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IDR eligibility checklist

Is your claim eligible for federal IDR? (2026 checklist)

Ineligible filings are the biggest waste of money in IDR — 42% of disputes in late 2025 were challenged on eligibility. Run a claim through this checklist before you file.

Interactive checklist

Answer for one claim.

  • Was the service furnished on or after Jan 1, 2022?
  • Is it emergency care, post-stabilization care, out-of-network care at an in-network facility, or air ambulance?Other services (e.g. elective OON office visits) don't qualify.
  • Is the coverage a commercial group or individual plan, or FEHB?Medicare, Medicaid, TRICARE, and uninsured/self-pay claims are excluded.
  • Is the plan self-funded (ERISA), or is the state one where the federal process applies to this claim?In bifurcated states, fully insured plans often go to a state process. See state guide.
  • Did the patient sign a valid notice-and-consent waiver?If yes for a non-emergency service, the claim may fall outside the NSA.
  • Are you within 30 business days of the initial payment/denial (or has open negotiation already been sent on time)?
  • Has it been at least 90 days since a prior IDR determination for the same item/service with this party?The 90-day cooling-off period.

Guidance only, not legal advice. Eligibility depends on facts we can't see here (plan documents, state law, prior disputes). We verify each claim before filing.

Short answer. A claim is eligible for federal IDR if it is for an item or service covered by the No Surprises Act — emergency services, or out-of-network services at an in-network facility — is not covered by a qualifying state process, and has completed the required 30-business-day open negotiation period. Ground ambulance services are not covered.

The rules behind the checklist

Federal IDR is available only for qualified IDR items and services: emergency services (including post-stabilization), non-emergency services by out-of-network providers at in-network facilities, and out-of-network air ambulance — furnished to people covered by group health plans, individual coverage, or FEHB, and only where no specified state law or All-Payer Model Agreement determines the out-of-network rate. Medicare, Medicaid, and other public programs are excluded, as are claims where a valid notice-and-consent waiver applies.

Timing rules are strict: open negotiation must be started within 30 business days of the initial payment or denial, IDR must be initiated within 4 business days after the 30-business-day negotiation period, and the same parties can't re-dispute the same item within the 90-day cooling-off period after a determination.

In the 22 bifurcated states, whether a claim goes federal or state depends mostly on whether the plan is self-funded (federal) or state-regulated (state process), with opt-in wrinkles in Georgia, New Jersey, and a few others.

Screening is the highest-value step in IDR. We do it claim by claim from your remits before anything is filed. Free claims review.

Find out what your out-of-network claims are actually worth.

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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