Independent Review Organizations

(May 2007)

If a health insurer or health maintenance organization (HMO) refuses to pay for a treatment because it considers the treatment medically unnecessary or inappropriate, you may be able to have an Independent Review Organization (IRO) review the decision.
IROs are independent third parties certified by the Texas Department of Insurance (TDI) to review the medical necessity and appropriateness of health care services provided or proposed to patients. The IRO’s decision is binding on the health care plan, which pays for the review.

When an IRO Review Is Available

Independent review is available if

• Texas law requires your health care plan to participate, or the plan voluntarily participates, in the IRO process
• your plan or its utilization review agent (URA) determines that a treatment recommended, but not yet performed, is medically unnecessary or inappropriate
• your plan or its URA determines that an ongoing treatment is medically unnecessary or inappropriate.

A health care plan must base its denial on written screening criteria established and updated with involvement by practicing physicians and other providers.

In most cases, you must use the health care plan’s internal appeal process before requesting an IRO review. You can bypass the appeal process, if you or your doctor believes your condition is life threatening. Call your insurer or HMO to learn about its appeal process.

When an IRO Review Is Not Available

Independent review is not available if

• your health care plan refuses to pay for a service the plan doesn’t cover, such as cosmetic surgery
• you received treatment before the plan determined that the treatment was not medically necessary or appropriate. This is considered a retrospective review of medical necessity.
• your health care plan is not required by law to participate in the IRO process. For example, Medicaid and Medicare, including Medicare HMO plans, and certain other health plans are not required to participate in the IRO process. Contact your health plan to find out if it is required to participate in the IRO process.

If your plan isn’t required to participate in the IRO process, you, your doctor, or another provider may file a complaint or appeal about the denial of health care or the denial of payment for health care already performed. Ask your health care plan or employer about its complaint or appeal process.

How to Obtain an Independent Review

You, your representative, or your provider may request an independent review. Only you or your legal guardian, however, may sign a medical records release form allowing the IRO to access documents relevant to the review.

The first step is to secure an appeal and independent review request form from your health care plan. Your plan must provide the form if it is required to participate in the IRO process and it denied a treatment because it regarded the treatment as medically unnecessary or inappropriate. You can bypass the appeal process if you or your doctor believes your condition is life threatening.

Note: Your health care plan or its URA must give you the independent review request form again after denying an appeal.
If you want an independent review, complete the form and return it to the health plan or URA. Contact the Texas Department of Insurance (TDI) if you believe your insurer or HMO failed to inform you of your rights.

Consumer Help Line
1-800-252-3439
463-6515 in Austin

The IRO Process Time Frame

The health plan or URA must immediately notify TDI of your request for an IRO review. TDI will assign your case to an IRO within one business day after receiving your request and notify all parties of the IRO assignment. TDI makes IRO assignments between 7 a.m. and 6 p.m., Central time, Monday through Friday, except holidays.

The health plan or URA must send the IRO the information and medical records needed for its review. The IRO must receive the information within three business days from the date of the review request. The IRO must reach a decision within 15 days after receiving the necessary information but no later than 20 days after the IRO receives its assignment. In cases involving life-threatening conditions, the IRO must reach a decision within five days after receiving the necessary information but no later than eight days after the IRO receives its assignment.

IRO Information Line
1-888-TDI-2IRO (834-2476)
322-3400 in Austin

The IRO Decision

Your insurer or HMO must pay for treatments the IRO decides are medically necessary or appropriate. The IRO will provide you with a notice of its decision that includes:

• the clinical basis for the decision
• the screening criteria used to make the decision
• a list of qualifications of the IRO staff who reviewed your case
• a statement certifying that the provider reviewing the case doesn’t have a conflict of interest with the treating provider or any of the providers who previously reviewed the case
• a certification by the IRO that the reviewing physician or provider has certified that no known conflicts of interest exist between the provider and any of the treating physicians or providers or any of the physicians or providers who reviewed the case for determination prior to referral.

Questions and Answers

Q. Are all health insurers and HMOs required to participate in the IRO process?
A. No. Call your plan to ask if it participates in the IRO process.

Q. How soon must I request an IRO review after my health plan denies me treatment?
A. There is no time limit to request an IRO review for treatment denials; however, you should try to request the review as soon as possible.

Q. May I request an IRO review for all treatment denials by my health plan?
A. No. The IRO process applies only when your health plan or URA decides that the health care your doctor recommends – but you haven’t received or are currently receiving – is medically unnecessary or inappropriate.

Q. What if I have an emergency? Do I have to wait for a treatment coverage decision from an IRO?
A. No. If you need emergency care, seek treatment immediately. The IRO process does not affect your right to seek emergency care.

Q. What if my insurer or HMO tells me that the IRO process is not available to me because my health plan does not cover the services in question?
A. You may file a complaint or an appeal with the insurer or HMO. If you are still not satisfied with your insurer’s or HMO’s decision, you may file a complaint with TDI.

Q. Can I sue the insurance company or HMO that refuses to pay for treatment?
A. If your HMO or insurer is subject to state law, you may be able to file a medical malpractice suit against your HMO or insurer, as well as your physician. If you file notice to your HMO or insurer of the intent to file a lawsuit, your HMO or insurer may request an IRO review within 14 days of receiving notice of a potential suit regarding treatment denial. If the HMO or insurer chooses to request an IRO review, it is legally required to comply with all state IRO requirements. You should contact your attorney for additional information or advice about suits against HMOs and insurers.

Q. Do IRO’s have to maintain the confidentiality of data?
A. Yes, in conjunction with the independent review process, the IRO must preserve the confidentiality of individual medical records, personnel information, and any proprietary information provided by payors. Personal information includes your name, address, telephone number, social security number, and financial information.

For More Information or Assistance

For answers to general insurance questions or for information on filing an insurance-related complaint, visit our website or call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday

www.tdi.state.tx.us
1-800-252-3439
463-6515 in Austin

For printed copies of consumer publications, call the 24-hour Publications Order Line

1-800-599-SHOP (7467)
305-7211 in Austin

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1-888-327-8818

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1-877-4FIRE45 (434-7345)

The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.

For more information contact: ConsumerProtection@tdi.state.tx.us