How to appeal a weight loss treatment denial in Texas

A denial is a step in a process, not the end of one. In Texas the route runs in a fixed order: an appeal to the plan first, then an independent review once the plan has given its final answer. This page sets out that order and who hears each stage.

By the Covered Weight editorial team · Updated Aug 6, 2026. Research and sourcing by Evan Reid.

Start here: what was denied?

A medication

72 hours

for the plan to decide a formulary exception, or 24 hours when the circumstances are exigent. This is a different and much shorter clock than the grievance rule below.

The drug clock, with its sources

A procedure, or care already given

30 days

for the plan to answer its own appeal. The independent review opens after that answer, on its own clock.

Every deadline, with what each one runs from

Both figures come from Texas's own governing sections. Your notice states the limit for your case, and it is the document that decides it.

One check first: which kind of plan you have. No state rule reaches a self-funded employer plan, which is most job-based coverage, and a deadline taken from this page would be the wrong one.

The order the steps run in

Step one
Read the notice, not a summary of it
The notice you received is the document that governs your case. It names the reason for the denial, the deadline for challenging it, and where to send the challenge. Every later step depends on those three things, and no general page can replace them.
Step two
Appeal to the plan
The first challenge goes to the plan that issued the denial. It is a request for the plan to look again, and it is the step that has to be finished before anyone independent will look at the case.
Step three
Ask for an independent review
Texas does not run its own external review program. Consumers here use the Federal External Review Process, administered by the U.S. Department of Health and Human Services.
A request goes to the Federal External Review Process rather than to a state office, which is why instructions written for a neighbouring state will send you to the wrong place.

The clock

Every limit below was read from Texas's own governing sections, and the middle column is the one to check against your notice: two states with the same number and a different starting event do not have the same deadline.

Appeal deadlines, with what each clock runs from and the section it was read from
Step	How long	The clock starts	Read from
Ask the plan to look againThe internal appeal. This is the step that has to finish first.	180 calendar days What this limit depends on Texas Chapter 4201 requires the appeal procedures to be reasonable rather than setting a filing window, so this is the federal floor for the plans the federal claims rules reach. Your notice states the limit your plan applies. What Texas does set is an acknowledgment duty: the agent must write back within five working days listing the procedures and the documents you have to send. For a denied medication specifically, Texas requires a separate expedited appeal route on top of the written one, and the statute says who has to conduct it: someone who has not seen your case before, practising in the same or a similar specialty.	receipt of a notification of an adverse benefit determination	29 C.F.R. § 2560.503-1(h)(3)(i) 29 C.F.R. § 2560.503-1(h)(3)(i), at least 180 days to appeal an adverse benefit determination Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (h)(3)(i) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination Paragraph (h)(3)(i), read from the eCFR section page. This is the federal floor for the internal appeal, cited because California's own Act sets no filing deadline; it reaches the plans the federal claims rules apply to and not every plan. Texas Insurance Code § 4201.355(a), acknowledgment of the appeal within five working days INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.355. ACKNOWLEDGMENT OF APPEAL, subsection (a) Texas Legislature · Source document · Read Aug 6, 2026 within five working days from the date the utilization review agent receives the appeal, the agent shall send to the appealing party a letter acknowledging the date of receipt From subsection (a). The same section requires the letter to list the procedures and the documents the appealing party must submit, and requires a one-page appeal form to be sent when an appeal arrives orally. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.357(a-1), expedited appeal for a prescription drug denial INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS, subsection (a-1) Texas Legislature · Source document · Read Aug 6, 2026 a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy From subsection (a-1), which adds this route on top of the written appeal and the (a) expedited route. The reviewer must not have seen the case before and must be of the same or a similar specialty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
The plan's answer, treatment not yet receivedA pre-service denial: the care has not happened yet.	30 calendar days What this limit depends on Texas says CALENDAR day explicitly, and puts “as soon as practicable” in front of the 30 days, so the number is an outer limit on a faster duty rather than a target. For a denied medication specifically, Texas requires a separate expedited appeal route on top of the written one, and the statute says who has to conduct it: someone who has not seen your case before, practising in the same or a similar specialty.	the date the utilization review agent receives the appeal	Tex. Ins. Code § 4201.359(a) Texas Insurance Code § 4201.359(a), internal appeal decided by the 30th calendar day INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.359. NOTICE OF APPEAL, subsection (a) Texas Legislature · Source document · Read Aug 6, 2026 as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal From subsection (a); the opening "The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal" was trimmed for the 200-character limit. Note the statute says CALENDAR day explicitly, and that "as soon as practicable" sits in front of the 30 days, so the number is an outer limit on a faster duty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.357(a-1), expedited appeal for a prescription drug denial INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS, subsection (a-1) Texas Legislature · Source document · Read Aug 6, 2026 a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy From subsection (a-1), which adds this route on top of the written appeal and the (a) expedited route. The reviewer must not have seen the case before and must be of the same or a similar specialty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
The plan's answer, treatment already receivedA post-service denial: a bill is already in play.	30 calendar days What this limit depends on One rule covers both in Texas, so a denial you are already being billed for runs on the same clock as one for care you have not had. That is stricter than the federal floor, which allows 60 days for a post-service appeal. For a denied medication specifically, Texas requires a separate expedited appeal route on top of the written one, and the statute says who has to conduct it: someone who has not seen your case before, practising in the same or a similar specialty.	the date the utilization review agent receives the appeal	Tex. Ins. Code § 4201.359(a) Texas Insurance Code § 4201.359(a), internal appeal decided by the 30th calendar day INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.359. NOTICE OF APPEAL, subsection (a) Texas Legislature · Source document · Read Aug 6, 2026 as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal From subsection (a); the opening "The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal" was trimmed for the 200-character limit. Note the statute says CALENDAR day explicitly, and that "as soon as practicable" sits in front of the 30 days, so the number is an outer limit on a faster duty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. 29 C.F.R. § 2560.503-1(i)(2)(iii)(A), 60 days to decide a post-service appeal Code of Federal Regulations, Title 29, Part 2560 (Rules and Regulations for Administration and Enforcement), Section 2560.503-1 Claims procedure, paragraph (i)(2)(iii)(A) U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · Read Aug 6, 2026 such notification shall be provided not later than 60 days after receipt by the plan of the claimant's request for review of an adverse benefit determination Paragraph (i)(2)(iii)(A), read from the eCFR section page. Same opening clause as the pre-service rule; the difference between the two is the 30 and the 60. Texas Insurance Code § 4201.357(a-1), expedited appeal for a prescription drug denial INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS, subsection (a-1) Texas Legislature · Source document · Read Aug 6, 2026 a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy From subsection (a-1), which adds this route on top of the written appeal and the (a) expedited route. The reviewer must not have seen the case before and must be of the same or a similar specialty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
The plan's answer when the case is urgentThe fast path. It exists only if the case meets the urgency test.	Texas requires an expedited appeal route to EXIST for emergency care, continued hospitalization, and prescription drugs or intravenous infusions, and requires who conducts it, without printing a number of hours in the sections read for this record. So this field carries no figure. Take the timing from your notice, and note that a life-threatening condition lets you skip the internal appeal entirely. For a denied medication specifically, Texas requires a separate expedited appeal route on top of the written one, and the statute says who has to conduct it: someone who has not seen your case before, practising in the same or a similar specialty.	the date the utilization review agent receives the appeal	Tex. Ins. Code § 4201.357 Texas Insurance Code § 4201.357(a-1), expedited appeal for a prescription drug denial INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS, subsection (a-1) Texas Legislature · Source document · Read Aug 6, 2026 a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy From subsection (a-1), which adds this route on top of the written appeal and the (a) expedited route. The reviewer must not have seen the case before and must be of the same or a similar specialty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.360, immediate appeal to an IRO in life-threatening circumstances INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES Texas Legislature · Source document · Read Aug 6, 2026 entitled to an immediate appeal to an independent review organization as provided by Subchapter I; and (2) not required to comply with procedures for an internal review From the section, which opens "Notwithstanding any other law, in a circumstance involving an enrollee's life-threatening condition, the enrollee is:". This is the exhaustion carve-out and it is the most consequential thing on the Texas page. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.357(a-1), expedited appeal for a prescription drug denial INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS, subsection (a-1) Texas Legislature · Source document · Read Aug 6, 2026 a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy From subsection (a-1), which adds this route on top of the written appeal and the (a) expedited route. The reviewer must not have seen the case before and must be of the same or a similar specialty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
Ask for an independent reviewThe outside review, after the plan has given its final answer.	The sections read for this record establish that Texas refers adverse determinations to independent review organizations by random assignment, and that the denial notice must tell you about that right and how to use it, without printing the number of days in those sections. So no figure is published here. The notice denying your internal appeal is the document that states your window, and for a life-threatening condition you may go to the independent review organization immediately.	the date of the notice denying the internal appeal	Tex. Ins. Code § 4202.012 Texas Insurance Code § 4202.012, adverse determinations are referred to IROs by random assignment INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS, Sec. 4202.012. REFERRAL Texas Legislature · Source document · Read Aug 6, 2026 The commissioner by rule shall require referral by random assignment of adverse determinations under Subchapter I, Chapter 4201 , to independent review organizations. The section in full. This is the fact that decides the boundary on this page: Texas HAS its own independent review system for the plans it regulates, so a Texan is not automatically sent to the federal process. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.360, immediate appeal to an IRO in life-threatening circumstances INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES Texas Legislature · Source document · Read Aug 6, 2026 entitled to an immediate appeal to an independent review organization as provided by Subchapter I; and (2) not required to comply with procedures for an internal review From the section, which opens "Notwithstanding any other law, in a circumstance involving an enrollee's life-threatening condition, the enrollee is:". This is the exhaustion carve-out and it is the most consequential thing on the Texas page. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number. Texas Insurance Code § 4201.359(a), internal appeal decided by the 30th calendar day INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.359. NOTICE OF APPEAL, subsection (a) Texas Legislature · Source document · Read Aug 6, 2026 as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal From subsection (a); the opening "The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal" was trimmed for the 200-character limit. Note the statute says CALENDAR day explicitly, and that "as soon as practicable" sits in front of the 30 days, so the number is an outer limit on a faster duty. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
The independent decision	Not printed in the sections read for this record, so no figure is published. The one review clock Chapter 4202 does state in those sections is for a preauthorization exemption rescission, which is a different proceeding from a denied treatment and is deliberately not reused here.	the referral of the determination to the independent review organization	Tex. Ins. Code § 4202.012 Texas Insurance Code § 4202.012, adverse determinations are referred to IROs by random assignment INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS, Sec. 4202.012. REFERRAL Texas Legislature · Source document · Read Aug 6, 2026 The commissioner by rule shall require referral by random assignment of adverse determinations under Subchapter I, Chapter 4201 , to independent review organizations. The section in full. This is the fact that decides the boundary on this page: Texas HAS its own independent review system for the plans it regulates, so a Texan is not automatically sent to the federal process. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.
The independent decision when the case is urgent	Not printed in the sections read for this record. What Texas does give you is the right to reach the reviewer immediately when the condition is life-threatening, without finishing the internal appeal.	the referral of the determination to the independent review organization	Tex. Ins. Code § 4201.360 Texas Insurance Code § 4201.360, immediate appeal to an IRO in life-threatening circumstances INSURANCE CODE TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW CHAPTER 4201. UTILIZATION REVIEW AGENTS, Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES Texas Legislature · Source document · Read Aug 6, 2026 entitled to an immediate appeal to an independent review organization as provided by Subchapter I; and (2) not required to comply with procedures for an internal review From the section, which opens "Notwithstanding any other law, in a circumstance involving an enrollee's life-threatening condition, the enrollee is:". This is the exhaustion carve-out and it is the most consequential thing on the Texas page. The url is a Wayback `id_` capture rather than the live page, and for a different reason than a blocked client: statutes.capitol.texas.gov serves a JavaScript shell containing no statute text, so every section url returns the same 250KB of fonts and CSS. The 2023 capture contains the real chapter. Legitimate here because this is a statute, which carries its own enactment history in the text; it would not be legitimate for a fee or a phone number.

Normally the utilization review agent's own appeal comes first. Texas then carves out the case where waiting is most dangerous: for an enrollee with a life-threatening condition the statute gives an immediate appeal to an independent review organization and expressly does NOT require complying with the internal review procedures first. If that is your situation, read that section before you spend time on the internal appeal.

If a medication was denied rather than a procedure

Texas is the only one of the four that legislates about a denied medication specifically. Section 4201.357 subsection (a-1) requires an expedited appeal route for a denial of prescription drugs or intravenous infusions, on top of the written appeal, and says who has to conduct it: someone who has not seen your case before, practising in the same or a similar specialty. It does not print a number of hours, so the figures below are the federal ones. It does not reach every plan: the federal exception rule governs plans that must cover essential health benefits, so a self funded employer plan may run its own process instead. Read your plan documents before taking this clock.

A standard request: 72 hours; From the plan's receipt of the exception request. The limit is federal, but Texas is the one state of the four that legislates about a denied medication directly, so read this next to section 4201.357 above rather than on its own.; 45 C.F.R. § 156.122(c)(1)(ii)
When the circumstances are exigent: 24 hours; From the plan's receipt of the exception request. 24 hours under the federal rule. Texas separately requires the expedited route to exist for a drug denial and requires who conducts it, without printing a deadline of its own.; 45 C.F.R. § 156.122(c)(2)(iii)

Where the request goes, and who decides it

Texas Department of Insurance, Independent Review Organization referral by the commissioner. The commissioner refers adverse determinations to independent review organizations by RANDOM assignment, by rule. Neither you nor your plan picks the reviewer, and the randomness is the statutory protection: it is what stops a plan steering its cases to a friendly reviewer.

The Texas independent review system reaches insurance the state regulates. It does not reach a self funded employer plan, where the employer pays claims from its own funds and federal law governs the appeal instead, and that is most people with job based coverage. This is the state where the distinction matters most on this site, because Texas runs its own review AND falls to the federal one depending on your plan, so read which kind you have before you take a deadline from this page. Medicaid is a third route again, with its own forum and its own clock, set out below.

What an external review is and what it can decide covers the step itself: who the reviewer has to be, what happens to the plan when they disagree with it, and how Texas's windows compare with the other published jurisdictions.

Texas publishes no standard form for this request, so the request goes in the way the forum above directs.

If the denial came from Texas Medicaid

The Medicaid route is a different forum on a different clock from the commercial one above, and the two are often confused. If a Medicaid managed care plan denied the care, that plan's own appeal comes first. Start from the notice the program sent you and follow the route it names.

Where a fair hearing goes, how long you have, and keeping benefits meanwhile

Where it goes: Texas Health and Human Services Commission, fair hearings
How long you have: See the note below; From the date of the action on your notice. No Texas figure is published here because none was read at a Texas primary source for this record. If a Medicaid managed care plan denied the care, that plan's own appeal comes first, and federal rules then give you between 90 and 120 calendar days from its notice of resolution to ask for the fair hearing. Your notice states the number Texas uses inside that band.

Keeping benefits while you argue

There is no number of days here, and that is the point: benefits keep running during the hearing only if the hearing is requested BEFORE the date of action on your notice. Find that date first, because it is the one deadline on this page that decides whether you keep coverage while you argue.

42 C.F.R. § 431.230(a)

You can also read what the published record shows about weight loss drugs and Texas Medicaid, which is useful background for an appeal even though it is not a rule.

What an appeal file usually contains

An appeal is a documents exercise. The plan denied a request against written criteria, so the reply that works is the one that shows the criteria being met, in the plan's own terms, with records from the people who treated you. The prescriber writes it; your job is usually to make sure nothing is missing.

The denial notice itself, including any reference or case number on it.
The criteria the plan applied, which the notice or the plan documents name.
The prescriber's letter, written against those criteria rather than in general terms.
The records that evidence each requirement the criteria list.

What a plan requires varies by plan, so treat this as the shape of a file rather than a checklist for yours. Where a plan's own criteria are published, the page for that plan type quotes them.

Which rule reaches your plan

The appeal route above is the one that applies when a state or federal rule reaches your plan. If your employer pays claims out of its own funds, the plan document sets the rules and the internal appeal is run under federal plan rules instead. Reading what the benchmark plans cover, Texas included is a fast way to see whether a state document reaches you at all.

Common questions

Can I go straight to an independent review?

Usually not. An external review normally starts only after the plan has given its final answer on an internal appeal, and filing out of order can cost you the review. The exception is an urgent case, where the two can run at the same time. Your notice says which applies.

How long do I have?

Read the notice you received. It sets the clock for your case and it is the authority, not this page. Covered Weight does not publish a deadline for a jurisdiction until it has read the governing document and can quote it, because a wrong deadline here is a right you cannot get back.

Who decides the external review?

Texas does not run its own external review program. Consumers here use the Federal External Review Process, administered by the U.S. Department of Health and Human Services.

Is the appeal different under Texas Medicaid?

Yes. A state program runs its own appeal and a fair hearing, on its own clock and in its own forum, and the order is not the same as it is for a commercial plan. Filing in the wrong forum is a common way to lose the right, so read the notice from the program rather than assuming the commercial route applies.