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No Surprises Act · New York
Out-of-network claims in New York — that payment is an opening offer
Dispute pathway: Federal IDR + state pathway
Out-of-network surgical and hospital-based claims in New York 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 New York
Federal IDR + state pathway
New York runs baseball-style Independent Dispute Resolution for surprise bills and emergency services (Financial Services Law Article 6; 23 NYCRR Part 400). An IDR entity assigned by DFS decides whether the plan's payment or the provider's fee is more reasonable; the 80th percentile of charges for the service, which the law calls the usual and customary cost, is one of the factors it weighs. Medicaid managed care disputes are excluded for filings on or after May 28, 2026.
State-regulated plans follow New York's IDR through the Department of Financial Services. Self-funded ERISA plans generally follow the federal IDR process; whether a self-funded plan can opt into New York's process is unresolved. Confirm routing by plan type before filing.
What's specific to New York
- The IDR entity picks either the plan's payment or the provider's fee, nothing in between. Evidence is due within five business days of the assignment notice, and a determination cannot be reconsidered.
- Rules changed for disputes submitted on or after August 26, 2026: both parties pay the IDR entity's fee up front, the prevailing party's fee is refunded, and decisions run 45 business days from receipt of all information.
Deadlines once a New York dispute is running
Submit all evidence to the IDR entity
5 business days
from the IDR entity assignment notice
Five business days from the assignment notice to get everything in. Miss it and the IDR entity decides on what it already has.
23 NYCRR 400.8(d)
IDR entity issues its binding determination
45 business days
from the IDR entity receiving all the information it needs
For disputes submitted on or after 26 August 2026; before that it was 30 business days from receipt of the dispute. A good-faith settlement negotiation of up to ten business days may run at the same time. The entity picks either the plan's payment or the provider's fee.
N.Y. Fin. Serv. Law §§605(a)(3), 607(a)(5), as amended by L.2026 c.57 Part BB; DFS Circular Letter No. 5 (2026)
Plan pays any additional amount owed
30 calendar days
from the determination
Where the determination goes the provider's way.
23 NYCRR 400.5(j)
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 New York'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 New York
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.