How to Review an IDR Entity for Conflicts of Interest
To check an IDR entity for conflicts, compare it with the payer and with your own group against the four situations in 45 CFR 149.510(a)(2)(iv), then keep a dated note. The other side has only 3 business days to answer your pick, so do the check before you file.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: a certified IDR entity has a conflict when it is a plan, provider or facility, an affiliate of one, or has a material familial, financial or professional tie to a party. Check candidates before you name one, and record the result in the dispute file.
What Counts as a Conflict of Interest for an IDR Entity?
A conflict of interest is a material relationship, status or condition that affects a certified IDR entity's ability to make an unbiased and impartial payment determination. That is the definition in 45 CFR 149.510(a)(2)(iv). The rule then lists the situations where a conflict exists.
| Situation in 149.510(a)(2)(iv) | What it means in practice |
|---|---|
| The entity is a plan, issuer, FEHB carrier, provider, facility or air ambulance provider | The entity cannot be the same kind of party as the plan or provider |
| The entity is an affiliate or subsidiary of one of those | Check the corporate parent |
| The entity is an affiliate or subsidiary of a trade or professional association for plans, issuers, providers or facilities | Check association ties on both sides |
| The entity, or personnel, contractors or subcontractors on your case, have a material familial, financial or professional relationship with a party or its officers, directors, managers, administrators, fiduciaries or employees | Check the people assigned, not only the company |
The rule applies the same test to both sides. A relationship with your own group counts as much as one with the plan. A certified IDR entity is one the Departments have certified under paragraph (e) of the rule.
What Do Familial, Financial and Professional Relationship Mean?
The rule defines each word, and the definitions are narrower and more specific than the everyday meaning. A material financial relationship is a financial interest of more than 5% of total annual revenue or annual income of a certified IDR entity or of an officer, director, manager, reviewer or reviewing physician it employs or engages (149.510(a)(2)(ix)).
| Term | Rule text in short | Section |
|---|---|---|
| Material familial relationship | Spouse, domestic partner, child, parent, sibling, and the spouse's or partner's parent, sibling or child, plus a child's parent or spouse and a sibling's spouse | 149.510(a)(2)(viii) |
| Material financial relationship | A financial interest of more than 5% of annual revenue or annual income | 149.510(a)(2)(ix) |
| Material professional relationship | A physician-patient relationship, a partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation or partnership, or an independent contractor arrangement that is a material financial relationship with an expert the entity uses or with an officer or director | 149.510(a)(2)(x) |
One more clock matters. The entity must not assign personnel who had a relationship with a party within the 1 year before the assignment that would breach the restrictions on aiding or advising a former employer or principal, written in the style of 18 U.S.C. 207(b) (149.510(c)(1)(iv)(A)(3)).
How Do You Check an Entity Before You Name It in the Dispute?
Run the check before you submit the notice of IDR initiation, because the notice names your preferred entity and the other side has only 3 business days to answer. CMS says on its About Independent Dispute Resolution page that disputing parties choose a certified IDR entity from a list of certified organizations.
Repeat the check for any entity the payer proposes. The 3 business day clock leaves little time to start from zero.
When Does the Entity Attest That It Has No Conflict?
The entity attests to the Secretary that it has no conflict before the selection becomes final. Under the amended text of 149.510(c)(1)(iv), the entity has 3 business days from preliminary selection to attest that it has no conflict, that it assigns personnel without regard to which side they will favor, and that no assigned person has a disqualifying conflict.
If the entity does not attest within those 3 business days, the Secretary randomly selects another certified IDR entity and notifies the parties within 1 business day after the 3 day period ends. Final selection is the date the Secretary notifies the parties that the attestation was made.
How Do You Object to the Payer's Choice of Entity?
Object in your notice of IDR initiation response, by naming an alternative certified IDR entity and explaining any conflict you know of. Section 149.510(b)(2)(iii)(A)(11) requires the response to state whether you agree or object, and an objecting party must name the alternative and, if applicable, explain any conflict of interest.
Silence is an answer. If the non-initiating party agrees or does not respond within 3 business days after the date of IDR initiation, the initiating party's preferred entity is considered jointly selected on the third business day (149.510(c)(1)(i)(A)). If the parties cannot agree by then, the Secretary selects the entity. That selection is random among certified entities within the allowed fee range, as the process page explains.
The payer's response names Entity B. Your check finds Entity B shares a parent company with a regional plan. You object and name Entity C, with one line in the response: Entity B is an affiliate of a health plan, which is a conflict under 149.510(a)(2)(iv)(B). If the payer then fails to respond by the third business day, Entity C is considered jointly selected.
What If You Find a Conflict After the Entity Is Selected?
You have two routes. The first is the entity's own process: under the amended text, the selected entity may ask either party for information at any time, including to assess whether a conflict exists, and a party that fails to answer within 5 business days may have the review decided without that information (149.510(c)(2)(ii)).
The second is a petition. Under 149.510(e)(5), a provider, facility, plan or issuer may petition for revocation of an entity's certification for failure to meet the certification requirements, using the Secretary's standard form and the process in guidance. A petition needs the entity's identity, the reasons and supporting documents. The text lets an entity keep working on cases already assigned while the Secretary reviews a petition, so raise a conflict in the dispute itself at once.
After the decision, the entity keeps its records for 6 years; what happens after an IDR decision covers that and the payment steps.
How We Handle Entity Selection
We manage out-of-network reimbursement end to end, including dispute submissions and deadline management under federal IDR. Entity selection is part of the documentation we validate before a dispute goes out. Our out-of-network billing and IDR service covers the full workflow for groups such as pathology billing practices. More posts are on the blog. To have a dispute checked before the entity is named, book a call.
- 45 CFR 149.510 Independent dispute resolution process · eCFR
- About Independent Dispute Resolution · CMS
- Federal Independent Dispute Resolution Operations (final rule, 91 FR 33900) · Federal Register
We check every rule, code and deadline against the official source. See our editorial policy.
Common Questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How do you choose an IDR entity and check for conflicts?
Pick from the certified organizations CMS lists, then compare each candidate with the payer and with your own group. Look at affiliates, trade association ties, familial or professional relationships and any financial interest above 5% of annual revenue or income. Keep a dated note of the check, and name a fallback entity.
02What is a conflict of interest for a certified IDR entity?
It is a material relationship, status or condition that affects the entity's ability to decide impartially (45 CFR 149.510(a)(2)(iv)). Examples are an entity that is a plan, provider or facility, or an affiliate of one, or one with a material familial, financial or professional relationship with a party.
03Does the IDR entity have to confirm it has no conflict?
Yes. The selection is finalized only if the entity attests to the Secretary that it has no conflict, assigns personnel fairly and uses no one with a disqualifying conflict. If it does not attest within 3 business days of preliminary selection, the Secretary randomly selects another certified entity.
04How long does the other party have to object to my preferred entity?
The non-initiating party has 3 business days after the date of IDR initiation to agree or object. If it agrees or does not respond, your preferred entity is considered jointly selected on the third business day. If it objects, it must name an alternative and explain any conflict.
05Can I challenge a certified IDR entity that has a conflict?
You can raise the conflict in the dispute, and a provider, facility, plan or issuer may petition the Secretary under 45 CFR 149.510(e)(5) to revoke an entity's certification. Use the Secretary's standard form and attach documents that support the reasons.
Talk to a Billing Lead.
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