The federal arbitration process created by the No Surprises Act for resolving out-of-network payment disputes between providers and health plans. A certified entity selects one of the two submitted offers.
The health plan's median contracted rate for the same or a similar service in the geographic region, calculated under federal methodology. It sets the patient's cost-sharing basis and is a factor the certified entity must consider.
The mandatory 30-business-day period in which the provider and plan attempt to settle a payment dispute before IDR can be initiated.
The formal notice that starts the open negotiation period. It must be initiated within 30 business days of the initial payment or denial.
An organization certified by the Departments of Health and Human Services, Labor, and Treasury to conduct federal IDR determinations.
Combining multiple disputed line items into one IDR dispute. Permitted for items involving the same payer and the same or related service codes on consecutive days, capped at 50 line items.
A determination format in which the arbiter must select one party's offer in full and may not split the difference or substitute its own figure. Federal IDR uses this format.
Billing a patient for the difference between the provider's charge and the amount the plan pays. Prohibited under the No Surprises Act for emergency services and for out-of-network ancillary services at in-network facilities.
Anesthesiology, radiology, pathology, neonatology, assistant surgeon, hospitalist, and intensivist services. Balance-billing protections for these cannot be waived by patient consent.
The process by which certain out-of-network providers may obtain patient agreement to be balance-billed. It is unavailable for emergency services and for ancillary services.
A written estimate of expected charges that must be provided to uninsured and self-pay patients. A separate track from provider-payer IDR.
The process available to a self-pay patient billed at least $400 more than the good faith estimate. Distinct from federal IDR.
The fee each party pays to the Departments to participate in a dispute, set at $15 per party per dispute by the final rule published June 4, 2026.
The fee charged by the entity conducting the determination, within ranges published by the Departments — roughly $200 to $840 single and $268 to $1,173 batched.
A state's division of surprise-billing disputes between its own process and the federal process, typically by plan type. 21 states use some form of bifurcation.
The considerations a certified entity may weigh alongside the QPA: provider training and experience, market share of the parties, patient acuity and case complexity, facility teaching status and case mix, and prior contracted rates between the parties over the preceding four years.
Considerations the certified entity may not weigh: usual and customary charges, billed charges, and public payer reimbursement rates including Medicare and Medicaid.
The phased CMS system for federal IDR submissions introduced under the 2026 final rule.
Definitions reflect federal regulation current as of September 9, 2026, including the CMS final rule published June 4, 2026. This is operational reference material, not legal advice.
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