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Independent Dispute Resolution (IDR) Services for Out of Network Claims

Independent dispute resolution is the federal process that lets providers challenge underpaid out of network claims under the No Surprises Act. ZanexMed manages independent dispute resolution from eligibility review to final payment, including deadlines, evidence and offer preparation.
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  • Process check for federal and state rules
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    Independent Dispute Resolution (IDR)

    What Is Independent Dispute Resolution?

    Independent dispute resolution (IDR) is the process where a neutral, certified entity decides how much an insurer must pay for an out of network claim when the provider and the plan cannot agree. The No Surprises Act created the federal process, which took effect in January 2022.

    It covers out of network emergency services, certain non emergency services from out of network providers at in network facilities, and air ambulance services. It does not apply to Medicare, Medicaid or TRICARE.

    Each side submits a payment offer. The IDR entity chooses one of the two offers, and the payer must pay the amount chosen. The Centers for Medicare and Medicaid Services publishes the official rules.

    Federal IDR Timeline

    Deadlines are strict, and a missed date can end a claim. Rules can change, so we confirm the current rules for every claim.
    StepDeadlineWhat happens
    Open negotiation30 business days from the initial payment or denialBoth sides try to agree on a payment amount
    Start IDRWithin 4 business days after open negotiation endsA notice goes to the other party and the government
    Choose an IDR entityWithin 3 business days of the noticeParties agree on a certified entity or one is assigned
    Submit offersWithin 10 business days of selectionEach side sends a payment offer and evidence
    DecisionWithin 30 business days of selectionThe entity picks one of the two offers
    PaymentWithin 30 days of the decisionThe payer pays the amount decided

    How Our Independent Dispute Resolution Services Work

    Our independent dispute resolution services follow six steps, with every deadline tracked from day one.

    1. Claim and eligibility review

    We check that the claim, plan and service qualify, and note every deadline.

    2. Open negotiation

    We open negotiation with the payer to try to settle before IDR.

    3. Start IDR and select an entity

    We send the notice on time and agree on a certified IDR entity.

    4. Evidence and offer

    We build a data backed offer and the supporting documents.

    5. Submit and track

    We submit the case and follow it to a decision.

    6. Collect and learn

    We collect payment and use results to improve the next offers.

    Independent dispute resolution services workflow from underpaid claim to IDR decision

    Which Claims May Qualify for IDR

    Not every claim qualifies. We check each one before anything is filed.
    • Out of network emergency services
    • Certain non emergency services from out of network providers at in network facilities
    • Air ambulance services from out of network providers
    • Plans covered by the No Surprises Act, including many self funded plans
    • Claims where open negotiation did not settle the amount
    • Claims that are still inside the IDR deadlines

    Texas and State Dispute Resolution

    Federal IDR is not the only route. Some states, including Texas, have their own surprise billing laws. In Texas, the process runs through the Texas Department of Insurance and uses mediation for facility claims and arbitration for physician and provider claims.

    State rules usually apply to fully insured plans. Self funded plans typically follow the federal process unless they opt in to the state one. Because the wrong route can end a claim, ZanexMed checks which process applies before filing.

    See our Texas IDR services and the full federal vs Texas IDR comparison. Freestanding ERs can also read our guide to freestanding ER billing in Texas. Anesthesia groups can see our anesthesia IDR services, and EMS agencies our guide to ground ambulance billing in Texas.

    What Wins an IDR Case

    The IDR entity picks one of the two offers, so the offer matters more than the argument. The entity considers the qualifying payment amount (QPA), which is based on the median contracted rate, along with factors such as provider training and experience, market share, patient acuity, case mix and good faith negotiation efforts.

    Offers that are too high or poorly supported tend to lose. We build each offer from data and attach the documents that show why it is fair. Both sides pay an administrative fee, and the losing side generally covers the IDR entity fee, so a realistic offer also protects your cost.

    GOT QUESTIONS?

    Independent Dispute Resolution FAQs

    Independent dispute resolution is a process where a neutral certified entity decides the payment for an out of network claim when the provider and the health plan cannot agree. It was created by the No Surprises Act.
    Out of network providers, facilities and air ambulance providers can use IDR for covered claims, and so can health plans. The claim must be covered by the No Surprises Act and still be inside the deadlines.
    After open negotiation ends, the process runs through filing, entity selection, offers and a decision, which together can take several weeks. The payer then has 30 days to pay.
    The qualifying payment amount (QPA) is generally the plan median contracted rate for the same service in the same area. The IDR entity considers it along with other factors.
    Both sides pay an administrative fee, and the party that loses generally covers the certified IDR entity fee. The amounts change each year, so we confirm them before filing.
    No. Federal IDR does not apply to Medicare, Medicaid or TRICARE claims.
    Federal IDR applies to many self funded plans, while Texas has its own state process for fully insured plans. We check which process applies to each claim.
    Pricing depends on claim volume and value. See our pricing page or contact us for a quote, and use the free IDR Claim Checker to test a claim.

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