State guide
Texas
Pick the kind of plan you have to see who to call first. Texas can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Texas usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Texas Department of Insurance (TDI). See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Texas.
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Medicare
Texas Health Information, Counseling and Advocacy Program (HICAP) gives free counseling. Or call 1-800-MEDICARE.
The short version for Texas
The Texas Department of Insurance (TDI) says only about 20% of Texans are in the fully insured plans it regulates; if your card shows "TDI" or "DOI", state protections apply. Texas is one of five states where external review of an ordinary health plan denial runs under the federal process instead of a state one, so you ask your health plan (or the federal contractor) for it, and it is free. Texas has strong laws on surprise bills and prior authorization, and since 2025 bars automated systems from making denials, but it publishes no searchable database of health external review decisions and no overturn statistics.
At a glance: independent review for plans Texas regulates
- Main regulator
- Texas Department of Insurance (TDI) · 800-252-3439
- Independent review
- The federal process run for the Department of Health and Human Services (External review (federal process). Texas also has a state-assigned Independent Review Organization (IRO) review, but TDI says that is for workers' compensation and disease-specific plans such as cancer plans)
- Deadline to request it
- 4 months after the date you receive the final denial from your insurer (federal rule stated on HealthCare.gov; the TDI page gives no deadline)
- Cost
- None. TDI says external reviews are free to you, and HealthCare.gov says there is no charge in the HHS-administered process.
- Decision time
- No later than 45 days after the request is received; fast track: No later than 72 hours after the request is received, sooner if medically urgent
Who regulates health plans
Look at your insurance card. If it has "TDI" (Texas Department of Insurance) or "DOI" (department of insurance) printed on it, the state regulates your plan. If the card says the plan is "administered by" an insurance company, or shows "ASO" (administrative services only), it is probably a self-funded employer plan overseen by the U.S. Department of Labor. Not sure? Call the TDI Help Line at 800-252-3439.
- Texas Department of Insurance (TDI)
Fully insured health plans: plans from an insurance company or health maintenance organization (HMO) that you bought yourself, through HealthCare.gov, or through an employer that buys insurance. Also Medicare supplement, long-term care, disability, short-term and limited benefit policies. It does not regulate self-funded employer plans, Medicare, Medicaid, military plans, or city, county, state, federal employee and teacher plans.
Phone: 800-252-3439. File a complaint online
Independent (external) review
- Process
- The federal process run for the Department of Health and Human Services. Run by Overseen by the U.S. Department of Health and Human Services (HHS). Each insurer either uses the HHS-administered process, run by the contractor MAXIMUS Federal Services, or hires its own accredited independent review organizations.
- Where you file
- insurer
- How
- Your final denial letter says who handles your external review; TDI says to ask your health plan for it. If your plan uses the HHS-administered process, you can file directly with MAXIMUS Federal Services online, or call 1-888-866-6205 to get a request form and then fax, mail or email it. If you get stuck and your card shows "TDI" or "DOI", call the TDI Help Line at 800-252-3439.
- Which denials qualify
- Denials that involve medical judgment (for example "not medically necessary"), denials that call a treatment experimental or investigational, and cancellation of coverage based on a claim that you gave false or incomplete information. A service your plan simply does not cover is not eligible.
- Appeal to the plan first?
- Usually yes: appeal to the insurer first. TDI says you can ask for an external review if you aren't happy with your appeal or were denied care for a life-threatening condition.
Free help in Texas
- Texas Department of Insurance Help Line
Answers questions, explains appeal options and takes complaints for fully insured plans (cards showing "TDI" or "DOI"); the federal Consumer Assistance Program directory lists it as the Texas resource. It cannot decide whether a treatment is medically necessary.
Phone: 800-252-3439
- Texas Health and Human Services Office of the Ombudsman, Managed Care Help
Helps people who get Medicaid through a health plan understand their coverage and rights and resolve problems getting care.
Phone: 866-566-8989
- TexasLawHelp
Free legal information and a way to find legal aid for low-income Texans; TDI lists it on its "Getting legal help" page as a next step when an insurance dispute is not resolved.
Medicare and Medicaid in Texas
- Medicare counseling
- Texas Health Information, Counseling and Advocacy Program (HICAP) · 800-252-9240 . Free help with Medicare appeals.
- Medicaid agency
- Texas Health and Human Services Commission (Texas Medicaid)
- Fair hearing deadline
- 90 days from the date of the case action or the effective date on your Notice of Case Action; 120 days for actions taken by a Medicaid managed care organization (health plan), counted from the plan's final decision. Your notice states the deadline that applies to you.
- Good to know
- You can ask in writing, by calling 2-1-1, or at a local Health and Human Services office. Late requests are reviewed for good cause. For a denial by a Medicaid health plan, the 120 days run from the plan's final decision, so use the plan's own appeal first. Hearings are usually held by conference call.
State laws that can help
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AI in utilization review. A 2025 law restricts the use of automated systems, including artificial intelligence, in making adverse determinations (denials) on health claims; the Texas Medical Association describes it as requiring a qualified human reviewer to make any decision that care is not medically necessary or is experimental, and it lets the Texas Department of Insurance audit how plans use these systems.
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Gold card. Doctors whose prior authorization requests for a service are approved at least 90% of the time can earn an exemption from prior authorization for that service in state-regulated plans, so their patients skip that step.
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Step therapy. When a state-regulated plan requires you to try a cheaper drug first, your doctor can ask for an exception; a denied exception can go to an independent reviewer on a fast track.
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Surprise billing. State and federal laws ban surprise bills in emergencies, for air ambulance services, for care you receive in an in-network hospital, and for labs and imaging ordered by an in-network doctor; Texas law also bans surprise ground ambulance bills for plans whose cards show "TDI" or "DOI" and for state employee and teacher plans.
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Mental health parity. State-regulated plans that cover mental health and substance use conditions must give the same level of benefits as for physical illness, and the Texas Department of Insurance takes parity complaints.
Sources and what we could not confirm
- CMS: State External Appeals Review Processes (table updated July 9, 2024)
- TDI: How to file an appeal or ask for an external review
- TDI: Request for review by an IRO
- TDI: Independent Review Organization FAQ
- HealthCare.gov: External Review
- TDI: Who can help me with my health plan?
- TDI: Health plan ID card examples showing TDI or DOI
- TDI: How to file a health insurance complaint
- TDI: Getting legal help
- TDI: HMO guide
- CMS: Texas Consumer Assistance
- Texas Health and Human Services: Fair and Fraud Hearings
- Texas Health and Human Services: Fair Hearings handbook section 1420, Period for Requesting a Fair Hearing
- Texas Health and Human Services: Ombudsman Managed Care Help
- Texas Health and Human Services: Medicare (Health Information, Counseling and Advocacy Program)
- SHIP National Technical Assistance Center: Texas
- Texas Medical Association: 2025 legislative wrap-up on technology laws (Senate Bill 815)
- Texas Legislature Online: Senate Bill 1264 (2019)
- TDI: How to get help with a mental health issue
Not confirmed (8)
- Which independent review process applies. resolved as federal from two sources (the federal list puts Texas in the HHS-administered / independent review organization column, and TDI's 'Request for review by an IRO' page, updated 3/27/2025, limits state-assigned review to workers' compensation and disease-specific plans). But TDI's Independent Review Organization FAQ and HMO guide still describe a state-assigned review for health denials (form LHL009 sent to the insurer, 3-day and 20-day decisions, insurer pays). Those pages were not reconciled by TDI; treat the state process as not applying to ordinary fully insured plans unless the denial letter offers it.
- Where to file for independent review. depends on the insurer's choice between the HHS-administered process and its own contracted reviewers; the final denial letter controls.
- Not confirmed. externalReview.deadline, standardDecisionTime, expeditedDecisionTime, eligibleDenials — taken from HealthCare.gov's description of the federal standards, not from a Texas page.
- The cost of independent review. HealthCare.gov says an insurer that contracts with its own independent review organization may charge up to $25; TDI's consumer page says external reviews are free. Not confirmed which applies for every Texas insurer.
- Whether you must appeal to the plan first. exact federal exceptions (for example urgent cases filed at the same time as the internal appeal) were not confirmed on a Texas page.
- Not confirmed. stateLaws (step-therapy) — bill caption and effective date confirmed on the legislature's site; the exception details (response times) were not confirmed on an official page.
- Not confirmed. stateLaws (ai-in-utilization-review) — bill caption and effective date confirmed on the legislature's site; the plain description relies on the Texas Medical Association summary, not the bill text.
- Notes on Medicaid appeals. the rule for keeping benefits during an appeal was not confirmed on an official state page.