Claim Review — Sample
Sample document · Prepared for illustration · Figures are representative, not a specific practice
Verdict
Eligible for federal IDR.
Non-emergency service by an out-of-network surgeon at an in-network facility, with no valid notice-and-consent on file. This is squarely within the No Surprises Act, and it's underpaid.
Why
- Service was furnished at an in-network ambulatory surgery center by an out-of-network provider. Under the NSA, the patient can't be balance-billed and the payment dispute goes to federal IDR.
- No valid notice-and-consent waiver was obtained. Had one been signed correctly, the claim would fall outside the process — this is the single most common reason a claim we review turns out ineligible.
- Plan is fully insured and issued in North Carolina. North Carolina has no qualifying state process for this service type, so federal IDR governs.
The money
| CPT | 64721 — open carpal tunnel release |
|---|---|
| Billed | $6,800 |
| Plan allowed | $1,410 |
| Plan paid | $1,128 |
| Payer's stated QPA | $1,410 |
| Comparable resolved disputes | $3,100 – $4,900 |
| Estimated recovery on this claim | $2,400 – $3,500 above what was paid |
Confidence is moderate. A copy of the plan's QPA disclosure would tighten this — payers frequently understate QPA, and a challenge to the calculation itself is often worth more than the offer.
The clock
| Date of service | March 4, 2026 |
|---|---|
| Open negotiation window | 30 business days, initiated through the federal IDR portal |
| Open negotiation must start by | on or before the deadline tied to your initial payment date |
| Estimated IDR filing deadline | shortly after the open negotiation window closes |
This one is still comfortably in window.
Roughly a third of the claims we review are not, which is the main reason practices lose money they were entitled to.
Deadlines are strict and there is no cure for missing one.
What we'd file
Offer: $4,200
Three supporting factors: the provider's level of training and the complexity of the specific case; the market rate for this service in this geography, which sits well above the payer's stated QPA; and the payer's own historical contracted rates for comparable open procedures. The QPA is a floor in this dispute, not a ceiling — and the gap between $1,410 and the comparable award range is the argument.
What it costs to pursue
- Administrative fee: $15 per party (down from $115 as of June 11, 2026)
- Certified IDRE fee: set per the current published range; the losing party pays it
- This claim could be batched with other 64721 disputes against the same payer, spreading the fee
Against a claim worth $2,400–$3,500, the arithmetic is not close.
What happens next
See it run on your own claim.
Fifteen minutes on Zoom, using your claim and your CPT codes. You will see the real output and get a price. Nothing to sign on the call.
Or we file it for you.
We prepare and submit, you keep the recovery.
Sample document. Figures are representative of a typical hand surgery claim and are not drawn from a specific practice. Not a guarantee of recovery, and not legal advice.
