Federal IDR guides
Does this claim go to federal IDR or the state?
Self-funded plans usually go federal. Fully insured plans go federal in 28 states plus DC, and to a state process in 21. Two steps to sort a claim.
Verified September 11, 2026
Short answer
Look at the plan first, then the state.
If the employer self-funds the plan, the claim usually goes to federal IDR, in every state. If the plan is fully insured, it depends where the service happened. In 28 states and Washington, DC, federal. In 21 states, the state runs its own process for some or all claims. Alaska is its own case, below.
Step 1. Is the plan self-funded?
Most large employers self-fund. Their plans usually go to federal IDR whatever state you are in. State surprise-billing laws do not reach them.
Two exceptions. Six states let a self-funded plan choose the state process instead: Georgia, Maine, Nevada, New Jersey, Virginia, Washington. In those states, ask the plan if it opted in. Most have not. And an all-payer model agreement overrides the federal process where one applies, whoever funds the plan. Maryland hospital services are the case to know.
A state or local government plan is not an ERISA plan. Those need their own check.
Step 2. If the plan is fully insured, where was the service?
These 28 states and Washington, DC send everything to federal IDR:
Alabama, Arizona, Arkansas, Washington DC, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Minnesota, Mississippi, Montana, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, West Virginia, Wisconsin, Wyoming.
These 21 states have their own process for some claims:
California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Maine, Maryland, Michigan, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Texas, Virginia, Washington.
In those 21, what goes where depends on the type of service and the type of plan. Sometimes the dollar amount too.
Both lists come from the CMS chart, which says on its face that it is current as of January 11, 2023. Treat it as a starting point, not as today's law.
Three examples
All three are for fully insured plans. Self-funded plans go federal in all of them.
Texas. The state handles most emergency care and most surprise bills at in-network hospitals. Federal IDR handles air ambulance and whatever Texas law does not cover.
California. HMO claims go to the state. Most PPO claims do too. Some PPO emergency claims go federal.
Florida. The state handles emergency care and in-network hospital claims, but only at or above its dollar minimums. Below them, federal IDR is the route: under $10,000 for hospital inpatient, under $3,000 for hospital outpatient, under $500 for professional claims. Rural hospitals are not subject to those minimums. Air ambulance is federal.
Each of our state pages says which process applies there, next to the federal IDR numbers for that state.
Air ambulance, and Alaska
Air ambulance goes federal almost everywhere. Federal law says state rate laws do not reach it.
Alaska is the one CMS singles out. It appears on neither list, and CMS records Alaska's position that its own insurance rule reaches out-of-network claims, air ambulance included. CMS noted that in January 2023 and Alaska's rules have changed since. Check Alaska directly before you file there.
The federal-only list also covers the US territories: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the US Virgin Islands.
A shortcut
Payers often stamp the EOB "federal surprise bill" or print a QPA on it. That means the payer treated the claim under federal law. It is good evidence. It is not proof. Check the plan type anyway.
Why it matters
File with the wrong one and you lose time you do not have. The federal filing window is four business days. Sort out the plan type before negotiation ends, not after.
What is changing
The map is changing
Everything above comes from the CMS chart of January 11, 2023. Three and a half years is a long time in this area. Some states have since told CMS they cannot keep up and want to send claims back to the federal process, and at least one state has repealed the rule CMS relied on. Before you rely on any state's entry, check the current CMS chart and the state's own rules.
Sources
CMS, "Applicable Federal IDR Process: Bifurcated States" chart, January 11, 2023; CMS state enforcement letters; 45 CFR 149.30; 45 CFR 149.510.
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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