Federal IDR in New York
New York 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 York.
2025 Q1–Q4 · State = Location of Service
Claim lines
172,610
Across 79,676 disputes
Decided lines
172,358
No-decision lines excluded
Provider win rate
86.5%
Defaults count as losses
Median prevailing offer
538%
Of QPA, uncapped median
606% of QPA median provider offer.
1.9% default-loss share of lines.
44 days median time to determination.
Applicability
Does New York law or federal IDR apply?
New York has a state surprise-billing law and independent dispute process for claims and coverage subject to New York insurance law, including specified state plans. The state process applies where New York law governs the plan and circumstances.
The New York Department of Financial Services states that federal protections apply to many employer and union self-funded plans that are not subject to New York law. Federal IDR can therefore govern eligible claims outside the state process. The correct path depends on plan type, service, facility, provider, and claim facts.
New York 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 | 41,566 | 41,519 | 86.3% |
| 2025 Q2 | 49,585 | 49,487 | 87.1% |
| 2025 Q3 | 42,133 | 42,073 | 87.0% |
| 2025 Q4 | 39,326 | 39,279 | 85.1% |
Payers with the most New York claim lines
| Payer | Lines | Provider win rate | Median prevailing / QPA | Default-loss share |
|---|---|---|---|---|
| UnitedHealthcare | 86,310 | 84.6% | 555% | 1.8% |
| Aetna | 28,870 | 91.7% | 286% | 1.2% |
| Anthem | 25,372 | 86.8% | 1710% | 3.2% |
| MultiPlan | 8,947 | 83.1% | 433% | 2.0% |
| ClearHealth Strategies | 6,438 | 91.0% | 540% | 1.6% |
| EmblemHealth | 3,723 | 93.1% | 2223% | 0.8% |
| Clear Health (cloud) | 3,270 | 84.4% | 260% | 2.8% |
| 1199SEIU Benefit Funds | 2,122 | 67.5% | 2300% | 3.9% |
Certified IDR entities in the New York 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. | 16,098 | 84.0% |
| Maximus Federal Services, Inc. | 8,891 | 89.8% |
| Provider Resources, Inc. | 8,618 | 96.6% |
| MCMC Services, LLC | 6,852 | 92.0% |
| EdiPhy Advisors, L.L.C. | 6,558 | 94.3% |
| C2C Innovative Solutions, Inc. | 6,487 | 86.7% |
| iMPROve Health | 4,694 | 81.3% |
| Island Peer Review Organization | 4,600 | 95.7% |
Specialty mix
The supplied analysis groups usable specialty labels into provider categories. The unknown bucket is omitted.
| Specialty | Lines | Provider win rate |
|---|---|---|
| Radiology | 61,289 | 91.0% |
| Emergency | 35,327 | 88.1% |
| Surgery | 34,376 | 87.1% |
| Other | 10,602 | 81.1% |
| Anesthesia | 10,135 | 78.7% |
| Neuromonitoring | 7,828 | 85.1% |
| Hospital medicine | 4,794 | 78.0% |
What the New York data shows
UnitedHealthcare accounts for roughly half of the listed New York payer lines, while Aetna and Anthem make up much of the next tier. Several payer rows carry uncapped prevailing-offer medians above the statewide median, including Anthem, EmblemHealth, and 1199SEIU Benefit Funds.
Radiology is the largest supplied specialty group, followed by emergency services and surgery. The statewide result combines these different payer and specialty populations and should not be read as a controlled comparison or a forecast for an individual provider group.
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 York 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.