CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Notice of IDR Initiation (Federal independent dispute resolution process)

Governs the use and content of the Federal Notice of IDR Initiation to start the Federal independent dispute resolution process under the No Surprises Act for out-of-network emergency services, certain out-of-network services at in‑network facilities, and air ambulance services; affects plans, issuers, FEHB carriers, providers, facilities, and providers of air ambulance services.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyNotice of IDR Initiation (Federal independent dispute resolution process)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and send the Notice of IDR Initiation to the other party and submit it to the Federal IDR portal the same day within the 4-business-day initiation window.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 business dayswindow to send Notice of IDR Initiation to other party after open negotiation

3 business daystime to agree on a certified IDR entity after Departments receipt

10 business daystime parties have to submit payment offers to the certified IDR entity after selection

1 per item/servicerequirement: use one Notice of IDR Initiation per out-of-network item or service (with batching exceptions)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Federal IDR Eligibility and Procedure

Federal IDR applicability and procedure

Eligibility, timing, exclusions, and procedural steps required to initiate the Federal independent dispute resolution (Federal IDR) process under the No Surprises Act.

ALL of the following

Applies to out-of-network emergency services, certain nonemergency services furnished by nonparticipating providers at participating facilities, and air ambulance services when an All-Payer Model Agreement or specified state law does not apply.
See definition of applicability under the No Surprises Act and interim final rules.

ALL of the following

Federal IDR may be initiated only after the 30-business-day open negotiation period ends with no agreement.
ANY of the following
- Standard: initiating party may start Federal IDR during the 4-business-day period beginning on the 31st business day after the start of open negotiation.
- Suspended-claim exception: for claims subject to a 90-calendar-day suspension period, initiating party may start during the 30-business-day period beginning after the end of the suspension period.

ALL of the following

Initiating party must furnish the written Notice of IDR Initiation to the other party and may deliver it electronically if electronic delivery is reasonably accessible to the recipient and other conditions in the Notice instructions are met.
The initiating party must submit the Notice to the Federal IDR portal the same day it furnishes the Notice to the non-initiating party; the Departments' receipt date is considered the initiation date.

ALL of the following

One Notice of IDR Initiation is required per out-of-network item or service unless the items/services meet the specific batching conditions set forth in the interim final rules; items/services that do not meet batching conditions require separate Notices.

ALL of the following

Items or services are not eligible for Federal IDR if an applicable All-Payer Model Agreement or specified state law applies; in that case, notify the initiating party and the requisite state entity under the Agreement or law.

ALL of the following

After the Departments' receipt of the Notice, parties have 3 business days to agree upon a certified IDR entity; if the parties do not agree within 3 business days, the Departments will randomly select a certified IDR entity.
Following selection of the certified IDR entity, each party has 10 business days to submit payment amount offers and any additional information to the certified IDR entity.

ALL of the following

The Notice of IDR Initiation must use the Departments' prescribed form and include required information such as identification of qualified item(s)/service(s), applicable service and place-of-service codes, claim identifiers, payment amounts (if applicable), and the OMB control number as required by the Notice instructions.
Form and exact fields are specified in the Notice instructions and form.

Service Identification and Batching Rules

Required Service Codesmixed

HCPCS/CPT	Enter applicable HCPCS or CPT codes for each item or service provided (e.g., 71020, 80050, J7321).
ICD-10	Enter diagnosis code(s) that support medical necessity (e.g., M54.5).
Place of Service	Enter appropriate POS code (e.g., 11=Office, 21=Inpatient Hospital, 22=Outpatient Hospital).
Modifier	Include applicable modifiers when required (e.g., -59, -25).

Batching allowance — conditions under which items/services may be batched vs one Notice per item/service

Batching allowanceThe initiating party must use 1 Notice of IDR Initiation per out-of-network item or service, unless: (1) the plan/issuer made an initial bundled payment for the claim or specifies the denial is on a bundled-payment basis; OR (2) items/services meet the interim final rules conditions for batching. When batching is used, each Notice must indicate 'Batched = Yes' and include the individual service details (service codes, dates, locations, qualifying payment amounts) for every item/service included.

When separate Notices requiredIf items/services were paid or denied individually (not bundled) and do not meet batching conditions, the initiating party must submit one Notice per item/service.

Operational noteParties do not need to include the instruction page with the notice. Ensure service codes and place-of-service codes are provided for each listed item/service to avoid processing delays.

What the Initiating Party Must Do

Note

Certified IDR entity selection and conflict process

Within 4 business days of initiating Federal IDR, the initiating party must electronically submit a Notice of Certified IDR Entity Selection (or a Notice of Failure to Select) to the Departments using the Federal IDR portal. If the parties have agreed on a certified IDR entity, the notice must include: (1) the certified IDR entity's name; (2) the certified IDR entity number assigned by the Departments; and (3) an attestation by the parties (or by the initiating party if the other party did not respond) that the selected certified IDR entity does not have a disqualifying conflict of interest.

If the parties fail to select a certified IDR entity within the 4-business-day time frame, the Departments will select a certified IDR entity through a random selection method.
If the selected certified IDR entity cannot attest it has no conflicts of interest, the certified IDR entity must notify the Departments via the Federal IDR portal within 3 business days.
Upon such notification, the parties have 3 business days to select another certified IDR entity or notify the Departments of a failure to select so that the Departments may randomly select another certified IDR entity.
If you believe Federal IDR is not applicable (for example, an All‑Payer Model Agreement or specified state law applies), you must provide information regarding lack of applicability on the same timeframe as the notice of selection (or failure to select).

Key Terms

Federal IDR process (definition)

DefinitionFederal independent dispute resolution (Federal IDR) is the Federal process established by interim final rules under the No Surprises Act to determine out-of-network payment rates after unsuccessful open negotiations for specified services.

ScopeApplies to out-of-network emergency services, certain nonemergency services by nonparticipating providers at participating facilities, and air ambulance services when no All-Payer Model Agreement or specified state law applies.

Initiation timingMay be initiated after the 30-business-day open negotiation period ends without agreement; initiation must occur during the 4-business-day window (or 30-business-day window for claims subject to suspension).

Notice submissionThe initiating party must furnish the Notice of IDR Initiation to the other party and submit the same Notice to the Federal IDR portal the same day; the Departments' receipt date is the initiation date.

Batched items and services