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No Surprises Act · California
Out-of-network claims in California — that payment is an opening offer
Dispute pathway: Federal IDR + state pathway
Out-of-network surgical and hospital-based claims in California are routinely paid below the billed charge or denied outright. Under the No Surprises Act that payment is an opening offer, and dispute resolution exists to contest it. Sydra checks what qualifies, assembles the submission, holds every deadline, and can file it for you.
How disputes route in California
Federal IDR + state pathway
California's AB 72 (2016; Health & Safety Code §1371.9) protects patients from surprise bills for non-emergency care by noncontracting individual professionals at contracting facilities. For DMHC-regulated plans, a provider who disputes the payment first completes the plan's Provider Dispute Resolution process and can then apply to DMHC's Independent Dispute Resolution Process (IDRP), where an independent reviewer sets the reimbursement. Emergency services and self-funded ERISA plans are outside this process.
Claims under DMHC-regulated plans can go to California's AB 72 IDRP, and insurers regulated by the Department of Insurance (CDI) have a separate track. Self-funded ERISA plans follow the federal IDR process. Confirm the plan's regulator before filing.
What's specific to California
- The DMHC process is not baseball-style: the reviewer is not bound to either side's number and sets its own reimbursement, itemized by billing code.
- It covers non-emergency services by a noncontracting individual health professional at, or as a result of services at, a contracting facility, and the plan's own Provider Dispute Resolution process must be completed first.
- CDI-regulated health insurers run their own AB 72 process (Insurance Code §10112.81), so the plan's regulator decides which California forum applies.
Deadlines once a California dispute is running
Payor acknowledges or issues the PDR determination
45 business days
from the payor receiving the dispute
If nothing comes back, dated proof of the attempt substitutes once this period matures. Completing the plan's Provider Dispute Resolution process is a hard gate before the IDRP.
DMHC IDRP eligibility criteria
Independent organization issues its binding written determination
30 calendar days
from review beginning
Binding on both parties. DMHC's written procedures, which fix exactly when this clock starts, have not yet been verified.
Health & Safety Code §1371.9
These are the steps once a dispute is already running. The window to file in the first place turns on the plan type and on which date the clock runs from, so we check it against the claim in front of us rather than a general figure.
Claims that go to federal IDR follow a defined pathway between a payer's underpayment and a binding payment determination — an open negotiation window, an eligibility determination, a batching decision, then a decision by a certified IDR entity. Claims under California's own law follow the state rules described above instead. Each step has its own deadline, and missing one can cost the claim. Providers win roughly 88% of federal IDR determinations they contest. Sydra is a capped, predictable fee — less than half of what most contingency firms charge. We file it, you keep the recovery.
Browse by specialty
Commonly disputed procedures in California
Return to the Federal IDR hub.
No outcome is guaranteed. Results vary by claim, payer, specialty, and documentation. State routing depends on plan type; confirm against the CMS applicability chart before filing. This is general information, not legal or financial advice.
Medically & clinically reviewed by Dr. John M. Abrahams, MD
Board-certified neurosurgeon and founder of Sydra · Last reviewed September 2026 · About the author
Sources
Figures reflect the published federal record across all disputes, not a prediction about any individual claim. This is general information, not legal or financial advice.