The Federal IDR Process Step by Step

How does federal IDR work?

Federal IDR is a process run by the Departments of Health and Human Services, Labor and the Treasury. A provider or facility and a health plan or issuer each submit one payment offer for an out-of-network item or service, and a certified IDR entity selects one. It is often called baseball-style or final offer arbitration because the entity cannot split the difference.

The process begins only after open negotiation ends without agreement. We cover that earlier stage on the open negotiation page, so this page starts on the day the 30 business day negotiation period closes.

Which version of the rule applies today?

The Federal IDR Operations final rule was published June 4, 2026 and took general effect August 3, 2026. Many changes apply later, so the older text of 149.510 still governs each piece until its applicability date.

Section 149.510(h)(10) says parties must keep following the requirements in effect before June 4, 2026 until the relevant applicability date. The IDR operations rule page covers the full rule.

What are the steps in the federal IDR process?

Eight steps run from the end of open negotiation to payment. The sections below explain what you send at each one.

How many business days do you have to start IDR after open negotiation?

You have 4 business days. Section 149.510(b)(2) says the notice of IDR initiation must be submitted during the 4 business day period that follows the end of the 30 business day open negotiation period, and CMS repeats this on its About Independent Dispute Resolution page.

We watch this deadline hardest. The count runs from the day the open negotiation notice was first sent, not from the remittance date.

What goes in the notice of IDR initiation

The notice also needs a copy of any remittance advice tied to the initial payment or denial, an attestation that the item or service is a qualified IDR item or service, a statement that the notice and consent exception does not apply, and your preferred certified IDR entity.

Documents to have ready

CMS's tips for disputing parties page lists what it encourages you to upload with the initiation:

• A complete copy of the remittance or denial notice for the disputed item or service, with codes.
• Proof that open negotiation started, such as copies of the emails sent to the other party.
• The claim number, correct contact information for the other party, a complete EOB and the QPA for the disputed items or services.
• If they apply, an email from an entity asking you to resubmit with batching corrections, or an email showing an extension was granted.

CMS tells parties to redact protected health information and personally identifiable information before uploading. If you plan to group claims, read the batching page before you submit, because a wrongly batched dispute can be sent back.

How do you pick a certified IDR entity?

You name a preferred certified IDR entity in the notice of initiation, and the other party has 3 business days to agree or object. If it agrees or says nothing, your pick stands. If it objects, it names an alternative, and the two sides keep exchanging notices until the third business day after initiation.

If the parties still disagree by the end of that third business day, the Secretary picks. Under the older text of 149.510(c)(1) the Secretary chooses at random from the certified entities that charge within the allowed fee range, and CMS then notifies both parties.

Conflict checks

Every entity must attest to the Secretary that it has no conflict of interest before the selection is final. Section 149.510(a)(2)(iv) defines a conflict to include an entity that is a plan, issuer, provider or facility, an affiliate or subsidiary of one, or an entity with a material familial, financial or professional relationship with a party. A material financial relationship means an interest above 5% of annual revenue or income.

If you know of a conflict with an entity the other side proposes, say so in your response notice. The regulation asks for an explanation of any conflict when you object.

What does the eligibility review check?

The eligibility review decides whether the item or service is a qualified IDR item or service. The version of 149.510(c)(2) in the final rule gives the selected entity 5 business days after final selection to decide and notify the parties and the Secretary. That paragraph applies to disputes whose open negotiation periods begin 90 calendar days after the Departments announce the supporting portal functionality.

If the entity finds the item or service ineligible, the dispute closes and the entity takes no further action. In a batched dispute, only the eligible items continue. The entity may also ask either party for more information at any time, and a party must respond within 5 business days through the portal.

When are IDR offers due, and what goes in them?

Offers are due no later than 10 business days after the certified IDR entity is selected. Section 149.510(c) requires each offer to be stated as a dollar amount and as the percentage of the QPA that amount represents.

The offer is more than a number. Both sides also send the QPA for the applicable year for the same or similar item or service, and information the entity requests. A provider group states its size by employee band, and a facility does the same on a different scale. Plans and issuers give their coverage area, the geographic region used for the QPA and whether coverage is fully or self-insured.

Your offer needs to be tied to the QPA, so the QPA page explains how the plan calculates it and how to check it. If the plan's QPA looks wrong, raise it in the information you submit with your offer.

Which factors does the IDR entity consider?

The entity must consider the QPA first, then any information from the parties on five listed circumstances. Section 149.510(c)(5)(iii) names those circumstances, and the entity must select the offer that best represents the value of the item or service.

The entity may also weigh other credible information that relates to the offer, as long as it is not one of the barred factors. Section 149.510(c)(5)(v) bars it from considering usual and customary charges, the amount that would have been billed had the NSA protections not applied, and payment rates from public payors such as Medicare, Medicaid, CHIP and TRICARE.

How long does the IDR entity take to decide, and when is payment due?

The entity has 30 business days after final selection to decide. It must pick one offer and send both parties and the Secretary a written decision that explains what information showed the chosen offer best represents the value of the item or service, including the weight given to the QPA.

Payment is due within 30 calendar days after the determination. Section 149.510(c) says the selected offer, less the initial payment and any patient cost sharing, must be paid directly to the provider or facility within that time. If the selected offer is lower than the initial payment plus cost sharing, the provider or facility owes the difference to the plan within the same 30 calendar days.

The decision is binding. The rule says it is binding in the absence of fraud or evidence of intentional misrepresentation of material facts, and it is not subject to judicial review except in the cases described in 9 U.S.C. 10(a)(1) through (4). There is no appeal to CMS.

If the plan does not pay

The 30 calendar day deadline is in the regulation, so track it from the decision date. Section 149.510 text sets out no enforcement procedure for a late payment. CMS takes questions at the No Surprises Help Desk, 1-800-985-3059.

What is the 90 day cooling-off period after an IDR decision?

After a single determination, the party that started the dispute cannot start another IDR against the same other party for the same item or service for 90 calendar days. Section 149.510(c)(5)(vii)(B) sets this suspension period.

For a batched determination, the rule sets a 30 business day suspension instead. The batching page covers the details.

What fees are due in federal IDR, and who pays?

Each party pays two fees: an administrative fee that goes to the government and a certified IDR entity fee that goes to the entity. Under 45 CFR 149.510(d)(2), the administrative fee is $15 per party per dispute for disputes initiated on or after June 11, 2026, and $115 per party per dispute for disputes initiated from January 22, 2024 through June 10, 2026. CMS confirmed both amounts in its June 3, 2026 notice.

The administrative fee is set through notice and comment rulemaking no more than once a calendar year, and it is not refunded. We have not listed the entity fee amounts, because each entity charges a predetermined fee and the Departments set the allowed ranges separately. Check the CMS No Surprises notices page for the current ranges before you budget.

What happens if you do not pay

Your offer is not considered received. Section 149.510(d) says that if a party fails to pay the administrative fee or the entity fee, its offer is not considered received, and it still owes the fee. CMS says the same on its tips page: if you do not pay both fees, your offer will not be reviewed.

Where do you file, and what if the portal is down?

You file through the federal IDR portal today, and CMS is moving the process to a new IDR Gateway. Its notices page says IDR Gateway account creation opened on September 15, 2026, organizations with Gateway accounts can submit web forms from November 13, 2026, and the web forms stop being available outside the Gateway after January 15, 2027, except the resubmission form.

If a portal outage or heavy volume makes a deadline impossible, the Secretary can extend it under paragraph (g), applicable from November 1, 2026, and must post a public notice of any extension. The only extension notice on the CMS page had already expired in 2025.

How we handle federal IDR for you

Our team prepares every notice and dispute package and tracks every deadline, including the 4-business-day window to start IDR. The submission in the federal portal is made by an authorized user located in the US, as the portal's rules require, usually a person on the client's team set up during onboarding.

The client pays the administrative fee and the IDR entity fee. Because a party that misses a fee deadline has its offer treated as not received, we track every fee deadline and tell the client in writing when each is due.

After a determination the payer must pay within 30 calendar days. If payment is late or wrong, we follow up and file a complaint with the No Surprises Help Desk, and our practice is to escalate when 45 days pass without payment. Our out-of-network billing and IDR service covers the full workflow. For a second look before the 4-business-day window closes, book a call.