Determining Eligibility for Federal IDR
The Federal Independent Dispute Resolution (IDR) process is a productive mechanism for resolving payment disputes between insurers and healthcare providers. Designed to ensure fairness and transparency, it addresses disagreements over out-of-network charges where insurers and providers cannot agree on payment amounts.
Not every dispute is eligible for the Federal IDR process, and the rules and timelines governing it can be complicated. Additionally, confusion and litigation have resulted in changes and clarifications since the implementation of the No Surprises Act.
The experienced team at FHAS has created a simplified form to assist parties in evaluating eligibility for IDR. This resource is designed to guide you through that initial assessment.
Date of Items or Service
Disputed payments must be for items or services furnished on or after January 1, 2022.
Dispute Type
Federal IDR eligibility is limited to disputes regarding:
- Emergency services
- Non-emergency services provided by an out-of-network provider at an in-network facility
- Air ambulance services by an out-of-network provider
Open Negotiation
Disputing parties are required to participate in a 30-business-day open negotiation period before initiating the IDR process.
Application of No Surprises Act
Both parties must be subject to the processes legislated by the No Surprises Act. Generally, this includes all healthcare providers and facilities that deliver emergency services or out-of-network services at in-network facilities, as well as all group health plans and health insurance issuers of group or individual health insurance coverage.
Billing Responsibility
The IDR process only applies to disputes about the total amount billed, excluding patient cost-sharing.
Time Compliance
IDR requests must be submitted within 4-business-days after the 30-business-day negotiation period ends.
Special Exceptions
In some cases, disputes that would otherwise meet the requirements are not eligible for Federal IDR. These include services provided by certain non-participating providers in specific circumstances. This can also involve disputes addressed by state laws which provide a method for determining the amount of payment or claims subject to a specified state law or All-Payer Model Agreement. These state-specific issues are addressed in further detail below.
Overriding State Laws or All-Payer Model
Federal IDR may not apply in states where a law specifically addresses payment disputes between healthcare providers and payers for out-of-network services.
There are currently 22 states that are considered bifurcated, meaning some out-of-network emergency or non-emergency services are subject to the federal IDR process and others are subject to a specified state law or all-payer model agreement. These bifurcated states include: Alaska, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Maine, Maryland, Michigan, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Texas, Virginia, and Washington.
Six states, Georgia, Maine, Nevada, New Jersey, Virginia, and Washington, also allow self- insured plans to opt into their specified state laws.
In these states, if your claim falls into a category addressed by state law, or a self-insured plan has opted to be covered by specified state laws, it may not be able to proceed under the Federal IDR process.
However, the Federal IDR process does typically apply to self-insured plans sponsored by private employers and /or private employee organizations in all states, except in cases where the state laws allow the plan to opt in to the specified state law or All-Payer Model Agreement. If the self-insured plan elects to do so, some claims may not be eligible for Federal IDR.