Health insurance denial in Texas: which appeal route applies
Updated November 5, 2026.
In short
- The appeal route depends on the kind of plan. "TDI" or "DOI" on the ID card means the Texas Department of Insurance regulates it.
- Most plans give 180 days to file the first appeal. Medicare Advantage gives 65 days from the date on the notice.
- After the plan's own appeal, an independent reviewer can look at most medical-necessity denials. Free help: TDI 800-252-3439, OPIC 1-877-611-6742, 1-800-MEDICARE.
Free during our test. No payment card. No charge later. The first 20 Texas adults are included.
The denial letter controls. This page sets out the government rules for four common kinds of plans. It does not judge any denial.
Step one: the kind of plan
- "TDI" or "DOI" on the card: a fully insured plan, regulated by the Texas Department of Insurance (TDI). TDI says a plan bought from an insurer, an HMO or HealthCare.gov is "likely a fully insured plan".
- No "TDI" or "DOI": TDI says the plan is self-funded: the employer "pays claims itself". Most people with a health plan in Texas have one, TDI says. Private employers' plans fall under the federal law ERISA.
- Medicare Advantage: Medicare's rules apply; TDI does not regulate Medicare.
The four routes at a glance
| Plan type | Who oversees it | First appeal deadline | Outside review route | Who to call |
|---|---|---|---|---|
| Texas-regulated ("TDI" or "DOI" on the card) | TDI | The letter gives it. OPIC: usually "within 180 days (six months)" of the notice | Follow the external-review instructions your denial letter must give you (Texas Insurance Code 4201.303 requires them for TDI or DOI plans). The route can be TDI's own (an independent review organization assigned by TDI, on form LHL009; 20 days, or 3 if life-threatening) or the federal external review process. TDI says external reviews are free to you | TDI 800-252-3439; OPIC 1-877-611-6742 |
| Self-funded job-based plan under ERISA | U.S. Department of Labor | At least 180 days from receipt of the denial (29 CFR 2560.503-1(h)(3)(i)) | Federal external review, asked for within 4 months of the final denial (45 CFR 147.136(d)(2)(i)) | The benefits office at work; Labor Department, Dallas, 972-850-4500 |
| Marketplace (HealthCare.gov) | TDI (these plans are likely fully insured) | 180 days from the notice; one internal level (45 CFR 147.136(b)(3)(ii)(G)) | External review within 4 months of the final denial, state or federal; the final letter must say how | HealthCare.gov 1-800-318-2596; TDI |
| Medicare Advantage | Medicare | 65 days from the date on the notice (Medicare.gov; 42 CFR 422.582(b)) | Automatic: if the plan keeps its denial, it forwards the case to an Independent Review Entity (Medicare.gov; 42 CFR 422.590) | The plan; 1-800-MEDICARE (1-800-633-4227) |
TDI's own outside review follows these steps when the letter names it
- Which outside review applies depends on the plan and the decision. TDI says the U.S. Department of Labor or HHS "oversees the external review process for most plans in Texas", and the federal list of state processes places Texas under "HHS Administered Process/Independent Review Organization Process" (CMS).
- The plan's appeal usually comes first. For a life-threatening condition, the IRO can be asked for after the first denial (TDI's IRO FAQ).
- The plan forwards the request to TDI and pays the IRO's fee. OPIC says the plan "must comply with the IRO's decision".
- OPIC says Medicare, Medicaid and ERISA plans "do not have to participate", and that plans need not offer an IRO for services they do not cover.
Plans outside these four
TDI does not regulate Medicaid, CHIP plans that aren't HMOs, military plans, government employee plans or teacher plans. Their letters give their own steps.
When waiting could seriously harm health
- Job-based and Marketplace plans: an expedited appeal can be asked for by phone; the plan decides within 72 hours (29 CFR 2560.503-1(h)(3)(vi), (i)(2)(i)). An outside review can be asked for at the same time (HealthCare.gov).
- Medicare Advantage: with a physician's support on those grounds, the plan must expedite and decide within 72 hours (42 CFR 422.584(c); 422.590(e)).
- Denial Reply does not handle these cases. The number on the letter and the doctor's office are faster.
Free public help
- Texas Department of Insurance: 800-252-3439. TDI's IRO office: 1-866-554-4926.
- Office of Public Insurance Counsel (OPIC), a state agency: 1-877-611-6742.
- Texas Medicare help line: 800-252-9240.
What Denial Reply prepares
Denial Reply prepares appeal paperwork, from the denial letter and records, for Texas adults denied back or neck surgery or a back or neck MRI or CT. The free decoder at /decode needs no upload: it shows the route and dates from the letter's wording.
Related guides: which kind of plan you have · Texas outside review
Who, how, why
- Who: Denial Reply. Drafted with AI and checked by the founder, who is not a doctor and is not licensed to practice law.
- How: From the OPIC, TDI, HealthCare.gov and Medicare.gov pages and the federal rules below, read November 3, 2026, and the CMS list of state external review processes and Texas Insurance Code 4201.303, read November 5, 2026.
- Why: To help people in Texas find which appeal steps apply. It is general information, not legal or medical advice.
Sources
- OPIC: https://www.opic.texas.gov/health-insurance/get-help/appeal-denied-claim/ (no date shown; read 2026-11-03)
- TDI, IRO FAQ (updated 9/13/2024): https://www.tdi.texas.gov/hmo/mcqa/irofaqs.html (read 2026-11-03)
- TDI, appeals and external review (updated 12/17/2025): https://www.tdi.texas.gov/consumer/complaint-health.html (read 2026-11-03)
- CMS, state external review processes: https://www.cms.gov/cciio/resources/files/external_appeals (modified 08/14/2026; read 2026-11-05)
- Texas Insurance Code 4201.303: https://tcss.legis.texas.gov/resources/IN/htm/IN.4201.htm (read 2026-11-05)
- TDI, self-funded plans (updated 6/23/2023): https://www.tdi.texas.gov/consumer/selffundedplans.html (read 2026-11-03)
- TDI, fully insured vs. self-funded (updated 12/17/2025): https://www.tdi.texas.gov/tips/fully-insured-vs-self-insured.html (read 2026-11-03)
- HealthCare.gov: https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ and https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (read 2026-11-03)
- Medicare.gov: https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans (read 2026-11-03)
- 29 CFR 2560.503-1: https://www.law.cornell.edu/cfr/text/29/2560.503-1 (read 2026-11-03)
- 45 CFR 147.136: https://www.law.cornell.edu/cfr/text/45/147.136 (read 2026-11-03)
- 42 CFR 422.582, .584, .590: https://www.law.cornell.edu/cfr/text/42/422.582 (and https://www.law.cornell.edu/cfr/text/42/422.584, https://www.law.cornell.edu/cfr/text/42/422.590; read 2026-11-03)