Texas Insurance Appeal Laws & Rights

Texas provides robust independent review protections for insurance denials. The Texas Department of Insurance (TDI) oversees the appeal and external review process, providing consumers with free access to independent medical opinions.

Regulatory Agency

Texas Department of Insurance (TDI)
  • Phone: 1-800-252-3439
  • Website: tdi.texas.gov
  • Handles complaints, appeals, and independent review

Texas-Specific Protections

Independent Review Organization (IRO)

  • Available for medical necessity and experimental treatment denials
  • Free to consumers
  • IRO assigned randomly from TDI-certified reviewers
  • Decision binding on the insurer
  • Standard review: 20 days
  • Expedited review: available for life-threatening conditions

Balance Billing Protections

Texas was one of the first states with surprise billing protections:
  • Protections for emergency and out-of-network services at in-network facilities
  • Mediation process for bills over $500

Additional Protections

  • Prompt pay law: Insurers must pay clean claims within 30 days
  • External review for experimental treatments: Strong access
  • Step therapy reform (2023): SB 1286 allows exceptions to step therapy

Appeal Timeline
StepDeadline
Internal appeal180 days from denial
IRO request45 days after final internal denial
TDI complaintNo specific deadline
| Expedited IRO | Available for urgent cases |

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Frequently Asked Questions

How do I request independent review in Texas?

After your internal appeal is denied, you can request an Independent Review Organization (IRO) review through the Texas Department of Insurance. The request must be made within 45 days of the final internal denial. TDI assigns a random certified reviewer. The process is free.

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