour urgent appeal

Who, how, why

Sources