Federal IDR glossary
Short, plain definitions of terms used in the No Surprises Act, Federal IDR and this site. Each links to a primary source.
- Balance billing
- A provider billing a patient for the difference between its charge and what the plan paid. The No Surprises Act bars it in covered situations. Source
- Surprise bill
- An unexpected bill from an out-of-network provider or facility the patient did not choose, such as in an emergency. Source
- Out-of-network (nonparticipating) provider
- A provider or facility without a contract with the patient’s health plan. Source
- Emergency services
- Screening and stabilizing care for an emergency medical condition at an emergency department or freestanding emergency department, and some care after stabilization. Source
- Ancillary services
- Services, such as anesthesiology, radiology and pathology, for which patients cannot waive surprise billing protections at in-network facilities. Source
- Notice and consent
- The written process by which, for some non-emergency care, a patient can agree to be billed as out-of-network. Source
- Recognized amount
- The amount patient cost sharing is based on; often the QPA, unless a state law or All-Payer Model Agreement sets it. Source
- Out-of-network rate
- The total amount the plan pays the out-of-network provider, set by state law, an All-Payer Model Agreement, agreement or a Federal IDR decision. Source
- Qualifying payment amount (QPA)
- Generally the plan’s 2019 median contracted rate for the service in the same region and market, adjusted for inflation. Source
- Open negotiation
- A 30-business-day period in which the provider and plan try to agree on payment before Federal IDR can start. Source
- Federal IDR
- The federal process in which an independent entity chooses between the provider’s and the plan’s final payment offers. Source
- Certified IDR entity (IDRE)
- An organization certified by the Departments to decide Federal IDR disputes. Source
- Initiating party
- The party (provider, facility or plan) that starts a Federal IDR dispute; the other is the non-initiating party. Source
- Batched dispute
- One dispute that combines multiple similar items or services between the same parties. Source
- Line item
- One item or service within a dispute. CMS publishes outcomes per dispute line item. Source
- Payment determination
- The IDR entity’s decision selecting one party’s offer. Source
- Prevailing offer
- The offer the IDR entity selected. Source
- Default decision
- In the CMS files, a determination made because one party did not submit an offer or fee; this site counts it as a determination. Source
- Split decision
- In the CMS files, a dispute whose line items were decided partly for each side; this site leaves split decisions out of win rates. Source
- Administrative fee
- A non-refundable fee each party pays to the Departments for each dispute ($15 per party for disputes started on or after June 11, 2026). Source
- IDR entity fee
- The certified IDR entity’s fee, ultimately paid by the party whose offer is not selected. Source
- Cooling-off period
- A 90-calendar-day period after a decision during which the initiating party cannot start a new dispute against the same party for the same service. Source
- Specified state law
- A state law that sets the out-of-network payment method for a given plan, provider and service, displacing Federal IDR. Source
- All-Payer Model Agreement
- An agreement between a state and CMS (for example Maryland’s) that can set out-of-network rates. Source
- Self-funded (ERISA) plan
- An employer plan that pays claims from its own funds; generally outside state insurance law. Source
- Opt-in state
- A state that lets self-funded plans elect to use its surprise billing process. Source
- Good faith estimate
- A cost estimate that providers must give uninsured and self-pay patients. Source
- Public use file (PUF)
- The quarterly data files CMS publishes on Federal IDR disputes; this site’s source. Source
- ×QPA (this site)
- The prevailing offer as a multiple of the QPA, from the CMS field “Prevailing Party Offer as % of QPA”. Source
- Win rate (this site)
- The share of determined line items in which the provider or facility offer was selected; split decisions excluded, default decisions included. Source
More in Learn: The No Surprises Act, in plain English · How Federal IDR works, step by step · What is the qualifying payment amount (QPA)? · Which services and specialties are covered? · State surprise billing laws and Federal IDR (including Texas)
General information, not legal advice. Rules change; check the cited sources. Last reviewed 2026-10-19.