Independent Review Organizations from the Texas Department of Insurance

Independent Review Organizations

(June 2009)

If a health care plan refuses to pay for medical care because it considers it 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 health care plan is required to comply with the IRO’s decision and to pay for the review.

When an IRO Review Is Available

Independent review is available if

Texas law requires your health care plan to participatein the IRO process
your health care plan or its utilization review agent (URA) determines that a treatment recommended, but not yet performed, is medically unnecessary or inappropriate
your health care 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 developed and updated with the involvement of practicing physicians and other providers.

Your health care plan has an internal appeal process that you typically must use before requesting an IRO review. You can bypass the appeal process if you or your doctor believes your condition is life threatening. Call your health care plan 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 it doesn’t cover, such as cosmetic surgery
you received treatment before the health care 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, ERISA plans, Medicaid, Medicare, including Medicare HMO plans, and certain other health plans are not required to participate in the IRO process. Contact your health care plan to find out if it is required to participate in the IRO process.

If your health care 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 care or the denial of payment for care you already received. 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. However, only you or your legal guardian may sign a medical records release form allowing the IRO to access documents it needs for the review.

The first step in the IRO process is to complete and return the independent review request form to the health care plan or its URA who actually denied the services Your health care plan or its URA must provide the form to you when it denies a treatment because it regarded the treatment as medically unnecessary or inappropriate. Your health care plan or its URA must give you the form again if it denies your appeal.

You don’t have to go through the appeal process if you or your doctor believes your condition is life threatening.

If you believe your health care plan failed to inform you of your rights, call TDI’s Consumer Help Line

1-800-252-3439
463-6515 in Austin

The IRO Process Time Frame

Once the health care plan or URA receives your request form, it must immediately notify TDI of your request for an IRO review. TDI will assign your case to an IRO within one business day of receiving your request and will notify all parties of the IRO assignment.

The health care plan or URA must send the IRO any information and medical records it needs for the review. You may also submit information and medical records to the IRO. Do not send medical records to TDI. The IRO must receive the information within three business days of the review request. The IRO must reach a decision within 15 days of receiving the 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 of receiving the information but no later than eight days after the IRO receives its assignment.

For questions or more information about IRO’s, call TDI’s Health and Workers’ Compensation Networks Division at

1-866-554-4926
322-4266 in Austin

The IRO Decision

Your health care plan must comply with the IRO’s decision and 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 written certification stating that the physician or 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

Questions and Answers

Q. Are all health insurers and HMOs required to participate in the IRO process?
A. No. Call your health care plan to ask if it is required to participate in the IRO process. If it is not required to participate, you can file a complaint or appeal with the heath care plan about the denial of health care or payment.

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 ongoing or recommended health care is medically unnecessary or inappropriate.

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. 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, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website

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

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)

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