Is your out-of-network claim eligible for Independent Dispute Resolution? The answer determines whether you have a clear, structured path to securing fair payment for the care you provided.

In early 2024, providers prevailed in 88% of IDR cases, according to Georgetown University data. But knowing which claims qualify is the critical first step. This guide walks you through exactly what makes a claim IDR-eligible, helping you identify thousands of dollars in recoverable revenue, so you can pursue disputes with confidence and maximize your reimbursement under the No Surprises Act (NSA).

What Is IDR? A Definition for Healthcare Providers

The Independent Dispute Resolution (IDR) provides a structured platform for healthcare providers like you and insurance companies to arbitrate a fair payment for out-of-network services. These disputes are resolved between providers and insurers.  

How IDR Fits Into Your NSA Workflow

IDR doesn’t function as a standalone option under the No Surprises Act. It plays a structured role in resolving disputes, and you’ll find that under the NSA, disputes usually follow this sequence: 

• Initial payment or denial issued by the health plan
• Mandatory open negotiation period between the provider and payor
• Federal IDR if negotiation does not resolve the dispute

IDR serves as the final, binding step in this process and resolves payment disagreements without involving the patient.

IDR vs. Negotiation: What Makes Them Different

You may have seen IDR described as arbitration, but it functions differently from traditional negotiation and non-NSA arbitration. Here’s how IDR differs from negotiation: 

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Negotiation

Independent Dispute Resolution (IDR)

Informal back-and-forth discussion between a provider and a payor

Formal, regulated process established under the No Surprises Act 

Not binding as either party walks away without reaching an agreement 

A binding resolution once a certified IDR entity issues a decision

Occurs at any point in the billing process

Occurs only after the required open negotiation period ends without resolution 

Influenced by leverage, contract terms, or historical payment patterns

Requires both parties to submit a final payment offer for review

No third-party involvement

A certified, independent third-party arbitrator makes a decision

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The qualifying payment amount (QPA) is central to how decision-makers rule in IDR claims. You need to review these QPA calculations, as reports show some providers question QPA accuracy. 

What Is the Qualifying Payment Amount in IDR?

This benchmark represents a health plan’s median in-network rate for a specific item or service. Insurers use the QPA rate as the benchmark, and calculate it using: 

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• Specific items or services 
• Contracts with the same or similar services 
• Geographic regions 
• Insurance market 

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Insurers are required to calculate the QPA in accordance with standardized rules under the NSA. Payors need to inform providers of the initial out-of-network payment or, if there is any, the notice of denial. This calculation captures what the plan pays in-network for a given service, not an arbitrary or negotiated out-of-network rate. This benchmark serves as a clear, standardized guideline. 

How the QPA Fits Into the NSA Workflow

Understanding the QPA helps all stakeholders evaluate whether IDR claims apply. At multiple stages, initial payment, negotiation, and arbitration, this figure guides the process:

• It anchors the plan’s initial payment on an out-of-network claim 
• It shapes the open negotiation period, helping both parties evaluate the payment dispute
• It guides the certified IDR entity’s decision when choosing between the provider’s and the payor’s final payment offers

Before any payment dispute proceeds to IDR, the claim must first meet specific eligibility requirements under the No Surprises Act. 

How the Qualifying Payment Amount Affects IDR Eligibility

The Qualifying Payment Amount plays a foundational role in determining whether an out-of-network payment dispute is likely to proceed through the IDR process. Because the NSA anchors the payment framework to the QPA, it directly affects:

• The initial payment amount a plan issues
• Whether a provider views that payment as reasonable
• Whether a dispute escalates beyond open negotiation

This median rate establishes the starting position for negotiations between both parties. When a payment closely aligns with the QPA, providers are less likely to pursue IDR.

How Low QPAs Affect IDR Eligibility

A reduced QPA serves as an early indicator that a claim is appropriate for IDR. When a payer issues an initial payment that reflects a QPA significantly below what a provider considers reasonable for the service, it signals a meaningful valuation gap. These gaps occur in specialties with high out-of-network volume and limited patient choice. In these situations:

• The provider challenges whether the payment fairly reflects the service delivered
• The QPA becomes a focal point during open negotiation
• The likelihood of escalation to IDR increases if bargaining does not close the gap

Understanding QPA mechanics helps you evaluate initial payments and negotiate effectively. With this foundation in place, let's examine the three core scenarios that determine whether your claim qualifies for federal IDR.

Which Out-of-Network Claims Qualify for Federal IDR?

The federal IDR process applies to a narrow set of out-of-network claims, but for providers, these claims result in millions of dollars of revenue. The latest figures reveal that IDR has processed more than a billion dollars in payments. Federal IDR applies to the following surprise billing scenarios: 

• Emergency medicine services, regardless of facility network status
• Ancillary services at in-network facilities where the patient can’t choose the provider, such as anesthesiology, radiology, pathology, neonatology, and assistant surgeons
• Air ambulance services

These categories qualify as the NSA is designed to protect patients from situations where they didn’t ask for treatment, and where choice was limited. When patients are in a position where they don’t have a choice, it’s usually because the network status is unknown or unavoidable at the time of care. When open negotiations don’t settle the claim, the IDR process provides an additional vehicle for claiming fair payment. 

Out-of-Network (OON) Claims Where the Provider Didn’t Choose to Be OON

The NSA covers certain OON claims in which the provider’s network status depends on the care setting, not on an intentional choice to stay OON. Federal IDR qualifying criteria applies in the following situations: 

• Out-of-network clinicians delivering care at in-network facilities: The patient seeks care at an in-network hospital or facility but receives services from clinicians who are not part of the plan’s network
• Out-of-network clinicians at out-of-network facilities providing emergency care: Emergency services trigger NSA protections regardless of the facility’s network status

These claims qualify because the patients don’t have a choice of providers. Even if the patient chooses an in-network provider, an OON provider assists with some or all of the treatment, depending on the situation. In emergencies, there’s no opportunity to check the provider's network status. 

Commercial Coverage Only

The federal IDR process applies to commercial health plans that fall within the NSA. Instances where the IDR doesn’t apply include: 

• Medicare
• Medicaid
• TRICARE
• Veterans Affairs (VA) programs
• Workers’ compensation plans

These programs follow separate statutory and regulatory payment rules, which explicitly exclude them from the NSA’s IDR framework.

Claims Where IDR Doesn’t Apply

Some out-of-network payment disputes don’t proceed to IDR. Even when a claim involves an out-of-network provider and a disputed payment amount, the No Surprises Act limits IDR eligibility based on jurisdiction, service type, and procedural compliance.

When a State Surprise Billing Law Takes Precedence

A common reason claims do not qualify for IDR is that state law governs the dispute. Under the NSA, IDR serves as a default process. If a state has its own surprise billing law that applies to a specific claim and health plan, that state process takes priority over the federal one. State processes replace federal ones when: 

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• The state has an established surprise billing law
• The health plan is fully insured and regulated at the state level
• The state law applies to the specific service in question

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When all three of these conditions exist, IDR won’t apply, even if the case looks like a viable IDR candidate. For providers that operate across multiple states, this requires careful jurisdiction assessment. In this case, the jurisdiction will depend on: 

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• Where they provided the service
• Whether the plan is fully insured or self-funded
• If the state law applies to the specific type of service

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It’s essential to do this step first before opening negotiations or applying through IDR to ensure the application remains valid. 

When the NSA Excludes a Service by Category

Some services fall outside the scope of the NSA altogether, which makes that claim ineligible for IDR. These services include: 

• Services where the patient chooses the provider, such as office visits, scheduled care, and elective procedures
• Non-emergency care delivered by out-of-network providers at out-of-network facilities, where the patient knowingly receives care outside the network

In these situations, the NSA does not impose balance billing protections, and contracts, patient consent, or standard out-of-network billing rules generally govern payment terms.

When a Claim Fails Procedural Requirements

Otherwise eligible claims require meeting all procedural steps to maintain IDR access. Missing deadlines or completing forms incorrectly can disqualify an otherwise valid claim.

Common procedural requirements include:

• Missed timelines: Not initiating open negotiation or submitting an IDR filing within the required federal window
• Incomplete or incorrect QPA disclosures: Missing required remittance information from the payor
• Existing governing contracts: Operating under in-network agreements or other binding payment arrangements

Because the NSA establishes strict sequencing and documentation requirements, meeting procedural requirements ensures your claim remains eligible for federal IDR.

Federal IDR–Eligible Claims: The Complete Checklist

Federal IDR eligibility depends on both the type of claim and strict procedural compliance. Before initiating federal IDR, providers and RCM teams use the following checklist to quickly determine whether a claim is likely to qualify under the No Surprises Act:

• Does the claim involve an NSA-covered scenario?
• Is the payer a commercial plan subject to the NSA?
• Is the disputed payment materially different from the QPA?
• Has open negotiation occurred without resolution?
• Does federal law govern this claim?
• Are all filing deadlines still open?

The Federal IDR Process, Step by Step

The No Surprises Act establishes a defined, sequential process for resolving out-of-network payment disputes once a claim meets the criteria. Each step builds on the last, and it’s important to see each step through for the claim to remain eligible under IDR. 

Step 1: Determine Eligibility (Federal vs State Law)

Before taking any action, you must determine which law governs the claim. Federal IDR applies when:

• The service qualifies under the NSA
• The payer is a commercial plan subject to federal oversight
• No applicable state surprise billing law takes precedence

If a state law governs the dispute, you must follow the state’s arbitration or mediation process rather than the IDR process. Identifying the correct jurisdiction at the outset ensures your dispute filing remains eligible. 

Step 2: Initiate Open Negotiation

Open negotiation is a mandatory prerequisite to IDR. Providers and payors must attempt to resolve the payment dispute directly before escalating it. During the required data exchange period, parties typically exchange:

• The initial payment amount and payment rationale
• The Qualifying Payment Amount (QPA)
• Any supporting context related to the service or claim

To avoid missing out on approvals, it’s crucial to negotiate within the required timeframe and provide all the necessary information and payment disclosures. Treat these negotiations as formal with proper documentation, and if the parties involved don’t resolve the claim within the required window, the claim may proceed to federal IDR. 

Step 3: File for Federal IDR

When open negotiation ends without resolution, either party initiates federal IDR by submitting the dispute through the federal IDR portal. To file successfully, the initiating party must:

• Select a certified IDR entity
• Submit a final payment offer
• Pay the required administrative and IDR fees
• Meet all federal filing deadlines
• Provide complete supporting documentation

Accurate and complete submissions matter, as the certified IDR entity relies on these materials when evaluating the dispute and selecting between the final payment offers.

Step 4: Arbitrator Review and Selection

A certified IDR entity reviews both parties’ submissions and selects one of the two final payment offers. These are the claims arbitrators are allowed to consider under IDR:

• The qualifying payment amount
• The provider’s training, experience, and specialty
• The complexity of the service
• Relevant market conditions

There are instances where the arbitrators can’t consider the claim. Instances of these claims include:

• Usual and customary charges
• Billed charges
• Public payer rates, such as Medicare or Medicaid

These guardrails ensure that IDR decisions follow standardized criteria rather than being subject to open-ended negotiation.

Step 5: Final Determination and Payment

When a claim qualifies for IDR, the entity issues a binding payment determination, selecting either the provider’s or the payor’s final offer. Once the official issues a decision, the losing party makes the payment in accordance with the determination and pays within the required timeframe. At this point, the dispute concludes, and the payment amount becomes final and enforceable.

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IDR Eligibility for Bundled Services, Facility Claims, and Serial Treatments

Even when a claim meets the core No Surprises Act eligibility criteria, certain situations require closer review to determine how it qualifies for federal IDR. Understanding these nuances helps you and the RCM teams identify eligible disputes they might otherwise overlook.

Claims With Bundled Services

Claims that include multiple CPT codes billed under a single encounter require additional eligibility assessment, particularly when some services appear NSA-covered, and others do not. In these cases:

• Eligibility depends on the nature of the overall encounter, not just individual line items.
• Services delivered as part of an emergency visit or protected ancillary care remain NSA-covered even when billed together.
• Non-covered services bundled into the same claim don’t independently qualify for IDR.

You need to assess whether the bundled services stem from an NSA-protected scenario and whether the dispute centers on payment for the protected portion of the encounter.

Facility vs Professional Claims

Facility and professional claims follow different eligibility rules, which affect whether IDR applies. Facility fees are eligible for IDR when:

• They relate to emergency services protected under the NSA
• The facility’s payment is subject to balance billing protections
• No applicable state law overrides the federal process

When only the clinician portion qualifies, the professional component enters IDR, while the facility component follows separate payment rules. This distinction is significant for hospital-based specialties, where clinicians and facilities bill separately for the same encounter.

Ongoing Services or Serial Treatments

Eligibility becomes less clear when care extends beyond a single encounter. For follow-up or staged services:

• The initial emergency service qualifies for NSA protections and IDR
• Subsequent services fall outside NSA coverage if the patient has the opportunity to choose providers or schedule care
• Each claim must be evaluated independently based on timing, setting, and patient choice

Providers often assume eligibility carries forward automatically, but the NSA requires a claim-by-claim assessment.

Payor Objections and Disqualifications

Payors may raise eligibility questions about:

• Service qualification for IDR
• Applicable state vs. federal jurisdiction
• QPA calculation accuracy

Providers can challenge these disqualifications when:

• The claim clearly falls under NSA-covered scenarios
• The payor misapplies state law or plan type
• QPA disclosures are incomplete or inconsistent

Understanding when an objection reflects a genuine eligibility issue versus a misapplication of the rules helps providers ensure they pursue all eligible disputes.

What Claims Does IDR Apply To and How to Act With Confidence

Understanding which claims qualify for IDR doesn't have to be complicated. Federal IDR eligibility comes down to three core questions: Does your claim involve emergency services or protected ancillary care? Is the payer a commercial plan subject to the No Surprises Act? Did open negotiation fail to resolve the dispute?

If you answered yes to all three, your claim likely meets federal IDR qualifying claims criteria. For providers in states with their own surprise billing laws, verify which jurisdiction applies before initiating the process. State law may take precedence over the federal IDR pathway.

What claims does IDR apply to ultimately depends on the clinical scenario, payer type, and regulatory jurisdiction. By evaluating IDR eligibility early in your revenue cycle, you can pursue disputes strategically and recover the fair reimbursement you've earned.

Need help determining which of your claims qualify for IDR? Radix Health specializes in eligibility assessment and end-to-end dispute resolution under the No Surprises Act. Contact Radix Health and request a demo to see how we simplify the process from start to finish.

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