After a Texas insurance carrier or utilization review agent denies health care as not medically necessary, the patient, a representative or the provider can request review by an independent review organization (IRO) on this form. It is used for health plans and for workers' compensation. The denying company forwards the request to the Texas Department of Insurance, which assigns the IRO and sends a letter naming it.
The requestor completes it: the patient or injured employee, a representative, a provider acting on the patient's behalf, or the provider that received the denial. The denying company or URA completes its own section on page 4.
Download the current version from the source each time; forms change without notice.
Request for a Review by an Independent Review Organization (IRO)
Solicitud para una revisión por parte de una Organización de Revisión Independiente
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Send it to the insurance company or utilization review agent that denied the services, using the address or fax on the denial letter. Do not send it to the Texas Department of Insurance. The company forwards it to TDI, which assigns an IRO and notifies the requestor by letter.
Yes. A provider acting on the injured employee's behalf or the provider that received the denial can file. In non-network workers' compensation claims, a provider requesting retrospective review pays the IRO fee before the review begins and is reimbursed by the carrier if the IRO decides in the provider's favor.
Per the form, life-threatening cases take 8 days and non-life-threatening preauthorization or concurrent reviews take 20 days for both network and non-network workers' compensation. Retrospective reviews in workers' compensation take 30 days from receipt of the IRO fee.