Federal IDR guides
Is this claim eligible for federal IDR?
Six questions decide whether an out-of-network claim can go to federal IDR. Plain answers, a plan-type table, and where it goes if the answer is no.
Verified September 11, 2026
Short answer
Six questions. Was the service in 2022 or later? Was it emergency care, out-of-network care at an in-network facility, or air ambulance? Did the payer pay or deny? Is the plan one the No Surprises Act covers? Do you have the QPA? Are you still inside the deadlines?
The first "no" tells you where the claim goes instead. A denial is usually an appeal. A late claim is time-barred. Neither one is "ineligible".
1. Was the service in 2022 or later?
Services before January 1, 2022 are out. The start is tied to the plan year, not the calendar: the law applies from the first plan or policy year beginning on or after January 1, 2022. For an early 2022 claim, check when the plan year started.
2. Is it one of the three covered service types?
Emergency care. Out-of-network care at an in-network facility. Air ambulance. That is the whole list.
Two traps.
For non-emergency care, an out-of-network hospital's own bill is not covered. The law protects the out-of-network doctor working inside an in-network hospital. Not the other way round.
A valid waiver removes protection. Only the federal notice-and-consent form does this, and only when every condition is met. Notice timing and signature timing are two different tests: when the notice had to go out depends on when the appointment was booked, and the consent must be signed before care. A signature on its own is not enough. The waiver is in the chart, not on the EOB. It can never be used for emergency care, anesthesia, radiology, pathology, hospitalists, lab and imaging, neonatology, assistant surgeons, intensivists, or when no in-network provider was available.
3. Did the payer pay or deny?
| The EOB shows | Where it goes |
|---|---|
| Paid, but too little | IDR |
| $0 because the plan will not cover the service | Appeal, not IDR |
| $0 on a covered service, for example an unmet deductible | IDR |
| $0, no reason, but a QPA is shown | Usually IDR |
| $0, nothing else | Read the reason before deciding |
| Some units paid, some denied | Split it by the reason, not by the dollar amount |
4. What kind of plan is it?
This is where most mistakes happen.
| Plan type | Federal IDR? |
|---|---|
| Self-funded employer plan | Yes |
| Self-funded government or church plan | Yes |
| Fully insured plan | Depends. If the state where the service happened has its own surprise-billing law, that process applies. Otherwise federal. |
| Fully insured, but the payer marked it a federal surprise bill | Usually yes |
| Federal employee plan (FEHB) | Yes |
| Medicare Advantage | No |
| Medicare, Medicaid, CHIP, TRICARE, VA | No |
| Medicare supplement | No |
Go by the program, not the brand. The same insurer runs commercial plans that qualify and government plans that do not.
5. Do you have the QPA?
The payer is supposed to send it. If it did not, that is the payer's fault, not a reason the claim is out. Ask for it and keep going.
6. Are you inside the deadlines?
Thirty business days to send the notice. Thirty business days to negotiate. A 4-day window to file. Miss one and the claim is time-barred. The full chain, with a worked example, is on the deadlines page.
After a decision, that decision is binding. The 90-day wait is a bar on starting another dispute with the same payer over the same or similar items, not a second try at the decided claim.
Watch out
Two words that get misused
"Denied" does not mean "ineligible". Read which kind of denial it is. A denial of coverage, including medical necessity, goes to the plan's appeals process. A denial of payment on a service the plan covers can still go to IDR. CMS treats a $0 payment on a covered service as an initial payment, not a coverage denial. While you work out which one you have, keep the 30-business-day clock running.
"Time-barred" does not mean "ineligible" either. The law applied and the patient was protected. You lost the IDR remedy, nothing else.
If the answer is no
| Verdict | Next step |
|---|---|
| Denial | Self-funded plan: appeal to the plan. Fully insured: the state insurance department. |
| State law applies | The state's own arbitration or mediation |
| Government program | That program's own appeal rights |
| Time-barred | Ask CMS for an extension if a payer failure caused the delay |
Inpatient stays are different
An out-of-network hospital's own facility bill for a planned admission is not covered. That is the same trap as above, not a rule about everything that happens during the stay.
Professional claims inside an inpatient stay are checked on their own. An out-of-network anesthesiologist at an in-network hospital can qualify under the non-emergency rule even though the admission was planned. One dispute covers several services only when the payment arrangement itself was bundled.
Sources
45 CFR 149.20, 149.30, 149.410, 149.420, 149.510; 5 CFR 890.114; CMS Federal IDR portal qualification screen.
Every number on this page comes from public CMS files or the federal rule. Our methodology explains how we count. Questions? sales@recoursehealth.com
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