Not legal advice. This page is a short, general explanation for orientation only. It is not legal advice and may not reflect the latest rules, deadlines or fees. Always check current guidance from CMS and the Departments, and consult a qualified attorney about your situation.
What Federal IDR is
The No Surprises Act created the Federal Independent Dispute Resolution (IDR) process. When an out-of-network provider or facility and a health plan cannot agree on payment for certain services, either side can ask a certified IDR entity to decide the payment amount.
What it covers
Broadly: out-of-network emergency services, certain non-emergency services from out-of-network providers at in-network facilities, and air ambulance services, where federal rules apply rather than a state surprise-billing law. Eligibility depends on the plan, the state and the service; certified IDR entities find some disputes ineligible.
The main steps
- Initial payment or denial. The plan sends an initial payment or a notice of denial, along with information about the qualifying payment amount (QPA).
- Open negotiation. Either party can start a 30-business-day open negotiation period. Many disputes settle here.
- Initiating IDR. If negotiation fails, either party can initiate Federal IDR through the federal IDR portal within a short window after open negotiation ends (4 business days under the current rules).
- Selecting an IDR entity. A certified IDR entity is selected and checks whether the dispute is eligible.
- Offers. Each side submits a final payment offer with supporting information. The entity picks one of the two offers (“baseball-style”); it does not split the difference.
- Decision and payment. The entity issues a payment determination. Any amount owed must then be paid within the time the rules set (30 calendar days under the current rules).
Key terms
- QPA (qualifying payment amount)
- Generally the plan’s median contracted rate for the same or similar service in the same area, adjusted over time. It is the benchmark the ratios on this site are measured against.
- Dispute line item
- A single item or service within a dispute. Disputes can be “batched” to include many similar items.
- Prevailing offer
- The offer the IDR entity selected.
- Split decision
- In a dispute with several line items, each side prevailed on an equal number of them. CMS notes each side then pays half the IDR entity fee.
- Default decision
- One party did not submit an offer or pay its fees, so the other party prevailed by default.
- Fees
- Both parties pay a non-refundable administrative fee, and the IDR entity charges a fee that is generally borne by the party whose offer was not selected. Amounts change; check current CMS guidance.
- Cooling-off period
- After a determination, the party that initiated the dispute generally cannot bring the same party to IDR over the same item or service for 90 calendar days.
What the public data can and cannot tell you
- It shows outcomes of disputes that reached a payment determination, by line item.
- It does not include disputes that were withdrawn, settled or found ineligible.
- It does not tell you what any single claim will be paid. See the methodology.
CMS resources
CMS publishes guidance, the IDR portal and the public use files on its No Surprises Act pages, including Independent dispute resolution reports.