Federal IDR payer outcomes
Centene (Ambetter) 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 centene.com.
2025 Q1–Q4 · Response domain: centene.com · Closing-quarter basis
How did providers fare against Centene (Ambetter) in federal IDR?
In 2025, providers had their offer selected on 90.3% of 128,402 decided claim lines answered from centene.com, across 21,484 disputes. Defaults count as losses in that rate and are reported separately below.
Claim lines
129,354
Across 21,484 disputes
Decided lines
128,402
No-decision lines excluded
Provider win rate
90.3%
Defaults count as losses
Median prevailing offer
289%
Of QPA, uncapped median
331% of QPA median provider offer.
100% of QPA median payer offer.
6.1% default-loss share.
31 days median determination.
Compared with all other payer domains
| Population | Provider win rate | Median prevailing / QPA | Default-loss share |
|---|---|---|---|
| Centene (Ambetter) | 90.3% | 289% | 6.1% |
| All other payer domains | 86.3% | 401% | 2.3% |
Payer identity
What centene.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 |
|---|---|
| AMBETTER | 38,560 |
| Ambetter Peach State | 30,374 |
| Ambetter | 20,718 |
| AMBETTER FROM PEACH STATE | 7,076 |
| Ambetter Magnolia | 4,268 |
Plan type mix
| Plan type | Lines |
|---|---|
| Individual health insurance issuer | 87,194 |
| No Plan/Issuer Response | 18,790 |
| Fully insured private group health plan | 13,089 |
| Either partially or fully self-insured private (employment-based) group health plan | 10,270 |
Centene (Ambetter) 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 | 18,366 | 18,364 | 89.5% |
| 2025 Q2 | 30,976 | 30,961 | 88.2% |
| 2025 Q3 | 41,328 | 41,082 | 90.8% |
| 2025 Q4 | 38,684 | 37,995 | 91.9% |
Where Centene (Ambetter) 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 |
|---|---|---|
| Hospital medicine | 48,289 | 96.5% |
| Emergency | 45,535 | 86.9% |
| Radiology | 13,002 | 87.2% |
| Surgery | 8,011 | 98.6% |
| Anesthesia | 4,886 | 88.0% |
| Neuromonitoring | 3,531 | 96.1% |
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 |
|---|---|---|
| Federal Hearings and Appeals Services, Inc. | 47,146 | 92.5% |
| Island Peer Review Organization | 9,422 | 76.7% |
| C2C Innovative Solutions, Inc. | 5,983 | 95.1% |
| MCMC Services, LLC | 4,892 | 95.1% |
| National Medical Reviews, Inc. | 4,429 | 99.4% |
| EdiPhy Advisors, L.L.C. | 2,753 | 99.6% |
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 centene.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 Centene (Ambetter) pattern means for provider groups
Centene's 90.3% provider offer-selection rate was 4.0 percentage points above the 86.3% leave-one-out rate, but its 289% median prevailing offer was well below the 401% comparison. Its 6.1% default-loss share was also 3.8 points higher than the rate across other payer domains. Those cross-currents make this a clear case for evaluating recovered dollars and default operations alongside headline win rate.
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 Centene (Ambetter)
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