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Who can use federal IDR?

Q: Who can use federal IDR?

Federal independent dispute resolution is open to out-of-network providers, facilities, and air ambulance companies with claims protected by the No Surprises Act. Three doors qualify: out-of-network emergency services, out-of-network care delivered at an in-network facility such as a hospital or ambulatory surgery center, and air ambulance transport. The patient must be on a commercial plan, because Medicare, Medicaid, TRICARE, and self-pay patients are outside the process. Before filing, the parties must complete 30 business days of open negotiation, and the provider then has 4 business days to initiate the dispute.

Q: Do my claims go to state arbitration or federal IDR?

It depends on the plan, not the provider. Self-funded employer plans, which cover most commercially insured patients, go through the federal process by default. Fully insured plans in a state that runs its own surprise billing arbitration follow the state process for the claims that state law covers, and the federal process fills the gaps. Most groups of any size end up with claims on both tracks, sorted claim by claim.

Federal independent dispute resolution is open to out-of-network providers, facilities, and air ambulance companies with claims protected by the No Surprises Act. Three doors qualify: out-of-network emergency services, out-of-network care delivered at an in-network facility such as a hospital or ambulatory surgery center, and air ambulance transport. The patient must be on a commercial plan, because Medicare, Medicaid, TRICARE, and self-pay patients are outside the process. Before filing, the parties must complete 30 business days of open negotiation, and the provider then has 4 business days to initiate the dispute.

Eligibility is the first question any filing service should answer about your book, because filing an ineligible dispute wastes fees and time. The rules below are the federal baseline. They apply the same way whether you are an emergency medicine group, a surgical practice, a radiology or anesthesia group, or the RCM company billing for any of them.

Door one: out-of-network emergency services

If the episode begins as an emergency, every out-of-network claim attached to it is protected: the emergency department evaluation, the physicians called in, the imaging and anesthesia, and post-stabilization care at the facility until the patient can consent and travel. Patients can never be asked to waive protection for emergency services. This is the biggest door by volume, and it is the one on-call specialists walk through when they cover the emergency department without being in the patient's network.

Door two: out-of-network care at an in-network facility

If you deliver care at a hospital, hospital outpatient department, critical access hospital, or ambulatory surgery center that is in the patient's network while you are not, the claim is protected. The patient owes only in-network cost sharing, and what the plan owes you is resolved through negotiation and, failing that, arbitration. One caveat applies to scheduled care: a patient can sign a notice and consent waiver that takes some services out of protection. The waiver rules are strict, written notice is generally required at least 72 hours ahead, and ancillary services such as anesthesiology, pathology, radiology, and assistant surgeons can never be waived. Note what the facility list excludes: care delivered in your own office does not qualify, no matter how complex.

Door three: air ambulance

Out-of-network air ambulance transport, both rotary and fixed wing, is protected whenever the patient's commercial plan covers the service. Air ambulance disputes run through the same federal portal with the same negotiation-then-arbitration sequence, and they are among the largest dollar disputes in the published record.

State process or federal process

Which process a claim uses depends on the plan, not the provider. Self-funded employer plans, which cover most commercially insured patients, go through the federal process by default. Fully insured plans in a state that runs its own surprise billing arbitration follow the state process for the claims that state law covers, and the federal process fills the gaps. Most groups of any size end up with claims on both tracks, sorted claim by claim, which is one of the first things a filing service should do with your remittance data.

The timeline that gates every filing

Eligibility alone does not get you to an arbiter. The No Surprises Act requires the sequence to run in order, in business days:

Open negotiation notice. Must be sent within 30 business days of the payer's initial payment or notice of denial.
Open negotiation period. Runs 30 business days from the notice. Either side can settle during it.
IDR initiation. If negotiation fails, the provider has 4 business days after the negotiation period ends to initiate the dispute in the federal portal.

Miss a window and the claim is out, regardless of how strong it was. Once filed, the median time from filing to decision is 37 days, and providers win 85.8 percent of disputes that reach a decision. The full published record is explorable at idrexplorer.com.

What does not qualify

Government programs. Medicare, Medicaid, TRICARE, and similar coverage have their own payment rules.
Self-pay and uninsured patients. They get a different protection, the good faith estimate, with no provider-payer arbitration.
In-network claims. If your group is contracted with the plan, underpayment is a contract dispute, not an IDR case.
Office-based care. Your own office is not a facility under the statute, so non-emergency office claims have no door.

If your claims clear these rules, the next questions are operational: what a filing service would actually do with them, what it would cost, and whether to run the process yourself. Surgeon-specific eligibility, including the assistant surgeon rules, is covered in depth at idrforsurgeons.com.

Not sure which door your claims use?

Bring your payer mix and rough out-of-network claim volume to a 30 minute call. We will sort the eligible claims, state and federal, and show you what similar groups are winning. Talk to an IDR specialist.