A large share of federal IDR disputes are found ineligible, and the administrative fee isn’t refunded when that happens. Screening claims before filing is the cheapest way to improve outcomes. Work through this checklist for every claim.
1. Is it a qualified item or service?
Federal IDR covers out-of-network claims for:
- emergency services, including post-stabilization services in some cases,
- non-emergency services by an out-of-network provider at an in-network facility, such as a hospital, hospital outpatient department, critical access hospital or ambulatory surgical center, or
- air ambulance services by an out-of-network provider.
Out-of-network services at an out-of-network facility generally fall outside these protections. So do ground ambulance services.
2. Did the patient validly waive protections?
For certain non-emergency services, a patient can consent to be balance-billed through the NSA’s notice and consent process. If a valid consent was obtained, the claim isn’t subject to the NSA payment rules and can’t go to IDR.
Notice and consent isn’t available for emergency services, or for ancillary services such as anesthesiology, radiology, pathology, neonatology, and assistant surgeons, hospitalists and intensivists.
3. Is it the right kind of coverage?
- The patient is covered by a group health plan (fully insured or self-funded), individual or group health insurance, or an FEHB plan.
- It is not a government program such as Medicare, Medicare Advantage, Medicaid or TRICARE. Those have their own payment rules.
4. Does a state process apply instead?
If the claim is governed by a specified state law or an All-Payer Model Agreement, the state process applies and the claim is ineligible for federal IDR. The deciding factor is usually whether the plan is fully insured and regulated by that state, or self-funded under ERISA. See Federal vs. state IDR.
5. Was open negotiation completed?
- An open negotiation notice was sent within 30 business days of the initial payment or denial.
- The full 30-business-day negotiation period has ended without agreement.
See our open negotiation guide.
6. Is the filing on time?
- You are within 4 business days of the end of the open negotiation period, or you have a documented basis for an extension.
7. Is the claim in a cooling-off period?
- There hasn’t been a determination on the same item or service between you and the same plan within the past 90 calendar days of a dispute you initiated. If there has, the claim waits until the cooling-off period ends.
8. If batching, do the claims actually belong together?
Batching multiple claims into one dispute can cut fees significantly, but batches must meet strict criteria. In general:
- same provider or facility (same NPI or TIN),
- same plan or issuer,
- the same or similar item or service, as defined by the service codes, and
- furnished within the permitted time window.
A batch with one ineligible claim can cause problems for the whole submission. Check current CMS batching guidance before combining claims.
9. Is the documentation ready?
- Remittance advice or EOB showing the initial payment or denial, and the QPA
- Copy of the open negotiation notice and proof of when it was sent
- Any counteroffers or correspondence from the negotiation period
- Supporting information for your offer, such as case complexity, acuity, your training and experience, and the network negotiation history with this payer
Why it’s worth the effort
Every ineligible filing costs a non-refundable fee and staff time, and it can use up the deadline you needed to refile correctly. A pre-filing review, even a short one, pays for itself quickly. Teramed runs this check on every claim before a dollar is spent filing.
This checklist is general information, not legal advice. Confirm current requirements at cms.gov/nosurprises.