Federal IDR Process: Your Right to Fair Arbitration

Requirement 1: Timing

Care received on or after January 1, 2022

The No Surprises Act took effect January 1, 2022. Care before this date is not eligible for federal IDR.

Requirement 2: Dollar Threshold

Balance bill is $400 or more

Federal IDR only applies to bills ≥$400. For smaller bills, file state-level complaints or negotiate directly.

Requirement 3: Protected Service

One of these scenarios:

• ✅ Emergency care at any facility
• ✅ Out-of-network provider at in-network facility
• ✅ Facility-based provider (anesthesiologist, radiologist, pathologist)
• ✅ Air ambulance service

Requirement 4: No Consent

You did NOT sign written consent to:

• ✅ Waive No Surprises Act protections
• ✅ Receive out-of-network care
• ✅ Pay balance billing

⚠️ Consent requires 72-hour notice + specific bill estimate. Generic waivers don't count.

Attempt Direct Resolution (30 Days)

Required first step before IDR:

• 📧 Send dispute letter to provider billing department
• 📋 Cite No Surprises Act violation
• 💰 Demand reduction to in-network rate
• ⏱️ Give 30 days to respond
• 📄 Save certified mail receipt

✅ 40% of cases resolve at this stage.

Gather Required Documentation

Collect evidence for your IDR filing:

• 📄 Copy of surprise medical bill
• 📋 EOB (Explanation of Benefits) from insurance
• 🏥 Proof facility was in-network (insurance card, provider directory screenshot)
• 📅 Date of service documentation
• 📝 Medical records (discharge summary, ER notes)
• ✉️ Copy of dispute letter sent to provider
• 📧 Provider's response (or no response)
• 💳 Insurance card front/back

File Federal IDR Online

Website: www.cms.gov/nosurprises/providers-facilities/disputes

• 🌐 Create account on federal IDR portal
• 📝 Complete online dispute form (20-30 minutes)
• 📎 Upload all documentation (PDF format)
• 💳 Pay $25-$50 administrative fee (credit card)
• ✅ Review and submit
• 📧 Save confirmation email and case number

💡 Fee is refunded if you win your case.

IDR Entity Assignment (7 Days)

Federal government assigns certified neutral arbiter:

• 🏛️ Certified IDR entity selected from approved list
• ⚖️ Arbiter has NO financial ties to either party
• 📧 You receive email with entity name and case number
• 📋 Provider also notified and can submit evidence

Evidence Review Period (15 Days)

Both parties submit evidence to IDR entity:

• 📊 IDR entity requests additional documentation
• 💰 Provider submits their case (billed charges justification)
• 📋 You can submit additional evidence (optional)
• 🔍 IDR entity reviews all submitted materials

IDR Decision (30 Days Total)

Within 30 days of filing, you receive final decision:

• 📧 Decision sent via email and mail
• 💰 IDR entity selects payment amount (usually QPA)
• 🔒 Decision is legally binding on both parties
• 🚫 No appeals allowed (with rare exceptions)
• ✅ Provider must accept and cannot balance bill you

Outcome Implementation (15 Days)

Provider must comply with IDR decision:

• 💳 If you win: Provider waives balance, insurance pays agreed amount
• 💵 If provider wins: You pay amount determined by IDR entity
• 💰 Administrative fee refunded if you win
• 📧 Updated bill sent within 15 days
• 🏦 Collections removed if bill was in collections

Balance Bill Waived

Provider MUST accept IDR decision and cannot charge you more than in-network cost-sharing (copay/coinsurance).

Filing Fee Refunded

Your $25-$50 administrative fee is refunded within 30 days.

Collections Removed

If bill was sent to collections, provider must remove from collections agency and credit bureaus.

Updated Bill Sent

Provider sends corrected bill showing only your in-network cost-sharing amount within 15 days.