2) Which claims are eligible for Federal IDR?

OON emergency services, OON non-emergency services at certain in-network facilities, and OON air ambulance—when no applicable State All-Payer model or “specified state law” sets the OON rate. IDR applies only if the NSA protections apply and the plan’s initial payment or denial is disputed after open negotiation. If a qualifying state law governs OON payment (or an All-Payer model applies), that typically controls instead of Federal IDR. Some nonemergency services may be excluded if a valid NSA notice-and-consent waiver was obtained.

3) What settings count as “in-scope” for NSA non-emergency protections?

Hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers (ASCs). 
NSA’s non-emergency protection generally does not extend to office-based settings. Ancillary services like anesthesia, pathology, radiology, neonatology, assistant surgeons, hospitalists, and intensivists at in-network facilities are always protected (no balance billing).

4) What is not covered?

Ground ambulance; services where a valid notice-and-consent waiver applies; and services paid by Medicare, Medicaid, TRICARE, VA, or IHS (already protected by program rules). Also, if state law sets the OON rate for insured plans, Federal IDR won’t apply (though state processes may). Federal IDR only addresses provider-plan payment disputes for NSA-protected items/services in eligible circumstances.

5) What’s the Qualifying Payment Amount (QPA)?

The plan’s median contracted rate (generally 2019 median), adjusted for inflation, for the same/similar service in the same geographic region and specialty. QPA sets patient cost-sharing and is one factor IDR entities must consider—along with other credible case-specific information. Public payer rates (Medicare/Medicaid) and “usual & customary” charges are prohibited factors.

6) What are the standard IDR timelines?

• Initial payment/denial by plan: within 30 calendar days of clean claim.
• Open negotiation: 30 business days.
• If unresolved, initiate IDR within 4 business days after negotiation ends. 

After IDR is initiated, parties jointly select a certified IDR entity within 3 business days (or the Departments assign one). Each party then submits its offer and materials (generally within 10 business days after selection). The IDR entity must pick one offer within 30 business days of selection. Payment of the final amount is due within 30 calendar days.

7) What is the 90-day “cooling-off” period?

After an IDR decision between the same two parties for the same item/service code, you generally can’t start a new IDR on that item/service for 90 calendar days. You can still negotiate and submit additional claims for the same item/service during the cooling-off, and those can be batched if they meet batching rules (e.g., same plan, similar condition, within the stated time window).

8) How much does IDR cost?

There’s a $115 administrative fee per party per dispute (for disputes initiated on/after Jan 22, 2024; still in force in 2025), plus a certified IDR entity fee set within federal ranges. The loser pays the IDR entity fee; the winner gets its IDR entity fee refunded. The $115 admin fee is non-refundable. For 2025, federal fee ranges remain $200–$840 for single determinations and $268–$1,173 for batched determinations (entities publish their fixed fees). Always verify the current list and fees when selecting an IDR entity.

9) Who are the certified IDR entities and how do we choose one?

HHS/DOL/Treasury maintain a live list; parties have 3 business days to agree on one after IDR initiation or the Departments assign one. Entities must meet arbitration, claims, clinical, coding, and legal expertise standards and attest to impartiality. Review posted fees/scope and state availability before selection.

10) Can I “batch” multiple claims in one IDR?

Yes—if they’re billed by the same provider (NPI/TIN), paid by the same plan, relate to a similar condition, and were furnished in the same 30-business-day period (or negotiation ended in the same 90-day cooling-off period). 
Air ambulance base + mileage for a single transport can be batched; different markets may produce different QPAs inside one batch. IDR entity fees for batched cases must stay within federal ranges unless specially approved.

11) What’s the difference between “batched” and “bundled”?

Batched = multiple separate claims considered together for one determination; Bundled = multiple items/services on the same claim considered together. Both approaches streamline like items/services, but the eligibility criteria and fee treatment can differ. Confirm with your IDR entity’s posted rules/fees.

12) What can the IDR entity consider?

The QPA and any credible additional information tied to the parties’ offers (e.g., training/experience, patient acuity, market share, teaching status/case mix, past contracting history). 
Prohibited: “Usual & customary” charges, billed charges, and rates paid by public programs (Medicare/Medicaid/TRICARE/VA/IHS) or amounts pegged to those rates. The IDR entity must pick one of the two offers—no “splitting the difference.”

13) When is payment due after a decision?

Within 30 calendar days after the IDR entity selects the winning offer. Patient cost-sharing doesn’t change due to the IDR outcome. The losing party must also pay the IDR entity fee; the prevailing party’s IDR entity fee is refunded within 30 business days. Administrative ($115) fees are not refunded.

14) When does state law override Federal IDR?

If a “specified state law” or All-Payer model applies to an insured plan for the service, that sets the OON rate and process—Federal IDR generally doesn’t apply. For self-funded ERISA plans, Federal IDR typically applies unless a plan voluntarily opts into a state process (where allowed). Always check state applicability during eligibility review.

15) What are my main NSA obligations as a provider/facility?

Don’t balance bill in protected scenarios; give required patient disclosures; cooperate with cost-sharing based on QPA; and follow timelines for negotiation/IDR. Post and provide the federal model disclosure on balance billing protections; ensure claims and EOB exchanges include required QPA info; and maintain records. For uninsured/self-pay patients, provide Good Faith Estimates (GFE) and follow the Patient-Provider Dispute Resolution (PPDR) rules.

16) Are there penalties for noncompliance?

Yes—HHS may impose civil monetary penalties up to $10,000 per violation for certain NSA violations. 
Enforcement spans posting/notice failures, unlawful balance billing, and other NSA breaches. State regulators and other federal agencies may also have roles depending on the scenario.

17) What is the Good Faith Estimate (GFE) and PPDR (for uninsured/self-pay)?

Providers must furnish a written GFE of expected charges when care is scheduled (or on request). If the final bill is $400+ above the GFE, the patient may trigger PPDR with a certified SDR entity. 
GFE must be timely and comprehensive to the extent known. PPDR is a separate consumer process (not the provider-plan IDR) to resolve excessive variance. Keep your GFE workflows tight to reduce PPDR exposure.

18) What should I include in my IDR submission?

Your payment offer, the plan’s QPA and claim data, and credible supporting facts (training/experience, acuity/complexity, market share, teaching status/case mix, negotiation history/past rates). Exclude prohibited factors. Organize by factor, cite codes/clinical context, include comparable in-network rates where relevant, and clearly tie why your offer best reflects the appropriate OON rate for these services in this market.

19) What if the plan says Federal IDR doesn’t apply?

During eligibility review, either party can raise applicability issues (e.g., state law applies, notice-and-consent waiver, not an NSA-protected setting). The IDR entity (or Departments) resolve eligibility. If deemed ineligible, the dispute is dismissed; admin fees may still apply. Consider state processes or contract remedies as appropriate.

20) How long does the whole process take, end-to-end?

Typical pathway: 30 calendar days to initial payment/denial → 30 business days open negotiation → ~6–10 weeks through IDR selection, offers, decision, and payment. Timelines can vary with batching and portal volume. 
The rulebook clocks are fixed (see Timelines above), but practical durations depend on portal and party responsiveness. Track every clock to avoid dismissal or defaults.

21) How does CollectionPro make NSA/IDR easier?

We screen eligibility, plan/state applicability, and batching potential; run open negotiation; craft IDR-ready files with QPA analytics, clinical context, and factor-based arguments; and manage fees, clocks, and follow-through to payment.
Our team optimizes codes, units, modifiers, comparable rates, and market analyses; selects the right IDR entity; assembles evidence against prohibited factors; monitors deadlines; and enforces post-decision payment—minimizing write-offs and admin overhead for OON claims.

22) What do you need from us to start?

Claim/EOB data, clinical summaries, prior negotiations, and any state-law notices/waivers. We’ll send a lightweight checklist and secure data template so we can quickly validate IDR eligibility, batching strategy, and the strongest evidence set for your offers.

23) Is CollectionPro a law firm?

No, CollectionPro is not a law firm and does not provide legal advice. CollectionPro provides IDR support, strategy, documentation, and dispute management services. For strict legal interpretation of the No Surprises Act and IDR regulations, please consult your legal counsel.

24) Does CollectionPro work with payers?

No. CollectionPro works exclusively with healthcare providers. CollectionPro never represents or provides consultation for insurance companies or payers. Its only focus is helping healthcare providers recover underpaid claims.

25) Who pays the fees, and when?

Each side pays the $115 admin fee up front; the losing party pays the IDR entity fee (winner gets its IDR entity fee refunded). Admin fees are not refunded. Our engagement can be fixed-fee or success-based. We’ll recommend a filing strategy (single vs. batched) that balances award likelihood against fee exposure.

26) What happens if a dispute is dismissed as ineligible?

The IDR admin fee can still be owed; entity fees depend on stage and cause of dismissal. We strive to catch eligibility issues (state law, setting, valid consent) before filing to avoid sunk fees.

27) Do you handle appeals?

IDR determinations are generally binding—there’s no standard “appeal,” but disputes may be re-filed after the cooling-off period for new claims. We do pursue post-determination compliance (payment within 30 days), escalate non-payment, and advise on alternative remedies where appropriate.

28) Does IDR change the patient’s bill?

No. Patient cost-sharing is based on in-network levels/QPA and does not change because of the IDR outcome. 

IDR only decides the plan-provider OON payment. Balance billing remains prohibited in NSA-protected scenarios.

29) Do offices/urgent cares get NSA protection for non-emergencies?

Generally, NSA’s non-emergency protections are tied to hospitals/HOPDs/critical access hospitals/ASCs—not typical office settings. Emergency and air ambulance protections still apply per statute. Always verify the facility type and circumstances before filing.

30) What if our billed charges are much higher than QPA?

Billed charges and “usual & customary” are prohibited IDR factors; focus your evidence on allowed circumstances (training, acuity, complexity, teaching status, market share, contracting history). We present factor-driven evidence to show why your offer is the most reasonable OON rate in this market for these specific services.

31) What are my disclosure duties to patients?

Post the federal balance-billing disclosure, prominently provide it to patients (paper/email), and place it on your public site; use the CMS model notice. For uninsured/self-pay, provide GFEs on schedule; PPDR may be available if the bill is ≥$400 above the GFE. Train front-desk/revenue teams on these steps.

• Open negotiation: 30 business days. IDR initiation: within 4 business days after negotiation ends. Entity selection: 3 business days. Offers: generally 10 business days after entity selection. Decision: 30 business days after selection. Payment: 30 calendar days.
• Admin fee: $115 per party per dispute (effective Jan 22, 2024; applies in 2025). Non-refundable. IDR entity fees within posted ranges.
• Batching basics: same provider (NPI/TIN), same plan, similar condition, same 30-business-day period (or same 90-day cooling-off window).
• Prohibited factors: billed charges, U&C, public payer rates (or pegged to them).
• State law may control OON payment in insured plans where specified; Federal IDR otherwise.