The independent dispute resolution process is a fixed sequence of statutory clocks. Here is the full path from an underpaid claim to a paid award, and where disputes are usually lost.
For an eligible out-of-network claim, the plan must pay or deny within 30 days of receiving a clean claim. The amount is usually at or near the qualifying payment amount (QPA) — the plan's median contracted rate for that service in that market.
Either party may start a 30-business-day open negotiation period by sending a compliant notice within 30 business days of the initial payment. This is where deadline #1 is missed most often.
The parties may agree on a rate. If they do, the claim is settled and no IDR fees are incurred. Many payers do not meaningfully engage.
If negotiation fails, the dispute must be initiated in the federal portal within 4 business days of the negotiation period ending. Similar items can be batched. Deadline #2.
The initiating party proposes an IDR entity; the other side can object. If no agreement, the Departments assign one. Both parties pay an administrative fee; the losing party ultimately bears the entity fee.
The IDR entity confirms the dispute is eligible — right service type, right plan type, not covered by a state process, cooling-off period observed. A large share of disputes are challenged here.
Each party submits one payment offer with supporting information. Baseball-style: the arbiter must select one of the two offers, not split the difference.
The IDR entity selects the offer that best represents the value of the service, considering the QPA plus additional factors like training, complexity, market share, and prior contracts. Determinations are binding.
The plan must pay within 30 calendar days. Late payment is common and enforceable only through CMS complaints and penalties, so follow-through matters. A 90-day cooling-off period applies before disputing the same service with the same party.
Send us a sample of recent OON remits. We'll tell you which claims are IDR-eligible, what similar disputes have paid, and what we'd file. No fee unless we win you more.
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