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Knowledge Base
IDR rules, processes, and decision trees
Eligibility Rules
Process & Timelines
Federal vs. State
Submission SOP
Research Findings
IDR Eligibility — Core Rules
Golden rule: Some payment must be applied. If any portion of the claim received a deductible, copay, coinsurance, or partial payment — the case is IDR-eligible.
Multi-CPT Code Cases
If a claim has multiple procedure codes and at least one received payment → file IDR on that code only. Do not include fully denied codes in the same filing.
Automatic Disqualifiers
- Pure denial — no payment applied at all → must appeal first
- Prior authorization failure — not eligible
Medical-necessity and experimental/investigational denials are also disqualifiers — see the full Not NSA-Eligible table below, which captures the appeal-first nuance for those.
Not NSA-Eligible — Claim Types — Jun 2026
Source: Callagy eligibility screen list. Use as the front-line screen before working a case.
| Claim type | Eligible? | Note |
|---|---|---|
| Medicaid / Medicare plans | ❌ Not eligible | Government plans are outside NSA. |
| Total billed amount is patient's responsibility | ❌ Not eligible | No payer payment dispute exists. |
| Denial — untimely filing | ❌ Not eligible | May move forward after a successful appeal. |
| Denial — not medically necessary | ❌ Not eligible | May move forward after a successful appeal. |
| EOB marked as duplicate | ❌ Not eligible | Exception: eligible if an original EOB exists AND billed charges match the new EOB. |
| Denial — cosmetic | ❌ Not eligible | May move forward after a successful appeal. |
| Denial — experimental / investigational procedure | ❌ Not eligible | May move forward after a successful appeal. |
| Denial — "Services were not rendered as billed" | ❌ Not eligible | — |
Appeal first, then re-screen: several of the above (untimely filing, not medically necessary, cosmetic, experimental/investigational) are not currently IDR-eligible but may become eligible after a successful appeal that reverses the denial and applies payment. Don't close these outright — flag for appeal where the merits support it.
NCCI Edits (CO-97) — May 2026
When a claim is denied CO-97 (National Correct Coding Initiative edit — payment for one code is bundled into another), this is a coding/billing dispute, not a payment dispute. Not IDR-eligible.
Exception: if the payer is applying NCCI edits incorrectly (modifier should override the edit), document this and escalate to Callagy — it may be a billing error to correct upstream.
Assistant Surgeon Rule — May 2026
Assistant surgeon services (modifier -80, -81, -82, -AS) are eligible for IDR only when: (1) the primary surgeon's claim is IDR-eligible, and (2) the assistant's denial is tied to the same payment dispute, not a separate medical necessity or credentialing issue.
Assistant-not-medically-necessary denials: if the EOB states an assistant surgeon was not medically necessary for a service, this can also result in a dismissal. Submit proof the assistant was necessary and have the claim reprocessed before treating it as IDR-eligible.
Virginia State Arbitration — "State Law Applied" EOBs — May 2026
Gate: When Availity EOB shows "State Law applied," this is a VA state arbitration case — not Federal NSA. VA state arbitration only accepts emergency services. Elective cases are a dead end.
| Scenario | VA State Arb? | Path |
|---|---|---|
| OON emergency, fully-insured | ✅ Eligible | Route to VA state arbitration |
| OON elective, fully-insured | ❌ No | No IDR path — document and close |
| OON elective at in-network facility, self-funded | ❌ VA / ✅ Federal | Re-screen for Federal NSA (ERISA plan required) |
| OON elective at in-network facility, fully-insured | ❌ No | No IDR path — appeal only |
Screening sequence: (1) Emergency? If no → stop. (2) If elective + in-network facility → check plan type. Self-funded ERISA = Federal NSA eligible. Fully-insured = no IDR path.
Settlement vs. Arbitration — Decision Logic — Jun 2026
Source: Gottlieb & Greenspan (Evan J. Gilman, external arbitration counsel). Applies once a VA case is in state arbitration and a payer settlement offer is on the table.
How the arbitrator sets the number: each CPT is given an index/range bounded by FH Allowed (lower) and FH Charged (upper) — FAIR Health benchmarks. The arbitrator "more often than not" lands between the two. Codes left off the fee index (e.g. CPT 32900) fall to a UCR analysis.
Settle or refer: stack the expected award per CPT across the FH Allowed → FH Charged band (UCR for off-schedule codes). If the offer is ≈ or above that estimate → accept (arbitration is unlikely to beat it and carries downside risk of landing lower in the range). If the offer is materially below → refer to arbitration.
Partial settlements — preserve arb rights: an offer may capture only part of the billed charges (e.g. one side of a bilateral / one instance on the HCFA). Confirm which portion the agreement releases before signing — language is often ambiguous. Accepting releases only the captured portion; any HCFA portion not included remains a basis to arbitrate if the payer later pays on it.
Process & Timelines
Critical: The 30-day IDR filing window runs from the EOB date, not the date of service.
⚠ Research Flag: The timeline sequence below reflects current Callagy operational practice. Research (May 2026) identified that the federal regulation (45 CFR 149.510) sequences the Open Negotiation Notice → 30-BD negotiation → 4-BD IDR initiation window differently than described here. Pending Callagy validation — see Research Findings tab for full detail.
4-Business-Day Correction Window
After Auctus notifies the payer of an underpayment, the payer has 4 business days to issue a corrected payment before IDR can be initiated. If they correct within 4 days — case closes. If not — file IDR.
EOB Timestamp Rule
Use the EOB date (Explanation of Benefits) as the anchor date for all deadline calculations, not the date of service or date of billing.
Untimely Filing Dismissals
If the IDR filing window has passed, the case is presumed ineligible. Note: CMS FAQ Part 69 allows an extenuating circumstances extension for documented extraordinary events (portal outages, natural disasters). Document before closing.
Post-Negotiation Arbitration Window
After the 30-day negotiation period ends without resolution, there is a 4-business-day window to initiate IDR at the NIDRS portal. Missing this window forfeits the case.
Key Dates Summary (per 45 CFR 149.510)
- Day 0: EOB received from payer
- Within 30 BD of EOB: Send Open Negotiation Notice (OMB 1210-0169) to payer
- +30 BD: Open negotiation period — if no agreement reached
- +4 BD: File IDR initiation notice at nsa-idr.cms.gov (NIDRS portal)
- +3 BD: Joint selection of certified IDR entity (or CMS assigns)
- +10 BD: Parties submit offers + supporting documentation
- +30 BD: IDR entity issues determination (baseball-style)
- +30 days: Payment due from payer after determination
Post-Award: Expect Non-Payment
EDPMA 2024 data: 69.2% of IDR awards are not paid by payers without enforcement action (up from 24% in 2023). Winning the award is not the end — post-award follow-up is now standard. Enforcement paths: DOL complaint, state insurance department, state court action. See Research Findings tab for jurisdiction-specific enforcement options.
Federal vs. State Determination
Follow this 5-step lookup in order. Stop when you have a definitive answer.
Step 1
Check the EOB — does it reference a state insurance department or state law?
✓ Yes → State IDR process. VA note: If Availity shows "State Law applied," confirm the service was an emergency before routing. Elective cases do not qualify for VA state arbitration — see Eligibility Rules tab for the full decision tree.
✗ No → Continue to Step 2
Step 2
Check ERA or Availity — does the plan description indicate fully-insured state plan? AND is the state one of the 21 SSL states?
✓ Fully insured + SSL state confirmed → State IDR process. SSL states: CA, CO, FL, GA, IL, IA, KY, ME, MD, MA, MI, MN, MO, NV, NJ, NY, OR, TX, VA, WA + others — confirm in Research Findings tab
✗ No — OR fully insured but non-SSL state → Federal IDR. (29 states + DC have no approved state IDR law — federal IDR applies even for fully insured plans)
Step 3
Texas cases only — check the insurance card for TDI or DOI marking.
✓ TDI/DOI present → State (Texas) IDR process
✗ Not present → Continue to Step 4
Step 4
Is the employer name visible on the card? Self-funded status is a plan design choice, not a size threshold — employer size is not a reliable indicator. If the employer name is visible, call the payer (Step 5).
✓ Known self-funded employer confirmed by prior lookup or payer call → Federal IDR (NSA / ERISA)
✗ Cannot confirm from card alone → Continue to Step 5 payer call. Do not infer self-funded status from employer size.
Step 5
Call the payer: "What is the funding type? Is this plan fully or partially funded, and what state is it funded in?"
✓ Fully insured → State process
✗ Self-funded / ERISA → Federal process
When genuinely uncertain after all 5 steps: Default to federal IDR first (shorter timeline). State filing only when state SSL law is confirmed applicable — dual-filing costs $230+ in non-refundable fees and risks jurisdictional dismissal.
⚠ ERISA Opt-In States (NJ, VA, GA, ME, NV, WA): In these 6 states, state law supersedes federal NSA for self-funded plans. NJX/YHQ prefixes (Horizon NJ) = NJ SHBP or Horizon Direct Access — must go through NJ DOBI process, not NIDRS. Filing federally for these cases triggers automatic dismissal + forfeited fees.
Case Submission Workflow
v0.1 — Draft This SOP is being built through Phase 1 observations. Update as Callagy refines the process.
Pre-Submission Checklist
- ✓ Provider is in-network with the plan
- ✓ Plan type confirmed — not EPO (unless at in-network facility), not FEHB (federal employees — separate OPM process, not NSA)
- ✓ Some payment has been applied (deductible/copay/partial)
- ✓ Not a pure denial — if pure denial, route to appeal first
- ✓ Not medical necessity or experimental denial
- ✓ Within 30 BD of EOB date (business days, not calendar)
- ✓ Federal vs. state determination complete — SSL state confirmed if routing to state
- ✓ QPA amount noted from EOB (payer required to disclose — request if missing)
- ✓ CARC and RARC codes noted from ERA (required for NIDRS portal submission)
- ✓ Case value check: expected additional recovery > $115 admin fee + staff time
Submission Steps
- 1. Gather: EOB (with QPA), ERA (with CARC/RARC codes), insurance card, claim details
- 2. Complete federal/state determination (see Federal vs. State tab)
- 3. Send Open Negotiation Notice (OMB 1210-0169) to payer — this starts the 30-BD negotiation clock. This is required before any IDR can be filed.
- 4. Track 30-BD negotiation period — if no agreement reached, proceed to step 5
- 5. Within 4 BD of negotiation end → file IDR initiation at nsa-idr.cms.gov (NIDRS portal)
- 6. Log submission date, NIDRS case number, entity selection deadline, offer deadline
- 7. Within 3 BD: coordinate entity selection with Callagy
- 8. Prepare offer documentation (include all 6 statutory factors — do not anchor to QPA only)
ASC In-Network Rule
If ASC in-network status cannot be confirmed → assume in-network, flag the case for Callagy evaluation. Do not hold the case pending ASC confirmation.
Research Findings
Source legend:
Auctus Research = online regulatory research, May 2026 ·
From Call = Callagy team ·
Pending Validation = not yet confirmed with Callagy
These findings require Callagy review before updating operational SOPs. Do not treat as authoritative until validated. Deep research sweep completed May 2026.
Critical Corrections
Items where current hub content may be inaccurate — highest priority to validate with Callagy.
CRITICAL Auctus ResearchPending Validation
Timeline Sequence — May Be Inverted
Per 45 CFR 149.510(b), the correct federal NSA sequence is: (1) Send Open Negotiation Notice (OMB 1210-0169) within 30 business days of the EOB → (2) 30-business-day open negotiation period → (3) 4-business-day window after negotiation ends to file IDR initiation notice at NIDRS portal. The hub currently presents the 4-BD window as a pre-IDR payer correction window, which does not match the federal regulation text. Per regulation, 4 BD is the window to initiate IDR after failed negotiation — not a payer correction period.
→ Validate with Callagy: Is the "4-BD payer correction window" a Callagy internal practice layered on top of the regulatory sequence? If so, how does it interlock with the 30-BD negotiation clock?
INGESTED Auctus ResearchCallagy confirm pending
Open Negotiation Notice — Now in Forms Tab
The NSA IDR process cannot begin without first sending the standardized Open Negotiation Notice (OMB Control No. 1210-0169) to the payer. The notice must include: provider NPI/TIN, payer information, claim/service date, the initial payment received, and the provider's opening offer. No submission to NIDRS is valid without proof this notice was sent — it is the true Day 1 action.
→ Resolved: the blank federal form is now hosted in the Forms tab (view/download), tethered to the Submission SOP, Process & Timelines, and the Open Negotiation Notice capability on the Coverage Map. Still open: Callagy to confirm their filled-template/cover-letter standard for sending it.
HIGH Auctus ResearchPending Validation
Federal vs. State Step 2 — Fully Insured ≠ State IDR (29 states have no SSL)
Current hub routes "fully insured state plan" → state IDR. Per CMS, only states with an approved Specified State Law (SSL) use state IDR. As of May 2026: 29 states + DC = federal IDR only, even for fully insured plans. 21 states have a bifurcated or approved SSL. Routing a fully insured plan to state in a non-SSL state wastes the 30-BD negotiation window and misses federal deadlines. The 21 SSL states include: CA, CO, FL, GA, IL, IA, KY, ME, MD, MA, MI, MN, MO, MT, NV, NJ, NY, OR, TX, VA, WA.
→ Step 2 must be "fully insured AND plan is in an SSL state" → state process. Otherwise → federal. State-by-state table needed in hub.
HIGH Auctus ResearchPending Validation
Texas Determination — TDI/DOI Alone Insufficient Post-2024
Texas SB 2476 (eff. Sept 2023) created a bifurcated system: state-regulated plans (TDI) use the Texas IDR process; self-funded ERISA plans still use the federal NSA process even when headquartered in Texas. TDI/DOI on the card confirms Texas-regulated → state process. However, many Texas employer plans are self-funded and show no TDI marker. The current Step 3 logic only addresses the TDI-present case — it does not handle the large population of Texas ERISA self-funded plans that require federal IDR.
→ Texas logic should be: TDI/DOI present = state IDR. No TDI/DOI = continue to Step 4 payer call (same as any other state).
HIGH Auctus ResearchPending Validation
"Large Employer" Shortcut Doesn't Exist in Law — Produces False Positives
Step 4 uses "large, publicly-traded company" as a proxy for self-funded status. Self-funded is a plan design choice — employers of all sizes self-fund. Using employer size creates both false positives (sending small self-funded employers to wrong track) and false negatives (routing large fully-insured employers to federal when they belong in state). There is no size threshold in ERISA or the NSA. The only reliable test is asking the payer directly.
→ Remove size-based shortcut from Step 4. Replace with: "If employer name is visible on card, call payer to confirm funding type. Do not infer from size."
HIGH Auctus ResearchFrom Call
"File Both Federal and State" — Forfeited Fees and Jurisdiction Conflict Risk
The workflow prescribes filing both federal and state simultaneously for ambiguous cases. Federal IDR costs $15 per party per dispute (non-refundable; cut from $115 effective 2026-06-11 per the CMS Federal IDR Operations Final Rule, May 2026). State processes add their own fees. Beyond cost, when both are filed the federal entity will typically assert preemption; the state filing gets dismissed but the fees are forfeited. In the 6 ERISA opt-in states (GA, ME, NV, NJ, VA, WA), state law supersedes federal for self-funded plans — filing federal there triggers dismissal.
→ Dual-filing should be a rare last resort. Default ambiguous cases to federal-only (shorter timeline); state only when SSL state confirmed applicable.
HIGH Auctus ResearchPending Validation
EPO Exclusion Too Broad — In-Facility NSA Coverage Still Applies
Hub excludes EPOs broadly. Under the NSA, the prohibition on balance billing applies at the facility level, not plan type level. An EPO member treated at an in-network emergency facility or in-network surgical facility receives NSA protections for OON providers at that facility. EPO alone is not a disqualifier — the question is whether the care was rendered at an in-network facility.
→ EPO pre-screening should ask: was care at an in-network facility? If yes, evaluate IDR eligibility normally.
HIGH Auctus ResearchPending Validation
"No Exceptions" on Expired Filing Window — Incorrect (CMS FAQ Part 69)
Current KB states "No exceptions" if the IDR filing window has passed. CMS FAQ Part 69 documents an extenuating circumstances extension — available when parties can show extraordinary circumstances (portal outages, natural disasters, documented system failures). Cases dismissed as untimely can petition for extension before the IDR entity closes them.
→ Update: "Expired window = presumed ineligible. Before closing, check if extenuating circumstances apply. Document any qualifying circumstances."
Federal Regulatory Detail
Key regulation specifics missing from the current hub. Source: 45 CFR 149.510 + CMS FAQs.
REGULATORY Auctus Research
Complete IDR Timeline per 45 CFR 149.510
Day 0: EOB received from payer
Within 30 BD of EOB: Send Open Negotiation Notice (OMB 1210-0169) to payer
+30 BD: Open negotiation period expires — if no agreement
+4 BD: Window to file IDR initiation notice at nsa-idr.cms.gov (NIDRS)
+3 BD: Parties jointly select certified IDR entity (or CMS assigns one)
+10 BD: Each party submits offer and supporting documentation
+30 BD: IDR entity issues determination (baseball-style arbitration)
+30 days of determination: Payment due from losing party
Note: All business days = exclude weekends and federal holidays.
Within 30 BD of EOB: Send Open Negotiation Notice (OMB 1210-0169) to payer
+30 BD: Open negotiation period expires — if no agreement
+4 BD: Window to file IDR initiation notice at nsa-idr.cms.gov (NIDRS)
+3 BD: Parties jointly select certified IDR entity (or CMS assigns one)
+10 BD: Each party submits offer and supporting documentation
+30 BD: IDR entity issues determination (baseball-style arbitration)
+30 days of determination: Payment due from losing party
Note: All business days = exclude weekends and federal holidays.
REGULATORY Auctus Research
NIDRS Portal Submission Requirements
Filing at nsa-idr.cms.gov requires:
• CARC code (Claim Adjustment Reason Code) from ERA
• RARC code (Remittance Advice Remark Code) from ERA
• Proof that Open Negotiation Notice was sent (date, method)
• QPA amount (from payer's EOB — payers must disclose this)
• Provider's initial offer amount
• NPI, TIN, service date(s), CPT code(s)
Missing CARC/RARC = portal rejection. These are not in the current submission checklist.
• CARC code (Claim Adjustment Reason Code) from ERA
• RARC code (Remittance Advice Remark Code) from ERA
• Proof that Open Negotiation Notice was sent (date, method)
• QPA amount (from payer's EOB — payers must disclose this)
• Provider's initial offer amount
• NPI, TIN, service date(s), CPT code(s)
Missing CARC/RARC = portal rejection. These are not in the current submission checklist.
REGULATORY Auctus Research
Batching Rules — 4 Requirements Must All Be Met
Multiple claims can be batched into a single IDR filing only if ALL four conditions are met: (1) Same provider NPI/TIN, (2) Same payer/plan, (3) Same or similar service type (same CPT or similar category), (4) All open negotiation notices sent within the same 30-BD open negotiation window. If any condition fails, separate filings required at separate $115 fees each. CMS FAQ confirms "similar" services must be clinically related — cannot batch an E&M with a surgical procedure.
REGULATORY Auctus Research
QPA Disclosure Is Mandatory — Payers Must Provide It
Under the NSA, payers are required to disclose the Qualified Payment Amount (QPA) on the EOB when an IDR-eligible claim is processed. The QPA is the plan's median contracted rate for the same/similar service as of Jan 31, 2019, indexed annually by CPI-U. If the payer's EOB does not include the QPA, this is a regulatory violation — providers can challenge the EOB and request QPA disclosure before the open negotiation clock starts.
REGULATORY Auctus Research
Certified IDR Entity Fee — $115 Refunded if Dismissed as Ineligible
The $115 CMS administrative fee (per party, per dispute) is non-refundable in all circumstances. However, the IDR entity's own fee (separate from the CMS fee) is refunded if the dispute is dismissed as ineligible/untimely. The certified IDR entity only charges its full fee when it actually arbitrates. 16 certified entities as of May 2026: FHAS, Maximus, C2C, MCMC, EdiPhy are the largest. Entity selection affects timelines and outcomes — some are faster, some favor providers more consistently.
State-by-State IDR Map
Federal vs. state routing by jurisdiction. Source: CMS SSL status + KFF + state insurance department filings, May 2026.
STATE MAP Auctus ResearchPending Validation
Federal IDR Only (29 States + DC) — No State SSL
All fully insured plans in these states use federal IDR:
AK, AL, AR, AZ, CT, DC, DE, HI, ID, IN, KS, LA, MS, MT (pending), NC, ND, NE, NH, NM, OH, OK, PA, RI, SC, SD, TN, UT, VT, WI, WY
Note: Montana has a pending SSL that may not yet be operationally active. Confirm with Callagy before routing Montana cases to state.
AK, AL, AR, AZ, CT, DC, DE, HI, ID, IN, KS, LA, MS, MT (pending), NC, ND, NE, NH, NM, OH, OK, PA, RI, SC, SD, TN, UT, VT, WI, WY
Note: Montana has a pending SSL that may not yet be operationally active. Confirm with Callagy before routing Montana cases to state.
STATE MAP Auctus ResearchPending Validation
State IDR (21 States with Approved SSL or Bifurcated)
Fully insured plans in these states use state IDR:
CA, CO, FL, GA*, IL, IA, KY, ME*, MD, MA, MI, MN, MO, NV*, NJ*, NY, OR, TX, VA*, WA*
*ERISA opt-in states (GA, ME, NV, NJ, VA, WA): State law supersedes federal NSA for self-funded plans in these states. Filing federal in these states on a self-funded plan triggers dismissal. This is the NJX/YHQ situation — NJ self-funded state employees go to ERISA state process, not federal IDR.
NJX prefix = NJ DIRECT / NJ SHBP (State Health Benefits Program — Horizon BCBSNJ). YHQ prefix = Horizon Direct Access product. Both require NJ DOBI process, not NIDRS.
CA, CO, FL, GA*, IL, IA, KY, ME*, MD, MA, MI, MN, MO, NV*, NJ*, NY, OR, TX, VA*, WA*
*ERISA opt-in states (GA, ME, NV, NJ, VA, WA): State law supersedes federal NSA for self-funded plans in these states. Filing federal in these states on a self-funded plan triggers dismissal. This is the NJX/YHQ situation — NJ self-funded state employees go to ERISA state process, not federal IDR.
NJX prefix = NJ DIRECT / NJ SHBP (State Health Benefits Program — Horizon BCBSNJ). YHQ prefix = Horizon Direct Access product. Both require NJ DOBI process, not NIDRS.
STATE MAP Auctus ResearchPending Validation
New Jersey Horizon Campaign (Active Sept 2025)
Horizon BCBSNJ began sending letters in September 2025 to orthopedic surgeons claiming prior federal IDR awards are invalid because NJ state ERISA opt-in law governs. NJ DOBI has sided with Horizon in multiple disputes. NJ cases for NJ state government employee plans (SHBP — NJX prefix) and Horizon Direct Access (YHQ prefix) should be treated as NJ state process only, regardless of ERISA status of the employer. This is an active payer enforcement campaign — do not file these federally without Callagy approval.
Litigation Landscape (May 2026)
Active legal cases affecting IDR strategy and QPA methodology.
LITIGATION Auctus Research
TMA III — En Banc Oral Arguments Heard, No Ruling Yet
Texas Medical Association v. HHS (TMA III) challenges the HHS rule that IDR arbitrators must give rebuttable presumption to the QPA — effectively forcing arbitrators to default to payer-set rates. The Fifth Circuit panel struck this down. HHS sought en banc rehearing; granted May 30, 2025. Full Fifth Circuit heard oral arguments September 24, 2025. No ruling as of May 2026. Until resolved, QPA is one factor among many — arbitrators must consider: provider experience, market share, patient acuity, prior negotiated rates, training, etc. Auctus/Callagy offer documentation should address all statutory factors, not just QPA.
LITIGATION Auctus Research
Guardian Flight — No Private Right of Action (5th + 11th Circuits)
Guardian Flight v. Aetna (5th Circuit, June 2025): court held no private right of action for providers to enforce IDR awards in federal court in the Fifth Circuit. Same in Eleventh Circuit. This means in TX, LA, MS, FL, AL, GA — providers cannot directly sue to enforce an IDR award. Must go through state courts or DOL enforcement mechanisms instead. Exception: Connecticut District Court (NorthStar v. Aetna/Cigna — $4.1M unpaid awards) does recognize implied private right of action under ERISA. NJ state DOBI process has enforcement teeth. Enforcement strategy must account for jurisdiction.
LITIGATION Auctus Research
TMA I and II — Provider-Favorable Wins (Established Law)
TMA I (2022): struck down HHS rule that arbitrators must "begin" with QPA. TMA II (2023): struck down HHS's independent dispute resolution interim final rule — the rule requiring QPA as presumptive standard. Both are settled law. Combined with TMA III (pending), the QPA is now legally just one factor. Offers should demonstrate all six statutory factors: (1) provider training/experience, (2) patient complexity/acuity, (3) prior billed amounts, (4) prior contracted rates for same provider, (5) market share, (6) teaching hospital status if applicable.
Payer Behavior Intelligence
Documented payer tactics that affect how cases should be filed and followed up. Source: EDPMA 2024, CMS PUF, industry reports.
CRITICAL Auctus Research
Payer Non-Payment After IDR Award: 69.2% in 2024 (up from 24% in 2023)
EDPMA 2024 report: payer non-payment after IDR determination jumped from 24% in 2023 to 69.2% in 2024. Winning the IDR arbitration is no longer the end of the process — mass non-payment is now the dominant payer tactic. The current hub treats "Award issued" as near-final; in reality, more than 2 in 3 awards currently require follow-up enforcement action. The enforcement path (DOL complaint, state action, litigation) must be built into the workflow as a standard post-award step, not an exception.
PAYER INTEL Auctus ResearchPending Validation
UnitedHealthcare — Systematic Eligibility Challenges + Duplicate Claim Tactic
UHC patterns documented in EDPMA/industry data: (1) files eligibility challenges on ~45% of cases — over 2x the industry average — to force dismissal before arbitration; (2) splits one patient encounter into multiple claims for the same service to create batching confusion; (3) systematically delays entity selection past the 3-BD window, forcing CMS default assignment; (4) challenges QPA calculations retroactively claiming different benchmark dates. Pre-screening UHC cases requires tighter eligibility documentation than average payers.
PAYER INTEL Auctus ResearchPending Validation
Cigna — Low QPA Anchoring + Retroactive Plan Redesign
Cigna patterns: (1) presents artificially low QPA figures by using non-comparable geographic benchmarks; (2) retroactively redesigns plans to assert that certain provider types are "in-network" for QPA purposes (reducing the QPA anchor); (3) uses Cigna's owned IPAs to manufacture in-network contract data that suppresses QPA. Cigna cases should include explicit QPA challenge documentation — request QPA methodology breakdown in offer submission.
PAYER INTEL Auctus ResearchPending Validation
Aetna — Geographic Manipulation and "Surprise Free" Misclassification
Aetna patterns: (1) assigns cases to geographic QPA regions that exclude the actual practice area to generate lower QPAs; (2) misclassifies emergency cases as non-emergency to argue NSA doesn't apply; (3) uses "surprise free" network design arguments to claim specific provider categories are outside NSA coverage. Aetna challenges are usually procedural rather than merits-based — strong Open Negotiation Notice documentation reduces challenge success rate.
PAYER INTEL Auctus ResearchPending Validation
Horizon NJ — Active State ERISA Campaign (Confirmed Active)
Confirmed from From Call notes (Callagy): Horizon refusing federal IDR awards on NJ state employee plans (NJX/YHQ prefixes). From research: as of Sept 2025, Horizon sent mass letters to orthopedic surgeons claiming all federal awards on SHBP plans are void. NJ DOBI is siding with Horizon. These cases must go through NJ DOBI arbitration process — filing federally wastes the timeline and fees. Callagy is tracking the NorthStar v. Aetna/Cigna case in CT as potential path to enforcement for similar situations nationally.
Industry Statistics (2024–2025)
Benchmark data for understanding IDR outcomes and case economics.
STATISTICS Auctus Research
Scale: 4.8M Cumulative IDR Disputes Filed (2022–2024)
CMS PUF (Public Use File) 2024: approximately 4.8 million total IDR disputes filed since NSA went live in 2022. 2024 alone saw ~2.5M new filings — a 3x increase from 2023 (800K). The system is severely backlogged. Median time from initiation to determination was 12–16 weeks in 2024 vs. the statutory 30 BD target. Plan for longer timelines than the regulation suggests.
STATISTICS Auctus Research
Provider Win Rate: 85–88% (2024–2025); Median Award 459% of QPA
When disputes reach arbitration (not dismissed), providers win 85–88% of the time in 2024–2025 (up from 72% in 2022–2023). Median arbitration award = 459% of QPA in 2024 (up from 327% in 2023). Surgical specialties: median award 13–17x QPA. Neurology: 9–13x QPA. 9–13% of all determinations awarded >10,000% of QPA (outlier cases, typically trauma surgery or complex interventional). This data supports aggressive offers in arbitration — don't anchor to QPA.
STATISTICS Auctus Research
Payer Eligibility Challenge Rate: 45% Challenged, 17% Actually Dismissed
CMS PUF 2024: payers challenged eligibility in ~45% of cases. Of those challenged, only 17% were actually dismissed by the IDR entity as ineligible. This means ~83% of challenged cases survive and proceed to arbitration. Strong pre-screening is the primary lever — cases that survive challenge almost always win. The goal is to minimize the 17% that get dismissed (from Auctus's side, this = submission quality) and win the 83% that proceed (from Callagy's side).
STATISTICS Auctus Research
$5B Total IDR Cost Burden (2022–2024); Average Case Value ~$1,040
Total industry cost of IDR administration (payer + provider side): estimated $5B through 2024. For Auctus's case economics: average IDR case value (provider award) ~$1,040 at median QPA multipliers. High-value cases (surgical, complex interventional): $5K–$50K+ range. Fee math: $115 Auctus + $115 payer = $230 CMS fees + IDR entity fee (variable, ~$200–$400). Case must recover at minimum $500–$700 to break even including staff time. Low-value cases may not be economically viable for IDR.
Specialty-Specific Rules
Edge cases and specialty-specific nuances not in current hub content.
SPECIALTY Auctus ResearchPending Validation
FEHB Plans — Federal Employees Not Subject to NSA
Federal Employees Health Benefits (FEHB) plans are excluded from NSA IDR. Federal employees and their dependents have a separate OPM-administered dispute process — not NIDRS. Identifiers on the insurance card: "GEHA," "BCBS Federal," "Aetna Federal," "United Federal." If any provider in the Auctus network sees federal employees (VA medical center employees, military civilian staff, federal agency workers), those cases cannot go through IDR — they require the OPM dispute route instead. See next-call question below.
SPECIALTY Auctus ResearchPending Validation
Anesthesia — Time-Based vs. Service-Based IDR Complexity
Anesthesia billing uses time units + base units rather than standard CPT/RVU. QPA methodology for anesthesia is disputed — payers often use facility-fee QPA benchmarks rather than professional service benchmarks. When anesthesia services are included in a surgical IDR bundle, they should typically be filed separately with a distinct QPA challenge because the QPA methodology for anesthesia differs from surgical services.
SPECIALTY Auctus ResearchPending Validation
Derm/Plastics/ENT Specific: Minor Procedures Often Under IDR Minimum
For Auctus's primary ICPs (derm, plastics, ENT), a significant portion of cases may fall below the economic break-even for IDR given the $115+ fee floor. Derm: minor excisions, biopsies — typical reimbursements in the $200–$800 range. After $115 fee + staff time, IDR may not be viable. Recommendation: build a minimum-value threshold into pre-screening (e.g., only file IDR if expected additional recovery exceeds $400 above QPA).
Pending Callagy Validation
Items where the current hub policy may have unintended consequences — need Callagy's expert read.
VERIFY WITH CALLAGY Auctus Research
ASC In-Network Assumption — What % Are Callagy Rejecting?
Current policy: if ASC in-network status cannot be confirmed, assume in-network and flag for Callagy. The flag mitigates the risk of sending ineligible cases, but the question is: what % of ASC-flagged cases does Callagy reject? If it's high, the policy creates noise; if it's low, it's working correctly. Without a validation tracker (Gap #3), this rate is unknown.
→ Ask Callagy: what % of ASC-flagged cases are they rejecting? Should the policy be "hold pending verification" instead?
VERIFY WITH CALLAGY Auctus Research
Payer Call Script — What Questions Are Actually Effective?
Current hub says: ask "What is the funding type? Is this plan fully or partially funded, and what state is it funded in?" Research confirms these are the right questions, but payer call center agents frequently cannot or will not answer them. What's Callagy's actual fallback when the agent says "I don't know" or refuses? The hub has no objection handling or escalation path for a dead-end call.
→ Ask Callagy: what do you do when the payer can't confirm funding type? What's the fallback and how long before you default to federal?
VERIFY WITH CALLAGY Auctus Research
Post-Award Enforcement — What's the Current Process?
Given 69.2% payer non-payment after award (EDPMA 2024), the workflow needs a standard post-award enforcement step. What is Callagy's current process when a payer doesn't pay after an IDR award? The hub shows "Award issued" and "Enforcement / legal escalation" as the last nodes — but doesn't define who does what, in what timeframe, and through what mechanism (DOL complaint, state action, NorthStar-style litigation).
→ Add post-award enforcement SOP to workflow. Define: day 30 post-award trigger, DOL complaint process, state action path by jurisdiction.
ASK NEXT CALL Auctus Research
FEHB / OPM Cases — Has Callagy Encountered These?
FEHB (Federal Employees Health Benefits) plans are excluded from NSA IDR — they have a separate OPM dispute process. Identifiers: "GEHA," "BCBS Federal," "Aetna Federal," "United Federal." Do Auctus's provider clients see federal employee patients? If yes, are those cases currently hitting the IDR pipeline incorrectly, or does Callagy recognize and route them separately? Is there a working OPM dispute process Callagy has used, and if so what does it look like?
→ Question for Callagy: Have you seen FEHB cases come through? How do you identify them, and what's the correct handling path?
VERIFY WITH CALLAGY Auctus Research
Phase 2→3 Transition Criteria Still Undefined
The Phase 1→2 gate is defined: Callagy validates Auctus's complete instruction set. The Phase 2→3 criteria (Auctus operates fully independently) are completely undefined. What metrics, case volume, error rate, or time period determine when Auctus is ready? Without this, Phase 3 never arrives because there's no test to pass.
→ Define Phase 2→3: e.g., 3 months of Phase 2 operation with <5% eligibility challenge rate on submitted cases, Callagy formal sign-off.
Sources
Primary references underlying Auctus Research findings. All links open in a new tab. Verify document currency before relying on specific guidance — CMS FAQs and regulations are updated periodically.
Federal Regulation
- 45 CFR Part 149 ↗
Core NSA IDR regulation — §149.510 is the IDR process rule - CMS No Surprises Act Hub ↗
Open Negotiation Notice (OMB 1210-0169), FAQs, guidance docs - NIDRS Portal ↗
Live IDR filing portal — nsa-idr.cms.gov
CMS Data & Reports
- CMS IDR Activity Reports (PUF) ↗
Quarterly dispute volume, dismissal rates, win rates - CMS NSA FAQs (Parts 1–69) ↗
Includes FAQ Part 69 — extenuating circumstances extension
Industry Reports
- EDPMA ↗
2024 NSA report — 69.2% payer non-payment stat, win rate data - KFF — No Surprises Act Tracker ↗
State SSL mapping, policy analysis, implementation tracking
Litigation
- TMA I, II, III — CourtListener ↗
TMA I: 587 F.Supp.3d 528 · TMA II: 656 F.Supp.3d 671 · TMA III: No. 22-40520 (5th Cir., en banc pending) - Guardian Flight v. Aetna — CourtListener ↗
No. 22-10512 (5th Cir. 2025) — no private right of action to enforce IDR awards in federal court
State — New Jersey
- NJ DOBI — Out-of-Network Law ↗
NJ state IDR process governing NJX/YHQ (SHBP/Horizon Direct Access) cases - Horizon BCBSNJ ↗
NJX = NJ DIRECT/SHBP · YHQ = Horizon Direct Access — confirm prefix routing
Research Methodology
- Deep research sweep conducted May 2026 using AI-assisted multi-source analysis across CMS.gov, eCFR, federal court records, EDPMA, KFF, and state insurance department publications.
- All findings marked Pending Validation require Callagy sign-off before updating operational SOPs.
Forms
Required federal IDR forms and templates — verify currency on CMS before relying on a copy
Open Negotiation Notice
OMB 1210-0169
Expires 11/30/2025 — confirm current revision
Federal template
The standardized federal form that initiates the 30-business-day open negotiation period — the mandatory step before any Federal IDR filing. The initiating party (Auctus, on behalf of the provider) sends it to the payer to dispute the out-of-network rate. One notice per item/service unless the payment was bundled or the items are being batched.
When to send: within 30 business days of the initial payment or notice of denial (the Date of Payment on the EOB). The 30-BD negotiation clock starts the day the notice is sent. After it expires, there are only 4 business days to initiate IDR via NIDRS.
Information the notice must carry
- Initiating party name + contact (email/phone) and relationship to the provider
- Per item/service: description, claim number, provider name + NPI, date of service, service code
- Initial payment amount (or N/A) and the offer for the total out-of-network rate (including cost sharing)
- Signature + date — keep a copy for the file as proof the notice was sent
Related
KB: Submission SOP
KB: Process & Timelines
Map: Open Negotiation Notice
Links
Filing portals and primary federal references — all open in a new tab
Portals & Filing Systems
Federal IDR Filing
- NIDRS Portal ↗
Live IDR filing portal — initiate disputes, submit offers, track determinations - CMS No Surprises Act Hub ↗
Open Negotiation Notice (OMB 1210-0169), guidance docs, dispute forms
Regulation & Guidance
- 45 CFR Part 149 ↗
Core NSA IDR regulation — §149.510 is the IDR process rule - IDR Guidance for Disputing Parties (PDF) ↗
CMS process guidance — batched/bundled definitions, step-by-step
Data & Reports
- CMS IDR Activity Reports (PUF) ↗
Quarterly dispute volume, dismissal rates, win rates - CMS NSA FAQs ↗
Includes FAQ Part 69 — extenuating circumstances extension
Related
KB: Process & Timelines
KB: Research & Sources
Map: IDR Initiation
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Backlog
IDR build & automation to-dos — managed in Donkey (
dashboard=idr), shown here in context. Add/complete via the Donkey flow.Loading…
Toolbox
Eligibility check and deadline calculator
Eligibility Check
Step 1
Was any payment applied? (deductible, copay, coinsurance, or partial payment)
Deadline Calculator — Federal IDR Timeline
Step 1 — EOB Date
Explanation of Benefits received date
Enter EOB date to see deadlines
Market Outlook
IDR trajectory research — where the money, the rules, and the gaming are heading. Last updated 2026-05-08.
Research Synthesis — May 2026
The system is bifurcating. Not one direction — two realities splitting apart.
88%
Provider Win Rate
H1 2025 — all-time high (was 70% Q1 2023)
33¢
QPA vs. In-Network
Average QPA = 33% of insurer's own contracted rates (NDP Analytics, Dec 2025)
69%
Post-IDR Non-Compliance
Insurers not paying within 30 days in 2024 (up from 24% in 2023)
4.8M
Total Disputes Filed
Through end of 2025. CMS projected 17K/year.
⚡ Key Dates & Triggers
Any day now
TMA III en banc — Fifth Circuit
Ghost rates in or out of QPA. Biggest single pending event. Provider win raises the QPA benchmark; insurer win locks in suppressed QPAs. Oral argument Sep 2025, supplemental briefs Jan 2026.
Aug 1, 2026
QPA Enforcement Discretion Cliff
Insurer-favorable 2021 QPA methodology expires. New QPA rule must be in place. Audit surge begins H2 2026. CMS has been explicit — no further extensions.
2026 (overdue)
IDR Operations Rule Finalization
Expands batching, requires CARC/RARC disclosures (shows why claim was underpaid). Pro-provider on transparency. 90–180 day implementation lag after publication.
Watch calendar
H.R. 4710 Markup Hearing
3× penalty bill (No Surprises Enforcement Act). Needs committee markup before floor vote. Watch House E&C and Senate HELP Committee calendars. Must happen by ~Sep 2026 or bill dies in 119th Congress.
Pending ruling
UHC v. Radiology Partners (D. Ariz.)
If UHC wins declaratory judgment of fraud → precedent allowing insurers to retroactively unwind IDR awards in federal court. Worst-case scenario for industry.
💰 Where the Money Is Going
Awards are trending UP. Every quarter since TMA I (2022) providers win bigger. But the benchmark is rigged — the QPA itself averages 33% of actual in-network rates, so "winning at 400% of QPA" often means winning at ~130% of true in-network.
| Period | Median Award vs QPA | Win Rate |
|---|---|---|
| Q1 2023 | ~220% of QPA | 70% |
| Q4 2023 | ~335% of QPA | 87% |
| Q1 2024 | 383% of QPA | 88% |
| Q4 2024 | ~459% of QPA | 85% |
| H1 2025 | 277–920% (by group) | 88% |
By Specialty (Q4 2024)
| Emergency Medicine | 2.5–3× QPA (stable) |
| Radiology | 5–6× QPA (escalating) |
| Surgery | 13× QPA |
| Neurology / Neuromonitoring | 17× QPA |
| Anesthesiology | ~2× QPA |
The Silent Loss: The 90% of eligible OON claims that never hit IDR are accepting insurer initial payments averaging 33¢ on the dollar of in-network rates. This pool of money dwarfs IDR recovery.
🎭 Insurer Gaming Playbook — 10 Documented Tactics
1. RICO / Treble Damage Lawsuits NEW 2025Escalating
11 suits in 12 months (Elevance, Anthem, UHC, Aetna). Designed to lose in court but win in market — legal fees, reputational risk, chilling effect. If UHC wins in Arizona, insurers can retroactively unwind IDR awards.
2. QPA ManipulationOngoing
Ghost rates (PCPs included in specialist QPA), cross-specialty contamination, exclusion of incentive payments. Result: QPAs average 33% of true in-network rates. CMS Aetna audit (July 2024) confirmed violations. TMA III en banc pending.
3. Non-Payment After Losing IDREscalating
24% non-compliance in 2023 → 69.2% in 2024. 22% of awards never paid at all. Insurers submit $0.00 offers. No civil enforcement in 5th Circuit — non-payment is essentially free in TX/LA/MS.
4. Cost-Sharing Clawback After IDR WinEscalating
After losing IDR, insurer raises patient's copay/deductible — shifts the loss to the patient. 50% of ED physician groups have seen this. Violates NSA. Zero enforcement action taken against any named insurer yet.
5. Administrative Exhaustion / False Eligibility ChallengesInstitutionalized
Insurers challenged 44% of all 2024 disputes as ineligible (1.46M disputes, 644K challenged). Documented false grounds: claiming state law applies when it doesn't; claiming OON provider is in-network. Each challenge costs provider $115 + delay.
6. Network Termination PressureEscalating
100% of providers threatened (avg 16 times each). 36% had contracts actually terminated citing NSA. Anthem Jan 2026 policy: penalizes in-network hospitals using OON physicians — a new structural pressure layer through hospital systems.
7. Default / No-Show StrategyOngoing
26% of Q4 2024 disputes decided by insurer default. 90% go to provider. Then insurer doesn't pay the default award. Fully risk-free in 5th Circuit — CMS enforcement resolved $11.3M total across all cases ever.
8. Re-Opening Closed IDR CasesGrowing
Exploiting CMS technical guidance (June 2025) intended for rare clerical errors to broadly revisit settled determinations and withhold payment. AMA explicitly called this out in May 2026 as a systemic pattern.
9. IDRE ShoppingOngoing
If provider misses CMS portal email by hours (even after-hours), insurer selects the IDR entity. Some IDREs rule for providers 95–98% of the time. Insurers time correspondence strategically to lock in preferred IDRE.
10. Open Negotiation Bad FaithStatus Quo
Insurers made a counteroffer only 26% of the time during required 30-day pre-IDR negotiation. Only 5% of disputes actually resolved in negotiation. CMS Aetna audit confirmed Aetna failed to inform providers of their right to proceed to IDR.
⚖️ Regulatory Scorecard
| Issue | Status | Favors |
|---|---|---|
| TMA II — no QPA rebuttable presumption Arbitrators must weigh all 6 factors equally; QPA is not the anchor |
Settled law | Providers |
| TMA III en banc — ghost rates Full 5th Circuit reconsidering QPA methodology; decision any day |
Pending ruling | TBD — biggest variable |
| IDR Operations Rule Expanded batching + CARC/RARC disclosure requirements |
Overdue; expected 2026 | Providers (moderately) |
| QPA Enforcement Discretion (2021 method) Insurer-favorable suppressed QPA methodology still permitted |
Expires Aug 1, 2026 | Insurers |
| IDR Award Enforceability 5th Circuit: no civil enforcement; SCOTUS declined review 2026 |
No change | Insurers (in 5th Cir.) |
| New QPA Methodology Rule Required after enforcement discretion expires; not yet proposed |
Expected 2026 | TBD |
| FAQ Part 69 — Deadline Extensions Provider gets extension if insurer failed to provide QPA disclosure |
Active | Providers |
| ERISA Preemption (self-funded plans) State balance billing laws don't apply; federal NSA only, weakest enforcement |
No change | Insurers |
| QPA Audit Surge CMS expected to scale audits after Aug 1 cliff; Aetna audit found violations |
Expected H2 2026 | Providers |
🔮 Expert Consensus — Georgetown, KFF, Brookings, McDermott+, AJR
Will IDR volume keep rising?High confidence
Yes — Georgetown (March 2026): "We have no reason to think these trends will not continue." March 2026 saw 313,828 disputes in a single month. No plateau visible in data.
Will provider payments stay above QPA?High confidence
Yes — absent rule change, awards stay well above QPA. Trending from 327% (2023) to 459% (Q4 2024). TMA II removal of the QPA anchor was the structural shift and it's settled law.
Will the CBO premium reduction happen?Definitely not
BMJ 2025, Commonwealth Fund, KFF all confirm: the projected 0.5–1% premium reduction is not going to be achieved under current IDR trajectory. Premiums are not going down.
Will IDR awards bleed into in-network renegotiations?Medium confidence
Commonwealth Fund (explicit prediction): IDR award levels are becoming reference points for in-network contract renegotiations upward. Demonstrating strong IDR wins directly raises all-in contract rates.
Is an "IDR death spiral" realistic?Medium — for small practices
AJR (Jan 2024): IDR is financially unviable for 7–12% of radiology OON claims at current fee levels for individual disputes. Georgetown Virginia comparison is the clearest evidence — federal system has been captured by volume operators; small practices are being priced out.
Will major structural NSA reform happen in 2026?Low-Medium confidence
Health Law Rx, McDermott+: "Major structural changes unlikely in 2026." More likely in 2027 if system costs hit premium visibility. Total 2025 system cost ~$6–7B annualized — that's the catalyst.
The Biggest Opportunity Nobody Is Talking About
For the ~90% of eligible OON claims that never enter IDR — those initial insurer payments average 33% of in-network rates. The money being left on the table dwarfs what's being recovered through IDR. Any service that closes that gap for independent practices (through IDR enablement, contract renegotiation anchored to IDR awards, or systematic QPA challenge) is targeting a larger market than pure IDR filing.
Sources: Georgetown CHIR (Health Affairs, Mar 2026) · CRS R48738/R48851 · NDP Analytics/AFHC (Dec 2025) · AMA (May 2026) · ACDIS HealthLeaders Survey · GAO-26-107169 · KFF/Peterson · Brookings (Apr 2026) · McDermott+ · Health Law Rx · AJR (Jan 2024) · EDPMA (Aug 2024)