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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.

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.

Request a free eligibility review