IDR process overview

    Eligibility checklist

    Check the claim facts before choosing federal IDR.

    Screen out-of-network claims for federal IDR by checking service category, facility context, plan type, state law, timing, and payer response.

    Potential federal IDR categories

    • Out-of-network emergency services, including qualifying post-stabilization services.
    • Certain non-emergency services by an out-of-network provider during a visit to an in-network hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center.
    • Out-of-network air ambulance services covered by the No Surprises Act.

    Claims that need another route

    • Coverage denials or medical-necessity denials that belong in an appeal or external review.
    • In-network underpayments governed by a provider contract.
    • Scheduled services where the patient knowingly chose an out-of-network provider at an out-of-network facility.
    • Ground ambulance services and care outside the three protected federal categories.
    • Medicare, Medicaid, CHIP, TRICARE, and other coverage outside the commercial federal IDR framework.

    Pre-filing review

    Six checks before recommending a route.

    1. 01Identify the exact payer product, plan type, and whether the plan is fully insured or self-funded.
    2. 02Confirm the service setting, facility network status, provider network status, and service category.
    3. 03Match the claim state, facility state, dates of service, and any applicable state surprise-billing law.
    4. 04Review the EOB, initial payment or denial notice, QPA information, adjustment codes, and payer correspondence.
    5. 05Calculate the open negotiation and IDR deadlines from retained source documents—not from memory.
    6. 06Confirm the claim has not already been resolved, released, or routed through an incompatible process.

    Operational guidance

    This guide is educational, not a claim-level routing determination. Verify the current federal instructions, plan and payer facts, state law, and exact dates before filing.

    CMS federal IDR overviewCMS deadline summary

    Continue your review

    IDR process managementIDR process overviewNo Surprises Act guideContact MedRes