Federal IDR · Guide
Self funded versus fully insured and why it decides your IDR pathA guide for surgical billing teams.
Plan type decides where your dispute goes. Self funded employer plans are governed by federal law and route to federal IDR in every state. Fully insured plans may route to a state process in states that have one. About 65 percent of covered workers are in self funded plans, so federal IDR is in play almost everywhere.
Answer one question first.
Before you think about benchmarks or offers, answer one question: is the plan self funded or fully insured? Everything downstream depends on it.
What self funded plans are.
Self funded plans are employer plans where the employer pays claims directly and uses an insurer only to administer them. These are governed by federal law, which means they route to federal IDR regardless of what state you are in. Since roughly two thirds of covered workers are in self funded plans, federal IDR is the dominant path almost everywhere.
What fully insured plans are.
Fully insured plans are the traditional model where the employer buys coverage and the insurer bears the risk. These can fall under a state surprise billing process in the states that have one. About 22 states have such a law for fully insured disputes.
The practical takeaway.
The practical takeaway is simple. Identify plan type first. Self funded means federal IDR. Fully insured means check whether your state runs its own process. Get this wrong and you can burn the filing window in the wrong forum. Sydra classifies the plan and routes the claim correctly before the clock starts.
Common questions.
How do I know if a plan is self funded?
The explanation of benefits and the plan documents indicate it, and a third party administrator name is often a clue. Sydra helps your team classify the plan before filing.
Why does it matter so much?
It determines the entire process, the deadlines, and the benchmarks. Filing in the wrong forum wastes the window.
This page is general information about the No Surprises Act dispute process, not legal advice. Eligibility depends on the specific plan, claim, and current federal and state rules. Confirm details for your claim before filing.
Sourced references
- 1. CMS Federal IDR Q1/Q2 2025 Public Use FileReleased January 21, 2026cms.gov/nosurprises/policies-and-resources/reports
- 2. Georgetown University CHIR · Health Affairs webinarMarch 2026 — 3.4 million disputes through June 2025; 88% win rate; median award ~4.5x in network rate
- 3. Zelis — NSA IDR Eligibility ChallengesMarch 2026 — 44% of 2024 IDR cases challenged as ineligible by non initiating party
- 4. ACEP analysis of CMS data~10% of eligible claims estimated to reach IDR arbitration
- 5. Brookings Institution NSA Arbitration DatabookApril 2026brookings.edu/articles/no-surprises-act-arbitration-databook
- 6. ACR — Providers Prevail in Vast Majority of IDR ClaimsJanuary 2026 — 88% of disputes found in provider's favor; 87% of awards exceeded QPA
- 7. No Surprises Act: Public Law 116-260, Division BB, Title I
- 8. Federal IDR regulations: 45 CFR Part 149ecfr.gov/current/title-45/subtitle-A/subchapter-F/part-149
- 9. CMS No Surprises Act overviewcms.gov/nosurprises
- 10. HHS HIPAA for professionalshhs.gov/hipaa/for-professionals
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