How to Appeal a Denied Medical Claim in Texas

A denied health insurance claim in Texas isn't the end of the road. Texas gives you a real, structured appeal process — including an outside review your insurer has to pay for and follow. Here's how it works, as best we can summarize current Texas guidance.

Step 1: Read the denial letter

Your insurer must send a written denial that explains why your claim was denied and how to appeal. Read it closely, and gather your policy, the denial, and your insurer's medical-necessity criteria. If you didn't get those, call and request them.

Step 2: File the internal appeal

First you appeal directly to your health plan — an "internal appeal." According to the Texas Office of Public Insurance Counsel, you generally have 180 days (six months) from the denial notice to file. Write a letter or use the plan's form, state which denial you're appealing and why, and include your provider's documentation of why the care is medically necessary. Keep copies of everything and follow up regularly.

Step 3: Request an external review by an IRO

If the internal appeal fails, you can ask for an external review by an Independent Review Organization (IRO) — an outside reviewer. For denials based on medical necessity (care the plan calls unnecessary, inappropriate, experimental, or investigational), your plan must give you an IRO request form, must pay for the review, and must comply with the IRO's decision. The IRO generally decides within about 20 days for non-emergencies, and faster for emergencies (roughly a few days). If your condition is life-threatening, you can skip the internal appeal and go straight to an IRO.

The plan-type caveat that matters most

The Texas IRO process is run through the Texas Department of Insurance (TDI) and applies to state-regulated plans — look for "TDI" or "DOI" on your insurance card. Plans like Medicare, Medicaid, and self-funded employer (ERISA) plans generally do not participate in the Texas IRO process — they have their own appeal paths. If you're not sure what kind of plan you have, TDI can tell you.

Get help

The TDI Consumer Help Line is 800-252-3439. Your provider's office can also help file the appeal. Persistence and strong medical-necessity documentation are what win these.

This isn't legal advice, and Texas rules and deadlines can change — confirm the current process and timeframes with the Texas Department of Insurance, and the appeal path with your specific plan, before you act.