Health insurance or Medicaid said no in Texas? Deadlines and free help

In Texas, your health plan is regulated by Texas Department of Insurance (TDI), if it is a state-regulated plan.

Texas uses the federal process for independent review of denials. You have 4 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Texas Medicaid

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (HealthCare.gov) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in Texas?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
4 months (federal rule) — The final internal appeal decision (see the national rule)
Hearing deadline
90 days — The effective date of the action or the date of the notice of adverse action, whichever is later.
Keeping your benefits during the appeal
If you already get benefits, they continue until the hearing decision if you ask for a fair hearing within 13 days of the adverse action notice (a mailed request postmarked within the 13 days counts).
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – HealthCare.gov
90 days (federal rule)

How long do I have? Deadline calculator

How do I know which plan type I have?

  • Texas Department of Insurance (TDI) · 1-800-252-3439 · Complaint form
    Fully insured health plans: insurance company policies and HMO plans, including plans you buy yourself (also through HealthCare.gov). TDI does not regulate self-funded employer plans, Medicare, Medicaid, CHIP plans that are not HMOs, military plans, city, county, state and federal employee plans, or teacher plans.

How to tell which agency regulates your plan

Check your health insurance card. If it has "TDI" or "DOI" on it, TDI regulates your plan. Most people with a plan through work have a self-funded plan; the card may say the plan is "administered by" an insurance company or HMO, or "ASO". The U.S. Department of Labor oversees those plans. If you are not sure, call TDI at 800-252-3439.

Step 1: Appeal to your plan in Texas

What it is called: Appeal of an adverse determination (HMOs also have a complaint and complaint appeal panel process)

Time to file

Texas law does not set a different time to file. Use the deadline on your denial notice; federal rules give at least 180 days for most plans.

How fast the plan must decide

Standard: 30 days; Urgent: 1 business day

You, someone acting for you, or your doctor can appeal by phone or in writing. The plan must send a letter acknowledging your appeal within 5 working days, and a physician must decide it. You get a written decision within 30 calendar days after the plan receives the appeal. Denials of emergency care, of continued hospital stays, of drugs or IV infusions you are already receiving, and of step-therapy exception requests get an expedited appeal, decided within 1 working day after the plan has all the information it needs. If your condition is life-threatening, or the plan stops drugs or IV infusions you are receiving, you can go straight to independent review without the internal appeal. Your doctor can also ask, within 10 working days, for review by a specialist in the same or a similar field.

Law: Tex. Ins. Code 4201.354-4201.360, 4201.3601; Tex. Ins. Code 843.252, 843.254, 843.258, 843.261

Step 2: Outside review in Texas

Program

External review (federal process); Independent Review Organization (IRO) review for some plans

Who runs it
  • Federal external review process (HHS-administered process or an independent review organization used by your plan, overseen by the U.S. Department of Labor or HHS): Most health plans in Texas, including fully insured plans. Ask your health plan for an external review.
  • Texas Department of Insurance, which assigns a TDI-certified Independent Review Organization (IRO): Workers' compensation and disease-specified plans (such as cancer plans)
Deadline to ask

Federal rule: at least 4 months.

Texas follows the federal external review process for most plans. Use the deadline in your plan's final denial letter.

The deadline runs from

The final internal appeal decision (see the national rule)

Do I have to appeal to my plan first?

In most cases you must finish your plan's internal appeal first. Under Texas law you can skip the internal appeal if your condition is life-threatening, or if the plan stops prescription drugs or IV infusions you are already receiving.

Cost

In TDI's IRO process, the plan or its utilization review agent pays the IRO fee. For the federal process, the national rule applies.

Federal rule: The HHS-administered federal process is free. A state program or a plan's contracted reviewer may charge a fee, but not more than $25.

Law: HealthCare.gov, External Review

What can be reviewed

Denials because the care is not medically necessary or appropriate, or is experimental or investigational. Plans do not have to send IRO review for services the plan does not cover at all.

Is the decision final?

The plan and its utilization review agent must follow the independent reviewer's decision. TDI cannot overturn an independent reviewer's decision.

How to ask

Follow the instructions in your plan's final denial letter. For TDI's IRO process, fill out and sign TDI form LHL009 (your plan sends it with the denial) and return it to the company that denied the care, not to TDI. The company sends your request to TDI within 1 working day, TDI assigns an IRO and mails you a letter naming it, and you can fax or mail extra records to that IRO.

Law: Tex. Ins. Code 4201.401-4201.403, 4202.003

Forms and online request
Phone

TDI Help Line 1-800-252-3439; TDI IRO questions 1-866-554-4926

HHS-Administered Federal External Review Process (MAXIMUS)

Only for plans that use the HHS-administered process. Ask your plan, or check your denial notice, to find out.

maximusferp.my.site.com · 1-888-866-6205 · MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534

Urgent care in Texas: faster decisions

Appeal to your plan

  • Your plan must decide an urgent appeal within 1 business day.

Outside review

Texas law lets you ask for independent review right after the first denial if your condition is life-threatening. In TDI's IRO process, the IRO must decide within 3 days for a life-threatening condition, for drugs or IV infusions you are receiving, or for a step-therapy exception request, and within 20 days in other cases.

Law: Tex. Ins. Code 4201.401-4201.403, 4202.003

Medicaid

You, your representative or your provider can ask for an expedited hearing if waiting could seriously jeopardize your life, physical or mental health, or ability to attain, maintain or regain maximum function. If granted, the decision is due within 5 working days after the hearings officer gets the request (Medicaid), or within 3 working days after the hearings officer gets the agency's evidence (managed care), if you agree to shorter notice and no more information is needed.

Law: 1 Tex. Admin. Code 357.3, 357.7, 357.17; HHSC Fair and Fraud Hearings Handbook 1420, 1522

Complaints about your plan in Texas

If your plan has "TDI" or "DOI" on the card, you can file a complaint with TDI online, and upload up to 24 pages of documents. TDI cannot decide whether a treatment is medically necessary and cannot make a company pay a claim if the company did not break the law. For a self-funded plan, follow your plan's complaint steps and contact the U.S. Department of Labor.

gov.sircon.com

Medicaid (Texas Medicaid (STAR, STAR+PLUS, STAR Kids, STAR Health)) denials in Texas

Who holds the hearing: HHSC Appeals Division, Fair and Fraud Hearings.

Hearing deadline: 90 days

All the details →

Marketplace decisions in Texas

Texas uses HealthCare.gov. Appeals go to the federal Marketplace Appeals Center.

HealthCare.gov

1-855-231-1751

Other rights in Texas

No AI denials

Since September 1, 2025, a utilization review agent may not use an automated decision system, including artificial intelligence, to make all or part of a decision to deny care as not medically necessary.

Law: Tex. Ins. Code 4201.156 (S.B. 815, 2025)

How fast a plan must decide a prior approval

An HMO or PPO insurer must decide a preauthorization request within 3 calendar days after receiving it. Notice of a denial must go out within 1 working day if you are in the hospital, and within 1 hour for care after emergency treatment. Notice of a denial to stop drugs or IV infusions you are receiving must come at least 30 days before they stop.

Law: Tex. Ins. Code 843.348(d), 1301.135, 4201.304

Step-therapy exception

Plans must have a process to ask for an exception to a step-therapy drug rule. A denial of an exception request gets an expedited appeal, and an IRO must decide it within 3 days.

Law: Tex. Ins. Code 1369.0546, 4201.357(a-2), 4202.003

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in Texas and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in Texas

Good to know in Texas

  • Texas law lets you skip the plan's internal appeal and go straight to independent review if your condition is life-threatening or the plan stops drugs or IV infusions you are receiving.

    Law: Tex. Ins. Code 4201.360, 4201.3601

  • Texas Medicaid members in a health plan can ask for an External Medical Review by an independent reviewer after the plan's appeal and before the State Fair Hearing.

    Law: Tex. Gov. Code 532.0404

  • In Texas the Medicaid fair hearing deadline is 90 days from the effective date of the action or the notice date, whichever is later, and 120 days after a health plan's final appeal decision.

Changes in 2024–2026

September 1, 2025: S.B. 815 bars utilization review agents from using automated decision systems, including AI, to make adverse determinations. April 1, 2025: Medicaid managed care provisions of Gov. Code ch. 533 were recodified into Gov. Code chs. 532 and 540. From 2026, federal rules require Medicaid managed care plans to decide standard prior approval requests within 7 calendar days.

Law: Tex. Ins. Code 4201.156; 42 CFR 438.210(d)

Questions about appeals in Texas

How long do I have to appeal a health insurance denial in Texas?

Texas law does not set a different time to file. Use the deadline on your denial notice; federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in Texas?

Follow the instructions in your plan's final denial letter. For TDI's IRO process, fill out and sign TDI form LHL009 (your plan sends it with the denial) and return it to the company that denied the care, not to TDI. The company sends your request to TDI within 1 working day, TDI assigns an IRO and mails you a letter naming it, and you can fax or mail extra records to that IRO.

Is outside review free in Texas?

In TDI's IRO process, the plan or its utilization review agent pays the IRO fee. For the federal process, the national rule applies.

How long do I have to ask for a Medicaid fair hearing in Texas?

90 days. The effective date of the action or the date of the notice of adverse action, whichever is later

Can I keep my Medicaid benefits while I appeal in Texas?

If you already get benefits, they continue until the hearing decision if you ask for a fair hearing within 13 days of the adverse action notice (a mailed request postmarked within the 13 days counts). This is the rule in the Texas Works Handbook, which covers Medicaid for children, families and pregnant women.

Who regulates health insurance in Texas?

Texas Department of Insurance (TDI). Check your health insurance card. If it has "TDI" or "DOI" on it, TDI regulates your plan.

Not about a denied claim?

Nearby states

Sources

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