Outside review for Texas-regulated health plans: the steps TDI publishes

When a Texas-regulated health plan decides a service is not medically necessary and its own appeal keeps that decision, Texas offers an outside review by an independent review organization (IRO). This page sets out only what the Texas Department of Insurance (TDI) publishes.

Which plans this covers

• TDI regulates plans whose insurance card shows "TDI" or "DOI". TDI says it "can help if you have a fully insured plan."
• TDI does not regulate Medicare, Medicaid, CHIP plans that aren't HMOs, military plans, government employee plans or teacher plans. Those plans, and many job-based plans, use other outside-review steps, which the plan's letter names.
• For anyone unsure of the plan type, TDI's line is 800-252-3439.
• Office of Public Insurance Counsel (OPIC), the state office that speaks for insurance consumers: 1-877-611-6742.

What the outside review is

TDI describes it as a decision, by someone who does not work for the insurance company or the provider, on whether the company must pay. In TDI's words: "External reviews are free to you." TDI "can't overturn an independent reviewer's decision."

When it can be asked

It can be asked for after the plan's appeal, or right away for "a life-threatening condition" (TDI's health complaint page). TDI's IRO questions page says that in most cases the plan's appeal comes first.

The steps on form LHL009

The form says it is provided because a request for care "has been denied as not medically necessary". Its steps:

1. The patient, the health care provider, or someone acting on the patient's behalf may file it.
2. Complete the form and sign the release so the IRO can receive the medical records.
3. Return it to the company that denied the care "as soon as possible", not to TDI. The company's address or fax number is on the denial letter.
4. The company forwards the request to TDI. TDI assigns an IRO and sends a letter naming it.
5. Medical records go to the assigned IRO, not to TDI (TDI's IRO questions page).

The form prints a time limit only for workers' compensation. For health plans, the denial letter should state it.

The reviewer's clock for health cases

TDI's form prints these IRO decision times:

• Life-threatening: 3 days.
• Not life-threatening, before the care (preauthorization) or during ongoing care (concurrent): 20 days.
• After the care (retrospective): 20 days.

These are the IRO's times, not a promise from Denial Reply. Denial Reply does not handle workers' compensation.

What can be gathered

• The first denial letter and the plan's appeal decision.
• The LHL009 form that came with the denial. If it is missing, ask the plan for it.
• The doctor's notes, imaging reports, and dated therapy and medicine records.
• Proof of sending and a copy of everything sent.

Deadline basics for Texas-regulated plans

• The enrollee, a person acting on the enrollee's behalf, or the doctor may appeal to the plan, orally or in writing (Texas Insurance Code 4201.354).
• For plans with "TDI" or "DOI" on the card, Texas law sets a faster appeal when the denied care is emergency care, continued hospitalization or another service, and the doctor states in writing, with supporting records, that it is needed to treat a life-threatening condition or prevent serious harm. That appeal must be decided within one working day after the reviewer has all the information it needs (Texas Insurance Code 4201.357).
• The letter gives the time limit for the first appeal. Federal rules give job-based and individual plans at least 180 days (29 CFR 2560.503-1(h)(3)(i); 45 CFR 147.136(b)).

When waiting could seriously harm health

Call the number on the denial letter and ask for an expedited appeal. Then ask the treating doctor to tell the plan why waiting could cause harm. For a life-threatening condition, TDI's page says an outside review can be asked for right away. Denial Reply makes no promise about timing.

Free public help

• The plan's member line, printed on the card.
• Texas Department of Insurance: 800-252-3439.
• Office of Public Insurance Counsel (OPIC), the state office that speaks for insurance consumers: 1-877-611-6742.
• Texas Medicare counseling (HICAP), for Medicare questions: 800-252-9240.

What Denial Reply prepares

Denial Reply prepares appeal paperwork for the plan's own appeal from the denial letter and the records, including a calendar of each step the letter gives. A free decoder that needs no upload is at /decode.

Related guides: federal outside review · ERS HealthSelect appeal steps · which kind of plan you have

Sources

• TDI form LHL009: https://www.tdi.texas.gov/forms/finmcqa/lhl009urairoreq.pdf (version 0824; read 2026-11-03)
• TDI, "Independent Review Organization FAQ": https://www.tdi.texas.gov/hmo/mcqa/irofaqs.html (updated 9/13/2024; read 2026-11-03)
• TDI, health complaints: https://www.tdi.texas.gov/consumer/complaint-health.html (updated 12/17/2025; read 2026-11-03)
• Texas Insurance Code 4201.354 and 4201.357: https://texas.public.law/statutes/tex._ins._code_section_4201.354 (read 2026-11-01)
• 29 CFR 2560.503-1; 45 CFR 147.136: https://www.ecfr.gov/current/title-45/section-147.136 (read 2026-11-02)