Request For A Review By An Independent Review Organization {LHL009}

LHL009 - REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION (IRO). This form is used when a patient, their representative, or a healthcare provider wants to request a review of a denied healthcare service by an independent third party. This request is made when an insurance carrier has denied coverage for a service, claiming it is not medically necessary. The form is submitted to the insurance carrier who denied the service, and the carrier then forwards the request to the Texas Department of Insurance (TDI). The IRO will independently review the case and make a decision on whether the denied service should be covered. The form is used for both health and workers' compensation cases and is free of cost to the patient, except in some workers' compensation cases. www.FormsWorkflow.com