INDEPENDENT REVIEW ORGANIZATIONS(IRO)

• Listing of Independent Review Organizations

Application and Attachments

• Application Form including list of exhibits to application (.pdf format)
• Biographical affidavit (.pdf format)
• Addendum to biographical affidavit (.pdf format)
• Holders of Bond Form (.pdf format)
• Certification of Independence Affidavit (.pdf format)
• Certification of Compliance Form (.pdf format)
• Agent for Process Form (.pdf format)
• Contractual Relationships Form (.pdf format)
• Renewal Form (.pdf format)

Applicable Law & Rules

• Texas Insurance Code art. 21.58C
• 28 TAC Chapter 12

Independent Review Organization (IRO) Decision Templates

   Health Care (HC) Decision Templates - HC

 

1. IRO Decision Report Template - HC  (PDF)  (Word)
2. IRO Decision Instruction Template - HC  (PDF)  (Word)

 Non-Network Workers' Compensation Decision Templates - WC

 

1. IRO Decision Report Template - WC  (PDF)  (Word)  
2. IRO Decision Instruction Template - WC  (PDF)  (Word)