Federal IDR payer outcomes
Anthem federal IDR outcomes
See 2025 CMS federal IDR volume, provider offer selection, leave-one-out comparisons, offer levels, defaults, states, specialties, and certified IDR entity mix for responses from anthem.com.
2025 Q1–Q4 · Response domain: anthem.com · Closing-quarter basis
How did providers fare against Anthem in federal IDR?
In 2025, providers had their offer selected on 87.5% of 317,853 decided claim lines answered from anthem.com, across 167,450 disputes. Defaults count as losses in that rate and are reported separately below.
Claim lines
320,368
Across 167,450 disputes
Decided lines
317,853
No-decision lines excluded
Provider win rate
87.5%
Defaults count as losses
Median prevailing offer
360%
Of QPA, uncapped median
424% of QPA median provider offer.
100% of QPA median payer offer.
2.5% default-loss share.
38 days median determination.
Compared with all other payer domains
| Population | Provider win rate | Median prevailing / QPA | Default-loss share |
|---|---|---|---|
| Anthem | 87.5% | 360% | 2.5% |
| All other payer domains | 86.4% | 401% | 2.4% |
Payer identity
What anthem.com represents
This page groups disputes by the email domain of the responding party recorded by CMS. The report-card pipeline uses response domain because plan names are free text with hundreds of spelling variants.
Plan names as entered by parties
| Plan name | Lines |
|---|---|
| BLUE CROSS | 50,762 |
| Anthem Blue Cross Blue Shield | 35,115 |
| ANTHEM BLUE CROSS BLUE SHIELD | 34,034 |
| Anthem Virginia | 23,267 |
| Anthem Inc. | 17,740 |
Plan type mix
| Plan type | Lines |
|---|---|
| Either partially or fully self-insured private (employment-based) group health plan | 157,075 |
| Fully insured private group health plan | 63,863 |
| No Plan/Issuer Response | 59,941 |
| Non-federal government plan (or state or local government plan) | 23,616 |
Anthem 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 | 66,112 | 66,083 | 85.3% |
| 2025 Q2 | 90,568 | 90,495 | 88.1% |
| 2025 Q3 | 99,804 | 99,129 | 88.0% |
| 2025 Q4 | 63,884 | 62,146 | 88.0% |
Where Anthem disputes occurred
State is the CMS Location of Service field. Prevailing-offer figures are uncapped medians and are printed as computed, including unusually high values.
Specialty mix
Usable specialty labels are grouped into provider categories. The unknown bucket is omitted.
| Specialty | Lines | Provider win rate |
|---|---|---|
| Emergency | 164,733 | 88.0% |
| Hospital medicine | 63,081 | 90.6% |
| Neuromonitoring | 28,637 | 85.7% |
| Anesthesia | 25,128 | 84.9% |
| Surgery | 19,612 | 89.8% |
| Other | 8,597 | 89.3% |
Certified IDR entity mix
CMS added the named certified IDR entity field beginning with the 2025 Q3 file. This table covers named Q3 and Q4 records only and should not be compared with the full-year payer totals.
| Certified IDR entity | Lines | Provider win rate |
|---|---|---|
| Maximus Federal Services, Inc. | 18,715 | 95.2% |
| EdiPhy Advisors, L.L.C. | 16,819 | 98.0% |
| Network Medical Review Company, Ltd. | 15,238 | 76.1% |
| iMPROve Health | 15,052 | 90.6% |
| Federal Hearings and Appeals Services, Inc. | 14,271 | 91.1% |
| MCMC Services, LLC | 13,046 | 94.8% |
Methodology, sources, and limits
This page uses all four 2025 CMS Federal IDR Public Use Files for out-of-network emergency and non-emergency items and services. Air ambulance is excluded. Lines are deduplicated to the latest quarterly record.
A payer is the email domain of the responding party recorded by CMS. This page includes responses from anthem.com. Recourse uses response domain because plan names are free text with hundreds of spelling variants.
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, payer, and prevailing-offer figures are uncapped medians as a percentage of QPA. Values are printed as computed, including unusually high medians. Leave-one-out comparisons include all other payer response domains.
Source: CMS Federal IDR Public Use Files, 2025 Q1 through Q4. Full calculation rules: Recourse methodology. Browse all profiles: payer outcomes directory.
What the Anthem pattern means for provider groups
Anthem's 87.5% provider offer-selection rate was 1.1 percentage points above the 86.4% leave-one-out rate. Its median prevailing offer was lower, at 360% of QPA versus 401% for other payer domains, while the default-loss shares were essentially aligned at 2.5% and 2.4%. The result again separates frequency from value: a slightly higher selection rate coexisted with a lower median prevailing offer.
A provider group's own result can differ because its specialties, services, states, offers, defaults, and filing operations differ from this payer-domain population. The report-card CTA below applies the same measurement framework to the group's own claims.
Your claims involving Anthem
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