Texas runs two review systems — and your denial probably uses the federal one

Open now, and a deadline extension runs to October 2, 2026

The federal process was unavailable for part of this summer. CMS closed the HHS-administered Federal External Review Process between July 1 and August 3, 2026 and reopened it on July 31, 2026, and it has extended the filing deadline for people the closure shut out.

• If you could not request external review between July 1, 2026 and August 3, 2026, you may be eligible — and if you are, you have until October 2, 2026 to request it.
• The extension also reaches any state: it covers a self-insured non-Federal governmental health plan that uses the federal process, wherever the plan is.
• If you submitted a request before July 1, 2026, you do not need to resubmit or send anything further now.
• If you already received a final decision through the federal process, the extension does not apply to you.

Two review systems, and the one your denial probably uses

Texas has a mature IRO apparatus that most Texans with commercial coverage never touch. Tex. Ins. Code ch. 4202 is the oldest independent-review statute in the country, but the state process was not deemed to meet the federal minimum standards, so CCIIO groups Texas with Alabama, Florida, Georgia and Wisconsin: a non-grandfathered issuer must offer either the HHS-administered Federal External Review Process, run by the contractor MAXIMUS Federal Services, or the alternative route of contracting with accredited independent review organizations.

TDI narrowed the state door itself. Its IRO request page, last updated 03/27/2025, routes form LHL009 to workers' compensation and to disease-specified policies such as cancer plans, and tells other health-plan members to ask their plan for an external review. TDI's consumer guidance says the same thing in the other direction: for most Texas plans, external review is overseen by the U.S. Department of Labor or HHS.

• ACA or other fully insured commercial plan: the federal lane, per the instructions printed on the final internal denial.
• Workers' compensation and disease-specified policies (for example a cancer policy): the TDI LHL009 IRO lane.
• A physician disputing a denied or rescinded preauthorization exemption: the TDI IRO lane, under Tex. Ins. Code 4201.656.

The four-month clock — and the 45-day rule that is not yours

For a fully insured commercial plan the operative deadline is federal: the request must be filed within four months after the date you receive the notice of adverse benefit determination or final internal adverse benefit determination. Texas law adds nothing to that. 28 TAC 19.1717, the state's independent-review rule, sets deadlines only on the carrier side, so there is no Texas day count for an enrollee or a provider to work against in a health case.

The 45-day figure that circulates in Texas appeal advice comes from 28 TAC 133.308(h), which is workers' compensation: the requestor files with the carrier or its utilization review agent no later than the 45th calendar day after receiving the denial of an appeal. Applying it to a commercial health-plan appeal would cost months of window that the federal rule actually gives you.

One timing item is live right now. The HHS-administered process was unavailable beginning 07/01/2026 and reopened as of 07/31/2026. CCIIO gives anyone who could not file between 07/01/2026 and 08/03/2026 until 10/02/2026 to request external review.

How to file

1. 1

   Confirm the lane on the denial notice

   For a commercial plan, the final internal denial names the external-review route the issuer elected. Do not send a commercial health-plan request to TDI.

2. 2

   Federal lane: file with MAXIMUS

   If the issuer uses the HHS-administered process, submit through the CMS portal at externalappeal.cms.gov/ferpportal (CMS encourages the portal over mail, fax or email). Consumer line 1-888-866-6205; issuers reach the contractor at [email protected].

3. 3

   Federal lane: the issuer sends the file

   The issuer must transmit its file to MAXIMUS within five business days. Send the clinical record supporting medical necessity with your request rather than assuming the plan's file is complete.

4. 4

   State lane: complete TDI form LHL009

   For workers' compensation, a disease-specified policy, or a gold-card exemption dispute, use the Request for a Review by an Independent Review Organization and send it to the URA or carrier that issued the denial, not to TDI. In health cases the carrier or URA must supply the LHL009 with the denial.

5. 5

   State lane: the carrier files it with TDI

   The URA, HMO, network or carrier files the request through TDI's online IRO system within one working day. Medical records go to the assigned IRO, never to TDI. TDI Managed Care Quality Assurance: 866-554-4926, [email protected].

Who assigns the reviewer, and how fast it moves

In the Texas state lane the carrier does not pick the reviewer, and this is written into statute rather than left to practice. Tex. Ins. Code 4202.012 directs the commissioner to require referral of adverse determinations to IROs by random assignment, and 28 TAC 19.1717(c)(1) executes it: within one working day of a complete request, TDI randomly assigns a certified IRO and notifies the URA, the payor, the IRO, the enrollee or representative, the provider of record and any other provider holding relevant records. Chapter 4202 also walls off the reviewers structurally — no two IROs sharing an office, no common ownership, no overlapping officers or directors, and Texas incorporation and domicile required.

In the federal FERP lane the assignment and the review both sit with the HHS contractor. The place carrier influence enters is the alternative federal route, where an issuer that elected to contract with accredited IROs is the party holding those contracts.

• Federal standard review: a written decision as expeditiously as the case allows and no later than 45 days after the examiner receives the request; the decision is final and binding on both sides, subject to other legal remedies.
• Federal expedited review: as fast as the medical circumstances require and within 72 hours, which may be given orally but must be confirmed in writing within 48 hours.
• Texas IRO, health column: 3 days when life-threatening, 3 days for a denied prescription drug or IV infusion on concurrent review, 3 days for a denied step-therapy exception, 20 days for non-life-threatening preauthorization or concurrent review, 20 days retrospective.
• Texas IRO, gold cards: 30 days from the request for a denied or rescinded preauthorization exemption.
• Texas process clocks: carrier or URA notifies TDI within one working day, TDI assigns within one working day, and the carrier or URA sends records within three working days of the assignment notice.

What the review costs, and who actually pays

Texas is unusual in publishing the reviewer's price. TDI's IRO FAQ sets a Tier 1 review, meaning one conducted by a doctor of medicine or osteopathy, at $650, and a Tier 2 review by any other health care provider at $460. Neither lands on the patient or the practice in a health case: 28 TAC 19.1717(c)(3) puts payment on the utilization review agent and lets it recover from the payor, and Tex. Ins. Code 4201.403 puts it on the URA as well.

• Federal HHS-administered process: no cost to the plan, the consumer, or the consumer's authorized representative.
• Texas health IRO: Tier 1 $650 (MD or DO reviewer), Tier 2 $460 (all other providers), borne by the carrier or its URA.
• Gold-card exemption dispute: Tex. Ins. Code 4201.656(b) makes the HMO or insurer pay for the review, plus a reasonable records-copying fee set by the Texas Medical Board.
• The one place the requester fronts the fee is outside health insurance — workers' compensation non-network retrospective medical-necessity review, and not when the requester is the injured employee.

Gold-carding: the law Texas wrote first

HB 3459 (2021, 87th Leg., ch. 1018), codified at Tex. Ins. Code ch. 4201 subchapter N and effective 09/01/2021, was the first physician preauthorization-exemption law in the United States. Under sec. 4201.653, a plan may not require preauthorization for a particular service from a physician or provider who, over the most recent one-year evaluation period, was approved (or would have been approved) on at least 90 percent of requests for that service and furnished it at least five times. The provider does not have to apply, and the plan may evaluate at most once a year.

The enforcement is in sec. 4201.656, and it is unusually direct: a physician whose exemption is denied or rescinded has a right to IRO review, the plan may not require an internal appeal first, and the plan pays for the review. TDI's published timeframe for that decision is 30 days from the request.

HB 3812 (2025, 89th Leg., ch. 640, effective 09/01/2025) closed the obvious loophole and added a paper trail. New sec. 4201.653(a-1) requires the evaluation to count every preauthorization request from that provider across the insurer's and its affiliates' books, regardless of which plan it came from, so a carrier cannot split a physician's volume across products to keep the approval rate under 90 percent. New sec. 4201.660 requires carriers to report annually to TDI on exemptions granted, denied and rescinded and on the number and outcome of gold-card IRO reviews, expressly public under the Texas Public Information Act.

• Step therapy: Tex. Ins. Code 4201.357 provides an expedited appeal when an exception to a step-therapy protocol is denied, and sec. 4201.357(b) caps resolution of that expedited appeal at one working day from receipt.
• TDI's published IRO timeframe for a denied step-therapy exception on preauthorization is 3 days.
• A gold-card dispute is the one Texas health matter that goes to a state IRO with no internal appeal in front of it.

The conversation Texas owes you before the denial

Texas puts an obligation on the reviewer before the adverse determination issues at all. Under Tex. Ins. Code 4201.206, a utilization review agent must give the provider who ordered or is to provide the service a reasonable opportunity to discuss the patient's treatment plan and the clinical basis for the determination with a physician licensed to practice in Texas — before issuing an adverse determination that questions medical necessity, appropriateness, or experimental or investigational status.

On appeal, Tex. Ins. Code 4201.153 requires the review to be conducted by a health care provider who has not previously reviewed the case and who is of the same or a similar specialty as the provider who would typically manage that condition, procedure or treatment. And where the treating provider requests a particular type of specialty reviewer no later than the tenth working day after the appeal is requested or denied, a provider of that same or similar specialty is to review it.

• Missed pre-denial discussion is a procedural point you can raise on its own.
• The tenth-working-day request is a hard date — calendar it when the appeal goes out.
• The appeal reviewer must be new to the case, not the same person a second time.