Texas external review
Texas review rights depend on which track your plan is on. TDI-regulated coverage (your insurance card says "TDI" or "DOI") uses the state's Independent Review Organization process — free, fast, filed through your insurer with form LHL009. Self-funded private employer plans generally use plan/federal ERISA review; other government and benefit programs have distinct rules. The denial notice identifies the applicable reviewer.
Deadlines and decision timelines
- Your filing window: 120 days after the final internal denial; confirm the triggering event on the notice.
- Standard review decided in: 20 days for preauthorization, concurrent, and retrospective denials (TDI track)
- Expedited review decided in: 3 days — life-threatening conditions — which also let you skip the internal appeal entirely
- Cost to you: None — the carrier pays the IRO fee
How to file, step by step
- Check your card, read your denial letter. "TDI" or "DOI" on the card means the state IRO track. Otherwise your denial letter carries the federal external review instructions.
- Finish the internal appeal. Required before an IRO review — unless your condition is life-threatening, which lets you go straight to independent review.
- Send form LHL009 to your insurer — not to TDI. This is the step people get wrong. Complete TDI form LHL009 (your insurer must include it with the final denial), sign the records release, and return it to the carrier at the address on your denial letter. The carrier must forward it to TDI within 1 working day.
- TDI assigns an IRO at random. You get the assignment letter, the carrier ships records, and the IRO decides: 3 days for life-threatening cases, 20 days for most others.
Who can use it
- State IRO track: TDI-regulated coverage — check your insurance card for "TDI" or "DOI".
- Self-funded private employer plans generally use the plan/federal ERISA review route. Government, church, FEHB, TRICARE, Medicare, and Medicaid plans have separate rules; do not assume HHS review applies. Read the current denial notice.
What to know
- TDI cannot overturn an independent reviewer's decision.
- Questions about the IRO process: 1-866-554-4926, option 2.
- CMS reopened the HHS-administered Federal External Review Process on July 31, 2026. Its limited extension gave eligible consumers whose original filing deadline fell July 1–August 3, 2026 until October 2, 2026 to file. That notice does not extend other deadlines or establish a new extension after October 2. The HHS process applies only when the plan elects it; other plans use a contracted independent review organization or a separate program's rules.
Denial data from plans operating in Texas
| Insurer | Contract / plan | Line | Requests | Denied | Appeals overturned |
|---|---|---|---|---|---|
| Centene | 29418 Ambetter | Marketplace | 218,062 | 32.94% | 61.91% |
| Centene | H0174 Wellcare | Medicare Advantage | 192,173 | 19.3% | 94.76% |
| Centene | H4506 Wellcare | Medicare Advantage | 90,924 | 13.23% | 96.74% |
| Centene | 87226 Ambetter | Marketplace | 89,666 | 32.48% | 60.06% |
| Centene | H7323 Wellcare | Medicare Advantage | 14,095 | 19.21% | 98.57% |
| Molina Healthcare | TX-CHIP-PERINATE-RSA-186-TO-200 | Medicaid | — | 33% | — |
| Molina Healthcare | TX-STAR | Medicaid | — | 17% | 54% |
| Molina Healthcare | TX-CHIP | Medicaid | — | 17% | 78% |
| Molina Healthcare | TX-CHIP-RSA | Medicaid | — | 15% | 76% |
| Molina Healthcare | TX-MARKETPLACE | Marketplace | — | 13% | 50% |
| Molina Healthcare | H7678 | Medicare Advantage | — | 11% | 53% |
| Molina Healthcare | H8197 | Medicare Advantage | — | 10% | 44% |
| Elevance Health | TX-Medicaid Wellpoint | Medicaid | — | 8.6% | 31.4% |
| Molina Healthcare | H2715 | Medicare Advantage | — | 6% | — |
| Molina Healthcare | TX-STAR-PLUS | Medicaid | — | 6% | 65% |
| Molina Healthcare | TX-CHIP-PERINATE-RSA-AT-OR-BELOW-185 | Medicaid | — | 5% | 100% |
| Molina Healthcare | TX-CHIP-PERINATE-MHT-AT-OR-BELOW-185 | Medicaid | — | 4% | — |
| Molina Healthcare | TX-CHIP-PERINATE-MHT-186-TO-200 | Medicaid | — | 0% | — |
Texas external review FAQ
Where do I send my Texas IRO request?
To the insurance carrier that denied you — not to TDI. Form LHL009 goes back to the carrier (address on your denial letter), and the carrier must forward it to TDI within one working day. TDI then randomly assigns the review organization.
How fast is an IRO decision?
Life-threatening cases: 3 days. Preauthorization, concurrent, and retrospective denials: 20 days. Life-threatening conditions also skip the internal-appeal prerequisite entirely.
Does it cost me anything?
No. The carrier pays the IRO's fee.
My employer plan isn't TDI-regulated — what then?
Self-funded private employer plans generally use plan/federal ERISA review. Government plans and programs such as FEHB and TRICARE have distinct rules. Your denial letter identifies the applicable route. CMS reopened the HHS-administered Federal External Review Process on July 31, 2026. Its limited extension gave eligible consumers whose original filing deadline fell July 1–August 3, 2026 until October 2, 2026 to file. That notice does not extend other deadlines or establish a new extension after October 2. The HHS process applies only when the plan elects it; other plans use a contracted independent review organization or a separate program's rules.
Can TDI reverse the IRO if I lose?
No — TDI can't overturn an independent reviewer's decision. If you lose the external review, remaining options are legal remedies outside the administrative process.
Primary sources
- CMS — HHS FERP reopening and limited deadline extension (verified 2026-10-05)
- HealthCare.gov — current federal filing instructions (verified 2026-10-05)
- TDI — health insurance complaints and appeals
- TDI — IRO frequently asked questions
- TDI form LHL009 — IRO request (with timeframe table)
- CMS — external appeals (federal process status)