Insurance Denial
Insurance Denial Support
Sometimes we receive notice that your insurance company has denied coverage for a procedure that your physician has determined to be medically necessary. We understand this is frustrating, and we want to help you understand your rights and the options available to you under Texas law.
Your Right to Information About the Reviewer
Under Texas law, health insurers and their utilization review agents (URAs) may only have a denial of medical necessity issued or upheld by a licensed physician — not a claims administrator or non-clinical staff member. You have the right to call your insurance company and request written information about the person(s) who reviewed your chart and made or upheld the denial decision. When you call, we recommend asking for the following, and following up in writing if the representative cannot answer on the phone:
- The full name of each individual (physician, nurse, or other reviewer) who reviewed your chart or participated in the denial decision
- The name of the company that employs or contracts with each reviewer
- Each reviewer’s medical and/or nursing license number(s), and the state(s) that issued them
- Each reviewer’s field of practice / medical specialty
- Each reviewer’s board certification(s), if any
- Written confirmation that the physician reviewer holds a license to practice medicine in Texas
What Texas Law Requires
The following provisions of the Texas Insurance Code (Chapter 4201, “Utilization Review Agents”) support these requests:
- Tex. Ins. Code § 4201.206 – Before an adverse determination is issued questioning medical necessity, the health care provider must be given a reasonable opportunity to discuss the treatment plan with a physician licensed to practice medicine in Texas. If the treating provider is a physician, that discussion must be with a Texas-licensed physician of the same or a similar specialty.
- Tex. Ins. Code § 4201.252 (Personnel) – Utilization review personnel must be appropriately trained, qualified, and, where applicable, currently and appropriately licensed, certified, or registered.
- Tex. Ins. Code § 4201.303 – The written notice of an adverse determination must disclose the clinical basis for the denial and the specialty of the physician or other provider who made the decision.
- Tex. Ins. Code § 4201.356 – A first-level appeal of an adverse determination must be decided by a physician; if the appeal involves a specialty service, a provider of the same or similar specialty must be involved in the review.
- 28 Tex. Admin. Code § 19.1705 – A utilization review plan must be reviewed and approved by a physician licensed to practice medicine in Texas.
Texas Licensing Requirement
Texas law generally requires anyone practicing medicine on a patient located in Texas — including a physician conducting utilization review of a Texas patient’s care — to hold a license issued by the Texas Medical Board under the Medical Practice Act (Tex. Occ. Code Ch. 155). A physician who is not licensed in Texas (including one holding only an out-of-state license) is generally not authorized to make or uphold a medical necessity denial for a patient receiving care in Texas. You may ask your insurer to confirm, in writing, that the physician who reviewed your case holds an active, unrestricted Texas medical license.
If the Insurer Does Not Provide This Information
If your insurance company refuses to provide this information or you believe the reviewer was not properly licensed or qualified, you may file a complaint with the Texas Department of Insurance (TDI) below. You also have the right to appeal this denial, and if the internal appeal is unsuccessful, to request an independent review by an Independent Review Organization (IRO) through TDI, at no cost to you.
- Phone: 1-800-252-3439
- Online: www.tdi.texas.gov/consumer/complfrm.html
How We Can Help
Our office is glad to help you gather your records, submit a formal appeal, and communicate with your insurance company.
Please contact us if you would like assistance or have any questions.
This information is provided for general informational purposes and reflects a summary of Texas Insurance Code Chapter 4201 and related regulations as of 2026. It is not legal advice. Laws and regulations may change, and individual circumstances vary. Patients with questions about their specific legal rights should consult an attorney or contact the Texas Department of Insurance.