Reference

No Surprises Act & federal IDR glossary

The terms that come up in every out-of-network dispute — defined in plain English, by people who file these claims. From the qualifying payment amount to batching and the 2026–2027 rule changes.

No Surprises Act (NSA)

The 2022 federal law that protects patients from surprise out-of-network bills for emergency care and for care from out-of-network providers at in-network facilities. It moves the payment dispute off the patient and into the Independent Dispute Resolution (IDR) process between the provider and the health plan.

Independent Dispute Resolution (IDR)

The federal arbitration process created by the No Surprises Act to settle out-of-network payment disputes. It is "final-offer" (baseball-style) arbitration: each side submits one payment amount, and a certified IDR entity picks one — there is no splitting the difference.

IDR entity (IDRE)

A federally certified, independent arbiter that decides an IDR dispute. The parties try to agree on one; if they cannot within three business days, the Departments assign one. The IDRE confirms the dispute is eligible before deciding.

Qualifying Payment Amount (QPA)

The health plan's median contracted (in-network) rate for the same service in the same geographic area, as of 2019 and trended forward. The QPA is the anchor the IDR entity starts from, and it is usually the number the provider must argue above.

Open negotiation

The mandatory 30-business-day period before IDR in which the provider and plan try to agree on payment. It begins when the provider sends a written open-negotiation notice. Most disputes are not resolved here, so it functions as a gate to IDR.

Open-negotiation notice

The written notice the provider sends the plan to start the 30-business-day open-negotiation clock. It identifies the claim and the requested amount. Missing or mistiming it can forfeit the right to pursue IDR.

Initiating IDR

Formally opening a dispute in the federal IDR portal after open negotiation fails. It must happen within four business days after the 30-day window closes; missing this window forfeits the dispute for that claim.

Final-offer (baseball) arbitration

The decision method IDR uses: each party submits a single payment offer and the arbiter must choose one of the two, not a compromise. This is why the offer amount and its justification are effectively the entire case.

Batching

Combining multiple related line items or services into a single IDR dispute to lower the per-claim cost. From November 1, 2026, up to 50 related services can be batched into one dispute.

Administrative fee

The per-party fee to use the IDR process, paid to the Departments. For disputes initiated on or after June 11, 2026, it dropped from $115 to $15 per party, per dispute — making many smaller claims worth pursuing.

IDR entity fee

The arbiter's own fee for deciding a dispute, separate from the administrative fee. Under final-offer arbitration, the losing party pays it.

Eligibility

Whether a claim actually qualifies for federal IDR — the right plan type (not, for example, a claim governed by a state IDR or an ERISA carve-out), a completed open negotiation, and timely initiation. Screening eligibility first avoids wasted fees on disputes that will be dismissed.

State IDR / balance-billing law

A state-run dispute or payment-standard process that applies instead of the federal IDR for certain fully-insured or state-regulated plans. Twenty-one states run their own process; which one governs a claim depends on the plan and the state.

Provider win rate

The share of decided IDR determinations in which the arbiter selects the provider's offer over the plan's. Across 2025 CMS data it runs about 85% overall, but varies by specialty and, sharply, by how well each group builds its offers.

Default / dismissal

Losing a dispute without a decision on the merits — usually because a deadline was missed or the claim was ineligible. Avoidable defaults are one of the most common reasons a self-filing group underperforms the benchmark win rate.

CARC / RARC codes

Standardized Claim Adjustment Reason Codes and Remittance Advice Remark Codes. For items and services on or after January 1, 2027, plans must attach standardized CARC/RARC codes and their IDR registration number to every payment or denial, making disputes easier to substantiate.

Contingency (percentage-of-recovery) model

The traditional pricing where an IDR or out-of-network recovery firm takes a percentage — typically 20–25% — of every dollar recovered, indefinitely. On roughly $1M recovered that is $200,000–$250,000; a flat-fee model runs the same book for about half.

Business Associate Agreement (BAA)

The HIPAA contract that governs how a vendor handles a provider's protected health information (PHI). Any platform touching claim-level PHI for IDR should operate under a BAA.