Is your out-of-network claim eligible for Independent Dispute Resolution (IDR)? 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 what makes a claim IDR-eligible, helping you understand the structured dispute resolution process established under the No Surprises Act (NSA) so you can pursue disputes with confidence and ensure your claims are resolved fairly.

What Is IDR? A Definition for Healthcare Providers

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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The qualifying payment amount (QPA) is one of several factors that a certified IDR entity (the third-party entity who arbitrates the IDR process) considers when making a payment determination. In addition to the QPA, a certified IDR entity must also consider information relating to the provider’s training, experience, and quality and outcomes measurements, such as: 

• The market share held by the provider or the plan
• Patient acuity and service complexity
• Teaching status, case mix, and scope of services
• Good faith efforts to enter into network agreements      

The QPA is an important item considered by decision makers in IDR claims. IDR initiators will often closely 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:

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

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:

• The QPA informs the plan’s calculation of cost-sharing for out-of-network claims, and serves as a reference point during the open negotiation period and subsequent IDR proceedings.
• 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.

IDR Eligibility

IDR eligibility is determined by whether a claim involves a “qualified IDR item or service.” A claim qualifies for IDR if it involves:

• An emergency service furnished by an out-of-network provider or facility
• A nonemergency service furnished by an out-of-network provider at an in-network facility (where notice-and-consent requirements under federal regulations were not met)
• Air ambulance services furnished by an out-of-network provider. 

When the initial payment on a qualifying claim is disputed, the provider may initiate open negotiation, and if the dispute remains unresolved, either party may proceed to IDR. In practice, providers are most likely to invoke the IDR process when they perceive a significant disparity between the payor's initial payment and the amount the provider considers reasonable for the item or service.

How the QPA Affects IDR Eligibility

As a component of the NSA payment framework, the QPA may affect:

• 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.

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. A claim does not qualify as a qualified IDR item or service if the out-of-network rate for that item or service is determined by reference to a specified state IDR law. A state law takes precedence if 

• The state has an applicable surprise billing law or dispute resolution law
• The health plan is fully insured and regulated at the state level (self-funded plans are typically governed by federal law)
• The state law applies to the specific item or service in question

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:

• 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

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

When the Patient Has Provided Consent to Out-of-Network Billing

A party may not initiate the federal IDR process with respect to an item or service if the out-of-network provider or facility provided notice and received consent from the patient. When a patient has been properly informed that the provider is out-of-network and has consented in writing to receive care at the out-of-network rate, the claim is not eligible for IDR.

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.

Checklist for Federal IDR–Eligible Claims

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 payor 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?

This list is not intended to be exhaustive; providers and RCM teams should consult applicable federal guidelines before initiating federal IDR. 

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 payor 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.

Providers and payors have a 30-business-day open negotiation period, beginning on the day the provider receives an initial payment or notice of denial. During this period, parties must attempt to resolve the payment dispute directly. The open negotiation notice must include sufficient information to identify the items and services in dispute, an offer of an out-of-network rate, and contact information. Failure to initiate open negotiation within the 30-business-day window will prevent the provider from proceeding 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

Step 4: Arbitrator Review and Selection

A certified IDR entity reviews both parties’ submissions and selects one of the two final payment offers. The certified IDR entity must consider:

• The qualifying payment amount(s) for the applicable year for the same or similar item or service
• The level of training, experience, and quality and outcomes measurements of the provider or facility 
• The market share held by the provider or facility or by the plan in the geographic region
• The acuity of the patient or the complexity of the service
• The teaching status, case mix, and scope of services of the facility, if applicable
• Demonstration of good faith efforts made by the provider or facility to enter into network agreements, and, if applicable, contracted rates during the previous four plan years

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

• Usual and customary charges
• Billed charges
• Public payor 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.

The amount of the selected offer must be paid directly to the provider not later than 30 calendar days after the determination. If the selected offer is less than the sum of the initial payment and any cost sharing paid by the patient, the provider will be liable to the plan or issuer for the difference, payable within 30 calendar days.

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.

Bundled payment arrangements are subject to rules for batched determinations, including:

• The items or services are billed by the same provider or facility (same NPI or TIN)
• Payment would be made by the same plan 
• They are the same or similar items or services (billed under the same service code)
• They were furnished within the same 30-business-day period 

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 payor 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, payor 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? Pivotal Health specializes in eligibility assessment and end-to-end dispute resolution under the No Surprises Act. Contact Pivotal Health and request a demo to see how we simplify the process from start to finish.

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