Federal IDR process, explained as simply as possible.

What the Federal IDR process is

The No Surprises Act created patient protections against many surprise out-of-network medical bills. It also created a payment dispute process for certain situations where the patient is protected from balance billing but the provider, facility, air ambulance provider, health plan, or issuer disagrees about the appropriate out-of-network payment amount.

The Federal IDR process is managed by the U.S. Departments of Health and Human Services, Labor, and Treasury. In some cases, state law or another process may apply instead of the federal process.

The process in 7 very plain steps

1. Payment or denial happens. A provider or facility receives an initial payment or a denial from a plan or issuer for an item or service that may be covered by the No Surprises Act.
2. Open negotiation starts. One party starts a 30-business-day open negotiation period.
3. The parties try to agree. If they agree on an out-of-network rate, IDR may not be needed.
4. If no agreement, IDR may be initiated. After the open negotiation period ends, either party can generally start Federal IDR within 4 business days.
5. A certified IDR entity is selected. The parties can choose from certified IDR organizations. Everyone involved must attest that there are no conflicts of interest.
6. Both sides submit offers. Each side submits a payment offer and supporting information.
7. The certified IDR entity picks an offer. The decision is binding on the parties, and payment must be made within 30 calendar days.

Key Federal IDR deadlines

Deadlines can change because of extensions or operational announcements. CMS maintains official notices and portal instructions.

Information to have ready before starting

CMS says parties should have enough information to identify the qualified IDR items or services and the other party. Common items include:

• Dates the items or services were provided
• Locations where the items or services were provided
• Types of services, such as emergency or post-stabilization services
• Service codes and place-of-service codes
• A complete Explanation of Benefits
• Claim numbers involved in the dispute
• An attestation that the items or services are within the Federal IDR scope
• Complete contact information for the non-initiating party
• A preferred certified IDR entity from the federal list

What disputes are eligible?

Not every out-of-network payment disagreement belongs in Federal IDR. Eligibility depends on the service, the plan or coverage, the state, the timing, and whether another law determines the payment amount.

CMS publishes a state-by-state applicability chart. If a state law or All-Payer Model Agreement applies, the Federal IDR process may not be the right route.

2026 Federal IDR operations rule: simple summary

On May 28, 2026, the Departments and the Office of Personnel Management released a final rule intended to make the Federal IDR process more standardized and easier to administer. Key operational changes include:

• More standardized remittance information. Plans and issuers must use specific claim adjustment and remark codes to indicate whether claims are subject to No Surprises Act surprise billing protections.
• Portal-based open negotiation notices. Open negotiation notices are to be submitted through the Federal IDR portal when the supporting functionality is available.
• Open negotiation response notice. The responding party must provide a response by the 15th business day of the 30-business-day negotiation period.
• Expanded batching rules. The rule expands when multiple items or services can be batched into one dispute, with a 50-line-item cap.
• Eligibility timing. Certified IDR entities must determine eligibility within 5 business days after final selection and notify the parties and Departments.
• Administrative fee. The administrative fee is $15 per party per dispute for disputes initiated on or after June 11, 2026.
• Federal IDR registry. Payers must register and provide information that helps providers identify the correct party for disputes, once registry functionality applies.

Many procedural changes take effect after the Departments announce that the needed portal functionality is available, so parties should check current CMS notices before relying on any timeline.

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