Federal IDR in California
California surprise billing law and federal IDR
See which dispute path may apply, then examine 2025 federal IDR volume, provider offer selection, payer outcomes, certified IDR entity mix, and specialties for services delivered in California.
2025 Q1–Q4 · State = Location of Service
Claim lines
209,891
Across 69,665 disputes
Decided lines
205,718
No-decision lines excluded
Provider win rate
88.5%
Defaults count as losses
Median prevailing offer
263%
Of QPA, uncapped median
289% of QPA median provider offer.
0.9% default-loss share of lines.
36 days median time to determination.
Applicability
Does California law or federal IDR apply?
California has state surprise-billing protections and payment rules, including AB 72 for specified nonemergency services provided by noncontracted providers at contracted facilities. Those rules apply where California law governs a state-regulated plan and the claim falls within the state law.
Federal protections and federal IDR can apply when California's specified state law does not control, including many self-funded employer plans and other federally regulated coverage. The correct path depends on plan type, service, facility, provider, and claim facts.
California outcomes by closing quarter
The quarter is the quarter in which a dispute closed. These figures are descriptive snapshots. They do not establish a directional pattern because CMS publishes in arrears and can restate records.
| Closing quarter | Lines | Decided lines | Provider win rate |
|---|---|---|---|
| 2025 Q1 | 26,508 | 26,492 | 89.5% |
| 2025 Q2 | 48,876 | 48,848 | 90.3% |
| 2025 Q3 | 72,670 | 71,573 | 88.1% |
| 2025 Q4 | 61,837 | 58,805 | 87.2% |
Payers with the most California claim lines
| Payer | Lines | Provider win rate | Median prevailing / QPA | Default-loss share |
|---|---|---|---|---|
| Anthem | 83,621 | 90.4% | 349% | 0.8% |
| Aetna | 25,978 | 93.7% | 248% | 0.3% |
| Cigna | 25,822 | 84.3% | 226% | 3.0% |
| MultiPlan | 22,529 | 84.0% | 190% | 0.1% |
| Blue Shield of California | 17,753 | 83.0% | 574% | 0.7% |
| UnitedHealthcare | 13,505 | 87.4% | 297% | 0.7% |
| ClearHealth Strategies | 2,710 | 88.5% | 314% | 0.3% |
| Clear Health (cloud) | 2,254 | 88.0% | 209% | 0.1% |
Certified IDR entities in the California data
CMS added the named certified IDR entity field beginning with the 2025 Q3 file. This table therefore covers named Q3 and Q4 records only and should not be compared with the full-year state totals.
| Certified IDR entity | Lines | Provider win rate |
|---|---|---|
| Federal Hearings and Appeals Services, Inc. | 37,484 | 86.4% |
| Maximus Federal Services, Inc. | 11,019 | 92.1% |
| Network Medical Review Company, Ltd. | 9,649 | 82.5% |
| EdiPhy Advisors, L.L.C. | 9,631 | 98.1% |
| C2C Innovative Solutions, Inc. | 9,108 | 91.8% |
| National Medical Reviews, Inc. | 8,650 | 85.0% |
| iMPROve Health | 8,648 | 91.6% |
| Provider Resources, Inc. | 8,101 | 92.8% |
Specialty mix
The supplied analysis groups usable specialty labels into provider categories. The unknown bucket is omitted.
| Specialty | Lines | Provider win rate |
|---|---|---|
| Hospital medicine | 117,156 | 89.2% |
| Emergency | 57,993 | 89.8% |
| Surgery | 10,513 | 87.7% |
| Other | 6,444 | 89.4% |
| Neuromonitoring | 4,855 | 87.4% |
| Anesthesia | 2,246 | 81.0% |
What the California data shows
Hospital medicine accounts for more than half of the supplied California claim lines, and Anthem is the largest listed payer. The statewide totals therefore reflect a concentrated specialty and payer mix rather than an even cross-section of all claims.
The payer rows show different prevailing-offer medians and provider win rates, while the named Q3 and Q4 entity results occupy a narrower but still distinct range. These descriptive aggregates do not isolate the effect of payer, specialty, service, or certified IDR entity.
A provider group's own result can differ because its payer mix, specialty, services, offers, defaults, and filing operations differ from the statewide population. The report-card CTA below applies the same measurement framework to the group's own claims.
Methodology, sources, and limits
This page uses all four 2025 CMS Federal IDR PUF files for OON emergency and non-emergency items and services. Air ambulance is excluded. Lines are deduplicated to the latest quarterly record. State is the Location of Service field.
Win rate is the share of decided lines where the provider offer was selected. Lines with no decision are excluded from both numerator and denominator. Default decisions count as losses and are also shown separately. Disputes are dated by closing quarter.
Provider-offer and prevailing-offer figures are uncapped medians of the respective offer as a percentage of QPA. Values are printed as computed, including unusually high medians. They are not rounded away or adjusted.
Source: CMS Federal IDR Public Use Files, 2025 Q1 through Q4. Q1 and Q2 data as of January 21, 2026; Q3 and Q4 published July 15, 2026. Full calculation rules: Recourse methodology.
Your California claims
See how your group's IDR outcomes compare.
Request a free per-group report card using the same 2025 CMS methodology shown on this page.