Out-of-network billing and IDR disputes

What is out-of-network billing and IDR?

Out-of-network billing is the work of getting paid fairly when your hospital, emergency department or group has no contract with the patient's plan. Under the No Surprises Act (NSA), the patient is protected from balance bills for many of these services, so the dispute is between you and the insurer.

Independent dispute resolution (IDR) is the federal process that settles that fight. A certified IDR entity reviews two offers, yours and the plan's, and picks one. Before that, the sides must try open negotiation, a 30-business-day window to settle.

Our job is the whole chain: screen the claim, prepare the open negotiation notice, move to IDR when talks fail, prepare the offer, track the fee and follow the payment until the money is in your account. You send the claims, records and remittances and pay the IDR fees when we tell you they are due. The rules are on our No Surprises Act hub.

Which disputes qualify for federal IDR?

A dispute qualifies when the service falls under the NSA protections and no state law sets the payment. Under 45 CFR 149.510(a)(2)(xi), that means an emergency service from a nonparticipating provider or facility, a nonparticipating provider's service at a participating facility, or air ambulance service, where the notice and consent exception does not apply.

Two exclusions catch teams by surprise. If a specified State law determines the out-of-network rate, the item is not a qualified IDR item. And a party may not start federal IDR if it knows, or reasonably should have known, that the provider got valid notice and consent (see notice and consent).

This is why we check jurisdiction first. At screening we verify benefits for every patient you send each day. Self-funded (ERISA) plans go to federal IDR, and fully insured plans regulated by a state go to that state's process. Medicare (including Medicare Advantage) and Medicaid (including Medicaid managed care) claims are outside the No Surprises Act dispute process.

Eligibility is then confirmed from the remittance remark codes. Payers must use specified remark codes to show whether a claim is subject to the Act for services on or after January 1, 2027. Since August 3, 2026, the rule also requires the plan's legal name, sponsor and registration number with the initial payment or denial, though registration depends on a registry that is not running yet. We also confirm the service was in an emergency department or freestanding emergency department.

How does the federal IDR process work step by step?

The federal IDR process runs in six stages: open negotiation, IDR initiation, entity selection, offers and fee, determination and payment. Each has its own clock in 45 CFR 149.510, and the table gives the deadline and the paragraph that sets it.

For your own dates, use our NSA deadline calculator and read the federal IDR process.

How long is the open negotiation period, and can we skip it?

Open negotiation lasts 30 business days, and you cannot skip it. Under 45 CFR 149.510(b)(2)(i), either party may start federal IDR only for an item the parties have not agreed on by the last day of the open negotiation period, and the filing window opens the first business day after that day.

The clock to start it is short: 30 business days from the day you receive the initial payment or denial, so we track the receipt date of every remittance, not the date of service.

The notice must carry your offer of an out-of-network rate for each item or service (45 CFR 149.510(b)(1)(ii)(A)(7)). We set it from the QPA and the facts of the claim. The 2026 rule adds a response from the receiving party by the 15th business day, but that part is not in force yet: it waits for the Departments to announce portal functionality, plus 90 days. The full mechanics are on open negotiation under the NSA.

What do we need from you, and what goes in the dispute file?

From you we need the UB-04 and CMS-1500 claim forms, the medical records, the remittances (835 ERA files or EOBs) and any payer contracts. Section 149.510(b)(1)(ii)(A) lists twelve items for the open negotiation notice, and we build the file around them so the same record carries into IDR.

• Your legal business name and contact details, and the plan's registration number or an attestation that it was not available.
• Dates of service, the date you received the initial payment or denial, and the payment amount.
• The QPA, if the plan gave it to you, and your offer for each item or service.

Under 45 CFR 149.140(d)(1), the plan must send the QPA for each item with each initial payment or notice of denial. When a remittance leaves it out, we ask in writing and log the request. The offer in IDR must show a dollar amount and the matching percentage of the QPA (45 CFR 149.510(c)(5)(i)(A)(1)).

Every case starts from a dedicated email address. Printed documents and proof of submission go in a separate folder for each case, so dates and notice delivery can always be shown.

Who pays the IDR fees, and what happens if one is missed?

You pay the administrative fee and the IDR entity fee, and we track every fee deadline. We tell you in writing when each fee is due, so no fee date passes unnoticed.

The dates matter because a party that does not pay on time has its offer treated as not received, and it still owes the fee (45 CFR 149.510(d)(1)(ii) and (d)(2)(iii)). The administrative fee is due when the certified IDR entity is selected. It is $15 per party per dispute for disputes initiated on or after June 11, 2026, and it is non-refundable. The entity fee is due no later than the date a party submits its offer.

The entity keeps the non-prevailing party's fee and returns the prevailing party's fee within 30 business days after the determination (45 CFR 149.510(d)(1)(iii)). Entity fee amounts are set by notice, so we confirm the current amount before each filing.

What happens after the IDR decision?

The decision is binding, and payment is due within 30 calendar days. Under 45 CFR 149.510(c)(5)(ix), the selected offer, minus the initial payment and the patient's cost sharing, is paid directly to the provider or facility within 30 calendar days after the determination.

The rule runs both ways: if the selected offer is lower than the initial payment plus cost sharing, the provider owes the plan the difference within the same 30 calendar days. We check every award against the payment received.

A decision is binding unless there was fraud or intentional misrepresentation of material facts (45 CFR 149.510(c)(5)(vii)(A)). After a determination, the initiating party cannot file again against the same other party for the same item or service for 90 calendar days.

Section 149.510 does not turn a decision into a standing rate for later claims, so each new underpaid claim goes through the process again. If payment is late or wrong, we follow up with the plan and file a complaint with the No Surprises Help Desk (1-800-985-3059), as the Departments advise. Our practice is to escalate when 45 days pass without payment, though the rule's own deadline is 30 calendar days.

How do batching rules affect small emergency claims?

Batching lets you put up to 50 qualified items into one dispute under one batched fee, which makes low-dollar emergency claims worth disputing (45 CFR 149.510(c)(4)(i)). The items must come from the same provider or facility, the same plan, similar treatment and the same 30-business-day period. For the full tests and the rules on bundled arrangements, see batching claims in federal IDR.

Do you work Texas TDI and other state pathways?

Yes. A fully insured plan regulated by a state goes to that state's process, and we work those pathways alongside federal IDR. In Texas, that covers fully insured plans regulated by the Texas Department of Insurance, usually marked TDI or DOI on the card, plus state employee (ERS, including HealthSelect) and teacher (TRS) plans. They use Texas mediation or arbitration. Self-funded employer plans use federal IDR.

State filing windows, forms and eligibility rules differ by state, so we pull them from the state's own source at the start of each case. See state surprise billing laws and the federal NSA.

How far back can you go on older claims?

We go back as far as each payer's filing limits allow, within the federal IDR windows. Open negotiation must start within 30 business days of the initial payment or denial, and IDR must generally start within 4 business days after it ends. A claim outside those windows cannot enter federal IDR.

Other routes, such as a state process or prompt-pay rights, may still exist depending on the plan and state. We review those options on a call.

How do you report results, and what are your win rates?

Reports are monthly and customized to what you need, and day-to-day updates go by email. An NSA client dashboard is being built. We measure four things from verified case-level data:

Our totals: 1,800 to 2,000 IDR cases finalized, and about 75% average win ratio. We show win rates by payer on a call, as totals with no patient or client details. We do not share references or sample dispute packages, because they contain other clients' and patients' information.

How does a case run from screening to payment?

A designated NSA team owns every case, and every step has a date on it.

Onboarding takes up to one week, and we agree the exact plan on the call. NSA and IDR work is a monthly retainer based on your volume of eligible IDR patients, quoted on a call; see pricing. This work sits next to our denial management, A/R recovery and payer contracting services. Emergency groups can read our emergency department page. To review your own underpayments, book a call.