Federal IDR in New Jersey
New Jersey 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 New Jersey.
2025 Q1–Q4 · State = Location of Service
Claim lines
157,940
Across 105,243 disputes
Decided lines
157,566
No-decision lines excluded
Provider win rate
86.0%
Defaults count as losses
Median prevailing offer
1348%
Of QPA, uncapped median
1993% of QPA median provider offer.
1.8% default-loss share of lines.
37 days median time to determination.
Applicability
Does New Jersey law or federal IDR apply?
New Jersey's Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act establishes state protections and a dispute process for plans and circumstances subject to New Jersey law. The state process continues to apply where the New Jersey Act governs.
The New Jersey Department of Banking and Insurance states that the federal No Surprises Act reaches health plans including self-funded plans and provides a separate federal IDR process. The correct path depends on plan type, service, facility, provider, and claim facts.
New Jersey 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 | 32,061 | 32,007 | 86.2% |
| 2025 Q2 | 42,030 | 41,856 | 86.7% |
| 2025 Q3 | 42,369 | 42,311 | 86.6% |
| 2025 Q4 | 41,480 | 41,392 | 84.4% |
Payers with the most New Jersey claim lines
| Payer | Lines | Provider win rate | Median prevailing / QPA | Default-loss share |
|---|---|---|---|---|
| MultiPlan | 49,352 | 81.8% | 1894% | 2.9% |
| UnitedHealthcare | 42,401 | 84.5% | 224% | 1.1% |
| Aetna | 24,926 | 90.7% | 2371% | 1.7% |
| Horizon BCBS of New Jersey | 8,623 | 87.8% | 2082% | 1.8% |
| ClearHealth Strategies | 8,058 | 83.7% | 1462% | 2.0% |
| EmblemHealth | 6,451 | 94.1% | 1938% | 0.6% |
| Cigna | 2,440 | 88.7% | 606% | 1.6% |
| Clear Health (cloud) | 2,432 | 85.7% | 308% | 3.1% |
Certified IDR entities in the New Jersey 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 |
|---|---|---|
| Maximus Federal Services, Inc. | 12,957 | 90.5% |
| Federal Hearings and Appeals Services, Inc. | 10,126 | 83.3% |
| EdiPhy Advisors, L.L.C. | 7,816 | 96.7% |
| iMPROve Health | 7,684 | 81.2% |
| C2C Innovative Solutions, Inc. | 7,049 | 91.5% |
| Provider Resources, Inc. | 6,852 | 94.5% |
| Network Medical Review Company, Ltd. | 5,649 | 81.6% |
| MCMC Services, LLC | 5,613 | 92.3% |
Specialty mix
The supplied analysis groups usable specialty labels into provider categories. The unknown bucket is omitted.
| Specialty | Lines | Provider win rate |
|---|---|---|
| Surgery | 54,205 | 87.5% |
| Anesthesia | 34,476 | 85.1% |
| Emergency | 24,531 | 85.8% |
| Hospital medicine | 13,275 | 93.7% |
| Neuromonitoring | 12,674 | 84.9% |
| Other | 10,039 | 85.3% |
What the New Jersey data shows
New Jersey's overall provider-offer and prevailing-offer medians are uncapped and substantially higher than the national medians in the supplied analysis. The payer table also contains a wide span of uncapped prevailing-offer medians, while UnitedHealthcare is a notable lower-median payer within the listed mix.
Surgery and anesthesia account for more than half of the supplied specialty lines. MultiPlan and UnitedHealthcare are the two largest listed payer populations. These distributions are important context for the statewide aggregate and do not establish causal differences among payers or certified IDR entities.
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 New Jersey 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.