Payment disputes between providers and health plans

About Independent Dispute Resolution

The No Surprises Act created new protections against out-of-network balance billing and established a new process called independent dispute resolution (IDR), which is managed by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury (the Departments). 

Providers (including air ambulance providers), facilities, and health plans can use the process to determine the payment rates for certain out-of-network charges. 

When a provider or facility gets a payment denial notice or an initial payment from a health plan for certain out-of-network services, the health plan, provider, or facility must start an open negotiation period that lasts 30 business days. At the end of the negotiation period, if the health plan and provider or facility have not agreed on a payment amount, either party can begin the IDR process. 

The Federal IDR process

In the Federal IDR process:

  • Disputing parties have the option to choose a third-party entity, known as a certified IDR entity, from a list of certified organizations to resolve their dispute. Everyone involved must attest to having no conflicts of interest.
  • The provider or facility and the health plan or issuer must submit payment offers and additional information supporting their payment offers to the certified IDR entity.
  • The certified IDR entity must select from the disputing parties' payment offers. Both the provider or facility and the health plan or issuer must abide by the decision, and payment must be made within 30 calendar days.

Note: A dispute cannot be initiated until the required 30-business-day open negotiation period has ended, and must be initiated within 4 business days after the open negotiation period has ended, except when extensions are made by the Departments. See the Notices page for information about any current extensions.

Start A Dispute

Have the following information ready: 

  • Information to identify the qualified IDR items or services, including:
    • Dates and locations that the items or services were provided
    • Types of items or services such as emergency services and post-stabilization services
    • Codes for corresponding service and place-of-service
    • A complete Explanation of Benefits (EOB)
    • Claim numbers involved in the dispute 
  • Attestation that items or services are within the scope of the Federal IDR process
  • Complete and correct contact information for the non-initiating party
  • Your preferred certified IDR entity from the list of certified organizations

Extensions to deadlines for extenuating circumstances 
If the disputing party experiences extenuating circumstances that prohibit them from complying with deadlines to submit information, they may complete the Request for Extension of Federal IDR Process Time Periods Due to Extenuating Circumstances form and email it to the Departments at Parties should include the IDR dispute reference number on the form.

If the parties agree on a rate after a dispute is initiated
Disputing parties can continue to negotiate until the certified IDR entity makes a determination. If the parties agree on an out-of-network rate for a qualified IDR item or service after initiating the Federal IDR process, but before the certified IDR entity has made a determination, the initiating party must notify the Departments. The initiating party should email the certified IDR entity and the Departments at Attach a document that contains the following:

  1. The agreed-upon out-of-network rate for the qualified IDR item or service (i.e., the total payment amount, including both participant, beneficiary, or enrollee cost sharing and the total plan or coverage payment, including amounts already paid).  
  2. Allocation of how parties agree to pay the certified IDR entity fee (if parties choose not to split the fee evenly).
  3. Signatures from authorized signatories for both the initiating and the non-initiating party.

This information must be submitted within 3 business days of the agreement.

State-by-state applicability of the Federal IDR process
Not all items and services are subject to the Federal IDR process. Some states have their own balance billing laws or other laws that determine out-of-network payment amounts. This resource (PDF) can help determine whether items or services in a state are subject to the Federal process.

Federal IDR reporting
The Departments have released several reports and updates on the Federal IDR process on the Independent Dispute Resolution Reports page.  

Getting help

Page Last Modified:
04/22/2024 02:00 PM