Patient-Provider Dispute Resolution (PPDR) Explained
Patient-provider dispute resolution (PPDR) lets an uninsured or self-pay patient dispute a bill that is at least $400 above the Good Faith Estimate. The patient has 120 calendar days from the initial bill, and you must stop collections while it is pending.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026In short: the patient-provider dispute process is the federal process under 45 CFR 149.620 for self-pay bills that exceed the estimate by $400 or more. The patient files with HHS within 120 calendar days, a Selected Dispute Resolution entity decides, and you must pause collections and late fees until it ends.
What Is Patient-Provider Dispute Resolution (PPDR)?
Patient-provider dispute resolution (PPDR) is the federal process an uninsured or self-pay patient can use when a bill is far above the good faith estimate (GFE). Under 45 CFR 149.620, the patient files with HHS, HHS assigns an outside Selected Dispute Resolution (SDR) entity, and that entity decides what the patient owes.
PPDR is not the provider-versus-insurer dispute. It runs between a provider or facility and a patient, it is decided on the estimate and the bill, and the patient starts it. When an estimate must be given is covered in our Good Faith Estimates guide. This page covers what happens after the bill arrives.
The CMS page for providers lists three things you may be asked for during a dispute: the estimate you gave the patient, the bill you sent, and any supporting documents that explain why the bill is higher. The sections below turn that into a working checklist.
Who Can Use the PPDR Process?
PPDR is for uninsured and self-pay individuals. The CMS guidance for uninsured or self-pay individuals names three groups: people without health insurance, people with insurance who receive an item or service their plan does not cover, and people with insurance who choose not to use their plan to pay for some or all of the cost.
A patient whose claim goes through insurance is not in this process. That patient is protected by the insurer-side rules, and disputes between you and the plan go through open negotiation and federal IDR instead.
The patient can act through an authorized representative. The rule excludes providers named in the estimate, providers associated with them, their non-clinical staff, and people employed by or associated with a facility that had services in the estimate.
What Is the Dollar Threshold over the Good Faith Estimate?
A bill qualifies when the total billed charges are at least $400 more than the total expected charges on the estimate. Under 45 CFR 149.620(a)(2)(ii), that is the definition of "substantially in excess." CMS repeats it as a bill "at least $400 more than the expected charges on the good faith estimate."
The test is run provider by provider. Under 149.620(b)(1), an item or service is eligible when the total billed charges by a particular convening provider, convening facility, co-provider or co-facility are substantially in excess of the total expected charges for that same provider or facility on the estimate.
If a co-provider on the estimate is replaced, 149.620(b)(2) compares the replacement's bill with the expected charges for the original co-provider. If the replacement gave the patient a new estimate, the comparison uses that new estimate instead.
A patient's estimate from a surgical facility lists $3,000 in expected charges. The final bill from that facility is $3,350. The difference is $350, under the $400 line, so the bill does not qualify. If the bill were $3,400 or more, it would.
How Long Does a Patient Have to Start PPDR?
The patient has 120 calendar days from receiving the initial bill. Under 45 CFR 149.620(c)(1), the initiation notice must be postmarked within 120 calendar days of receiving the initial bill that contains charges substantially in excess of the estimate.
The notice goes to HHS, not to you. The patient can use the federal IDR portal, submit it electronically, or mail it. HHS strongly recommends the portal. The date of initiation is the date HHS receives the notice.
The notice must include the information that identifies the item or service and the date it was provided, a readable copy of the bill, a readable copy of the estimate, your contact information if it is not on the estimate, the state where care was furnished, and the patient's communication preference. The patient also pays the administrative fee.
Count the 120 days from the initial bill, not the last statement.
What Fee Does the Patient Pay?
The patient pays a $25 administrative fee to start the process, according to the current CMS "Dispute a medical bill" page, which calls it a non-refundable fee. The regulation itself does not set the amount: 45 CFR 149.620(g)(2) says the Secretary will specify it through guidance.
CMS's PPDR guidance says the $25 amount may change in future years and that any change will be shared in advance through additional guidance. No notice changes it, so confirm the figure on CMS before you quote it to a patient.
Who bears the fee depends on the result. Under 149.620(g)(1)(iv), the provider is the prevailing party when the SDR entity sets the payment at the full billed charge, and the patient prevails when the entity sets it below the billed charge.
| Outcome | What happens to the $25 fee |
|---|---|
| SDR entity sets payment below the billed charge | The entity subtracts the fee from the amount the patient owes you (149.620(f)(3)(iii)(C) and (g)(1)(ii)). |
| SDR entity sets payment at the billed charge | The fee is not subtracted. The patient pays the billed charge (149.620(g)(1)(iii)). |
| Settlement before a decision | You apply a reduction of at least half the fee, which is $12.50 at the current amount (149.620(g)(1)(v)). |
What Must the Provider Do While a Dispute Is Pending?
You must stop collection activity on the disputed item or service. Under 45 CFR 149.620(c)(5), while PPDR is pending the provider or facility must not move the bill into collection or threaten to, and if the bill is already in collection it should cease collection efforts.
You must also stop late fees. The same paragraph requires suspending the accrual of late fees on unpaid amounts until the process has concluded.
You cannot retaliate. Under 149.620(c)(6), you must not take or threaten retributive action against the patient for using the process.
The SDR entity's notice to both sides must include these requirements. Place a hold on the account the day the notice arrives and tell anyone who works it, including any outside collection vendor.
A patient who paid part of the bill before a decision has not agreed to settle at that amount. Under 149.620(f)(1)(ii), paying billed charges, or a portion, before a determination does not show agreement to that or any other amount.
What Happens After the Patient Files?
HHS assigns an SDR entity, the entity checks the file, and you get 10 business days to send your documents. The SDR entity then has 30 business days to decide. The timeline below follows 45 CFR 149.620; business days are counted the way the federal rules count them.
- Day 0Initial bill sentThe patient receives the first bill with charges at least $400 above the estimate. The 120-day count starts on receipt.
- Within 120 calendar daysPatient filesThe patient sends the initiation notice to HHS and pays the administrative fee. Your collection and late-fee hold begins when the dispute is pending.
- After filingSDR entity assignedHHS assigns an entity. It reports any conflict within 3 business days. HHS then assigns a new entity.
- 21 calendar daysNotice checkedIf the notice is incomplete or the item looks ineligible, the patient has 21 calendar days to add information.
- Within 10 business daysProvider sends documentsAfter the selection notice, you send the estimate, the bill and any support for the extra charge.
- Within 30 business daysDecisionThe entity sets the amount the patient owes, item by item. The decision binds both sides absent fraud or misrepresentation.
How Does the SDR Entity Decide What the Patient Pays?
The SDR entity decides item by item whether you gave credible information that the extra charge reflects a medically necessary item or service and was based on unforeseen circumstances you could not reasonably have anticipated when you gave the estimate. Under 149.620(f)(3)(ii), credible information is information that "upon critical analysis is worthy of belief and is trustworthy."
An SDR entity is a dispute resolution entity certified and contracted by HHS for this process. It is different from a certified IDR entity, which decides provider-payer disputes.
| Situation | Amount the SDR entity sets (149.620(f)(3)(iii)) |
|---|---|
| Item is on the estimate and the billed charge is equal to or lower than the estimate | The billed charge. |
| Item is on the estimate, billed charge is higher, and you did not show credible information | The expected charge from the estimate. |
| Item is on the estimate, billed charge is higher, and you did show credible information | The lesser of the billed charge or the median payment by plans for the same or similar service by similar providers in the geographic area, taken from an independent database. If that median is below the estimate, the estimate applies. |
| Item is not on the estimate and you did not show credible information | $0. |
| Item is not on the estimate and you did show credible information | The lesser of the billed charge or the independent database median. |
The entity adds up the amounts for all items. If the total is lower than the billed charges, it subtracts the patient's administrative fee. It then sends both sides the amount and its reasons, and closes the case.
The estimate for one service is $1,200. The bill is $1,900, a $700 difference, so it qualifies. If you send no credible support, the entity sets $1,200, subtracts the $25 fee, and the patient owes $1,175. If the entity sets $1,900, the patient owes $1,900 and the fee is not subtracted.
The decision is binding on both sides unless there is fraud or evidence of misrepresentation. Under 149.620(f)(4), you may still offer financial assistance or a lower amount, the patient may agree to pay the billed charges in full, or the two of you may agree on a different amount.
What If the Patient's Notice Is Incomplete or Ineligible?
The SDR entity first validates the notice. Under 149.620(c)(4), it checks that the item or service meets the eligibility test and that the notice has the required information, and if not it gives the patient 21 calendar days to send more. That window extends to 35 calendar days if an accessible-format insufficiency notice was requested and not provided within 14 calendar days.
You do not send anything until the entity tells you the item has been found eligible. At that point the 10-business-day clock starts, from your receipt of the selection notice.
Either side can also say the assigned entity has a conflict of interest. Under 149.620(e), the entity must report a conflict to HHS within 3 business days, and HHS then selects a new entity. An entity that is itself a provider, facility or their affiliate has a conflict by definition.
Can the Provider Settle Before a Decision?
Yes. The provider and patient can agree on a payment amount any time after the process starts and before the decision, including financial assistance, a lower amount, or the patient agreeing to pay the billed charges in full.
You must notify the SDR entity as soon as possible and no later than 3 business days after the agreement. Under 149.620(f)(1)(i), the notice must state the settlement amount and date, include documents showing both sides agreed, and show that you reduced the amount by at least half of the administrative fee. The entity then closes the case as settled.
What Should a Provider Keep on File for a PPDR Dispute?
Keep the three items the rule requires you to send, plus a record that shows you met the other duties. The rule requires you to submit the estimate, the billed charges, and, if available, documentation that the difference reflects a medically necessary item or service and was based on unforeseen circumstances.
| Keep on file | Why |
|---|---|
| The estimate as the patient received it, with the date and method of delivery | Required submission under 149.620(f)(2)(i)(A). A readable photocopy or electronic image is accepted. |
| The bill the patient received, with its date | Required submission under 149.620(f)(2)(i)(B), and the date starts the 120-day count. |
| Clinical documentation for each line above the estimate: why the care was medically necessary and what was unforeseen | This is the credible-information test under 149.620(f)(3). Without it, the entity sets the estimate amount. |
| A line-by-line comparison of estimate and bill | The entity decides each item separately, and new items not on the estimate default to $0 without support. |
| Co-provider substitutions and any new estimate issued | These change which estimate the bill is compared with under 149.620(b)(2). |
| The date the account hold was placed, and any collection or late-fee actions stopped | Shows you followed 149.620(c)(5). |
| Any settlement offer, acceptance and the reduction applied | Needed for the 3-business-day settlement notice. |
We recommend assembling this file before the 10-business-day request arrives, because the clock does not leave time to search for records. Those 10 business days start when you receive the selection notice.
Is PPDR the Same as the Federal IDR Process for Payers?
No. Federal IDR resolves payment disputes between providers and health plans for out-of-network care, and PPDR resolves bills between providers and uninsured or self-pay patients. They use different entities, deadlines and fees.
| Row | PPDR | Federal IDR |
|---|---|---|
| Parties | Patient and provider or facility | Provider or facility and plan or issuer |
| Who starts it | The patient, within 120 calendar days of the initial bill | Either party |
| Decided by | SDR entity assigned by HHS | Certified IDR entity |
For the provider-payer side, see our federal IDR process guide and the No Surprises Act hub.
Can a State Process Replace the Federal One?
Yes, if HHS determines the state process meets or exceeds the federal minimums. Under 45 CFR 149.620(h), HHS then defers to the state and sends requests from that state to it. A state process must be binding unless the provider offers a lower amount, consider a compliant estimate, charge no more than the federal fee if it charges one, and have conflict-of-interest standards at least as strong.
This page does not list which states currently have an approved process, so check CMS before telling a patient which process applies.
How We Handle PPDR Disputes
Our work starts with eligibility: was the patient uninsured or self-pay, was a compliant estimate delivered, and does the bill clear the $400 line for that provider. We track the 120-day and 10-business-day dates, hold collections, and assemble the estimate, bill and clinical support the rule asks for.
This sits inside our patient billing work. Our team is offshore plus our registered office in Richmond, KY, and works inside your existing systems. To talk through your self-pay accounts, book a call.
- 45 CFR 149.620 Requirements for the patient-provider dispute resolution process · eCFR
- Providers: payment resolution with patients · CMS
- Dispute a medical bill · CMS
- Good Faith Estimate and Patient-Provider Dispute Resolution process for uninsured or self-pay individuals · CMS
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.
01What is patient-provider dispute resolution (PPDR)?
PPDR is the federal process under 45 CFR 149.620 that lets an uninsured or self-pay patient dispute a bill that is far above the Good Faith Estimate. The patient files with HHS, HHS assigns a Selected Dispute Resolution entity, and that entity decides the amount the patient owes.
02Who can use the PPDR process?
Uninsured patients and self-pay patients, which includes insured patients whose plan does not cover the item or service and insured patients who choose not to use their plan. CMS guidance describes these three groups. Patients whose claims run through insurance are not in this process.
03What is the dollar threshold over the Good Faith Estimate?
The total billed charges must be at least $400 more than the total expected charges on the estimate. Under 45 CFR 149.620(a)(2)(ii), that is what substantially in excess means. It is measured for each provider or facility named on the estimate.
04How long does a patient have to start PPDR?
The patient has 120 calendar days from receiving the initial bill. The initiation notice must be postmarked or submitted in that time to HHS, preferably through the federal IDR portal, with the administrative fee. The rule allows HHS to extend time periods in extenuating circumstances.
05What fee does the patient pay?
CMS currently lists a $25 non-refundable administrative fee. The regulation leaves the amount to HHS guidance, and CMS says it may change with advance notice. If the entity sets payment below the billed charge, the fee is subtracted from what the patient owes.
06Who decides a PPDR case?
A Selected Dispute Resolution entity that HHS certifies, contracts and assigns decides each case. It must have no conflict of interest and must decide within 30 business days after receiving the provider's documents. Its decision binds both sides absent fraud or misrepresentation.
07Can the provider settle before a decision?
Yes. After the process starts and before the decision, you and the patient can agree on an amount. You must notify the SDR entity within 3 business days of the agreement and show a reduction of at least half the administrative fee, which is $12.50 at the current fee.
08What does the provider have to submit?
Within 10 business days of the selection notice, you submit the estimate, the billed charges, and, if available, documents showing the extra charge reflects a medically necessary item or service and unforeseen circumstances. Readable photocopies or electronic images are accepted.
09Does PPDR apply to insured patients who skip their plan?
Yes. CMS guidance lists people with insurance who plan not to use their coverage to pay for some or all of an item or service as eligible, along with people whose plan does not cover the item. Those patients are treated as self-pay for this purpose.
10What happens if the patient wins?
If the entity sets the payment below the billed charge, the patient owes that lower amount, reduced by the administrative fee. For items on the estimate with no credible justification, the amount equals the estimate. Items not on the estimate with no justification come to $0.
11How should we prepare documents for a PPDR dispute?
Keep the estimate as delivered, the bill with its date, clinical support for every line above the estimate, and a line-by-line comparison. Add the account hold date and any settlement records. Gather them before a request arrives, because the window is 10 business days.
Self-Pay Accounts over the Estimate?
We assemble the estimate, bill and clinical support and track every PPDR date for you.