Texas General Lines — Life, Accident, Health and HMOTexas Statutes and Rules Specific to Accident, Health and HMOMedium
A Texas HMO enrollee has received an adverse determination from their HMO regarding a denied medical service. They have completed the internal grievance process and wish to pursue an external review. Under Texas regulations, who is responsible for selecting the independent review organization (IRO) for this external review?
- AThe HMO, from a list approved by the TDI.
- BThe enrollee's primary care physician.
- CThe enrollee, from a list provided by the HMO.
- DThe Texas Department of Insurance (TDI).
Show answer & explanationAnswer & explanation
Correct answer: D. The Texas Department of Insurance (TDI).
In Texas, for an external review of an HMO adverse determination, the Texas Department of Insurance (TDI) is responsible for assigning an independent review organization (IRO) from its list of approved IROs. This ensures impartiality in the review process.
Why the other options are wrong
- A. This is incorrect; the HMO does not select the IRO to ensure impartiality.
- B. This is incorrect; the enrollee's physician is not involved in IRO selection.
- C. This is incorrect; the enrollee does not select the IRO in Texas.
HMO External Review IRO Selection (TX)
For external reviews of adverse determinations by an HMO in Texas, the Texas Department of Insurance (TDI) is responsible for selecting and assigning an independent review organization (IRO) to conduct the review.
- Applies to HMO adverse determinations.
- Follows completion of internal grievance process.
- TDI selects the IRO.
- Ensures impartiality of the external review.
Memory trick: When an HMO says 'no,' the TDI steps in to pick an 'independent' referee.