CurrentMedicarePolicy N/A

Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities

Guidance governing the Federal IDR Process under the No Surprises Act for certified IDR entities, outlining pre-initiation steps, initiation, certified IDR entity selection, offers, decision timelines, fees, batching, reporting, and exclusions for federal programs and certain state law/All-Payer Model Agreement scenarios.

Policy Summary

PayerMedicare

PolicyFederal IDR Process guidance for certified IDR entities (December 2023 update)

Policy CodePolicy N/A

Change TypeAdministrative update (guidance clarification)

Effective DateDecember 2023 (update to March 2023 Guidance) as written

Next Review DateN/A

Key ActionEither party may initiate Federal IDR by submitting a Notice of IDR Initiation within 4 business days after the close of the 30-business-day open negotiation period, including the preferred certified IDR entity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysInitial payment/notice deadline

30 business daysOpen negotiation period

4 business daysIDR initiation window after negotiations

30 business daysCertified IDR entity decision time

30 days

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Payment due after determination

6 yearsRecord retention

When Federal IDR Applies and Procedural Requirements

Applicability

Situations where the Federal IDR Process applies and does not apply:

Applies when the dispute concerns a qualified IDR item or service (emergency services; certain nonemergency items/services at in‑network facilities furnished by out‑of‑network providers; and air ambulance services) and no applicable All‑Payer Model Agreement or specified state law governs the OON payment method.

Applies to group health plans and health insurance issuers (group and individual markets), and FEHB carriers, for plan/policy/contract years beginning on or after January 1, 2022, as provided in the October 2021 and August 2022 rules.

Does NOT apply to

Items/services payable by Medicare, Medicaid, CHIP, or TRICARE.
Items/services where a specified state law or an All‑Payer Model Agreement establishes the method for determining the total amount payable for OON items/services (state process governs).

Pre-Initiation Requirements

Pre‑IDR procedural requirements and disclosures that must be completed before open negotiation or IDR initiation:

Plan/issuer must send an initial payment or a notice of denial of payment to the provider/facility/air ambulance provider within 30 calendar days after claim submission; the initial payment should be the amount the plan reasonably intends to be payment in full prior to open negotiations or IDR initiation.

When patient cost sharing is based on the QPA, the initial payment or denial must include: the applicable QPA for each item/service; if the QPA is based on a downcoded service code/modifier, a statement explaining the downcoding, why it occurred, which codes/modifiers were altered/added/removed, and the QPA amount that would have applied absent the downcoding; and a certification that the QPA was determined in compliance with applicable rules.

The 30‑business‑day open negotiation period does not begin until an initial payment or notice of denial that complies with disclosure requirements has been provided; if disclosures are deficient, providers retain the right to initiate open negotiation within 30 business days of receiving the initial payment/denial or may request an extension to initiate Federal IDR, and parties must comply with balance‑billing restrictions pending coverage determinations.

Procedural Criteria

Procedural criteria to pursue Federal IDR for out‑of‑network items/services:

Parties must first undertake and exhaust a 30‑business‑day open negotiation period for eligible items/services (emergency, certain nonemergency at in‑network facilities, and air ambulance) before either party may initiate the Federal IDR Process.

If parties do not reach agreement by the end of open negotiation, either party may submit a Notice of IDR Initiation to the other party and to the Departments via the Federal IDR portal within 4 business days after the close of the open negotiation period (or during the 30‑business‑day window after a 90‑calendar‑day cooling off period, if applicable). The Departments’ receipt date is the initiation date.

The Notice of IDR Initiation must include: initiating party type; contact information for both parties (email, mailing, phone); sufficient claim identification (description, batched/bundled indicator, service dates, location/state, claim numbers, corresponding service/place‑of‑service codes, type of item/service); QPA for each item/service; allowed cost sharing; initial payment amount (if any); plan/issuer/FEHB information; provider/facility information including NPI; start date of open negotiation; date of initial payment/denial; and initiating party's preferred certified IDR entity.

After initiation, the non‑initiating party has 3 business days to object to the initiating party’s preferred certified IDR entity (otherwise selection defaults); if parties do not agree within 6 business days the Departments randomly select a certified IDR entity.

Federal IDR applicability, batching, COI, offers, and selection

Determination of applicability, batching eligibility, conflicts of interest, offer content, and selection rules:

Federal IDR applies to non‑federal governmental plans, private insured and self‑insured plans, and FEHB carriers unless a self‑insured plan has opted into a specified state law or an All‑Payer Model Agreement; certified IDR entities must determine applicability for disputes (including in bifurcated states).

Batched IDR is permitted when items/services are billed by the same provider/group/facility under the same NPI or TIN; payment would be made by the same plan/issuer/FEHB carrier (with specified rules for fully insured, self‑insured, and FEHB); items/services are related to a similar condition; and items/services were furnished within the same 30‑business‑day period with an associated 30‑business‑day open negotiation period that ended within 4 business days of IDR initiation (or whose open negotiation periods expired during the same 90‑calendar‑day cooling off period).

Certified IDR entities and their personnel must attest to no conflicts of interest and must notify the Departments within 3 business days if they cannot attest; personnel must not have disqualifying familial, financial, or professional relationships or recent employment/agency relationships with a party (see COI rules).

Offers must include the dollar amount and the percentage of the QPA, contact information, QPA information, and other specified data; the certified IDR entity will provide submission instructions and parties must use the Federal IDR portal.

Determination considerations, prohibitions, timelines, reporting, and fees

Factors certified IDR entities may consider, prohibited factors, timelines, reporting requirements, and fee effects:

Permitted considerations for non‑air ambulance items/services include: provider/facility training, experience, quality and outcomes; market share of provider or plan in the geographic region; patient acuity or complexity; facility teaching status, case mix, and scope; and demonstration of good faith contracting efforts (including contracted rates over the prior 4 plan years); certified IDR entities may request additional relevant information not including prohibited factors.

Permitted considerations for air ambulance services include: provider quality/outcomes; patient acuity/complexity; medical personnel training/experience; air ambulance vehicle type and clinical capability; population density at point of pick‑up; and demonstration of good faith contracting efforts (including prior 4 plan years' contracted rates); certified IDR entities may request additional relevant information not including prohibited factors.

Prohibited factors that must not be considered include: usual and customary charges (or rates expressed as a proportion thereof); the amount that would have been billed absent the NSA regulatory provisions; and payment or reimbursement rates payable by public payors (Medicare, Medicaid, CHIP, TRICARE, VA, Section 1115 demonstrations) or rates expressed as a proportion of public payor rates.

Fee and process criteria for Federal IDR

Fee collection, allocation, and treatment of batched and bundled claims during the Federal IDR Process:

Certified IDR entity fee must be paid by both parties by the time of offer submission; the certified IDR entity retains the non‑prevailing party's fee as compensation unless the parties settle or withdraw, in which case half of each party's fee is returned unless directed otherwise.

For batched claims, the certified IDR entity may make different payment determinations for each qualified IDR item/service; the party with the fewest favorable determinations is the non‑prevailing party responsible for paying the certified IDR entity fee; if each party prevails equally, the fee is split evenly; the certified IDR entity collects a single administrative fee from each party for batched claims.

Bundled payment arrangements (single service code representing multiple items/services, e.g., DRG) are subject to the batched determination rules, but the certified IDR entity fee and administrative fee are the same as for single determinations.

If a certified IDR entity is revoked while determinations are ongoing, it must refund previously paid IDR and administrative fees and parties will pay the reassigned certified IDR entity as directed.

Federal IDR procedural criteria

Stepwise Federal IDR process steps and associated timelines parties and certified IDR entities must follow:

Step 1 — Initial payment or denial: Plan/issuer must send an initial payment or notice of denial within 30 calendar days after a bill is submitted; notice must include QPA information, QPA certification, contact information for open negotiation, and explain any downcoding and the alternative QPA amount.

Step 2 — Open negotiation period: Parties must exhaust a 30‑business‑day open negotiation period before initiating Federal IDR; the period begins when the open negotiation notice is first sent; one notice generally per out‑of‑network item/service unless batching is permitted.

Step 3 — Notice of IDR Initiation: Either party may submit a Notice of IDR Initiation within 4 business days after the close of the open negotiation period (or during the 30‑business‑day window after a 90‑calendar‑day cooling off period); notice must include the initiating party's preferred certified IDR entity and required claim/party details.

Step 4 — Certified IDR entity selection and attestation: If the non‑initiating party does not object within 3 business days, selection defaults to the initiating party's preferred entity; if parties cannot agree, the Departments randomly select within 6 business days; the selected certified IDR entity must attest to no conflicts of interest and determine applicability within 3 business days of selection.

Codes, QPA Disclosure, and Batching Identifiers

Payment disclosure requirementsmixed

QPA	Applicable Qualifying Payment Amount must be included with initial payment or notice of denial of payment

Payment disclosure requirements - supporting detailmixed

downcoding explanation

If the QPA is based on a downcoded service code or modifier, plan must explain the downcoding and state the amount the QPA would have been absent the downcoding

Claim Identification Codesmixed

service codes/modifiers

Any corresponding service and place-of-service codes must be included in the Notice of IDR Initiation (to identify the qualified IDR items or services)

Downcoding informationmixed

downcode

Alteration by a plan, issuer, or carrier of a service code or modifier to one associated with a lower QPA; plans must provide statement, explanation, and the amount that would have been the QPA had the service code or modifier not been downcoded

Reported billing codesmixed

CPT/HCPCS/DRG/NDC

Billing codes to be reported describing items or services included in IDR notices (e.g., CPT, HCPCS, DRG, or NDC codes)

Service code systems referencedmixed

CPT/HCPCS/DRG

Service code that identifies and describes an item or service (e.g., CPT, HCPCS, or DRG)

QPA and downcodingmixed

QPA disclosure

Plans must include the QPA in initial payment/denial notices and, if QPA is based on a downcoded service code or modifier, must explain the downcoding and state the amount the QPA would have been had the service code or modifier not been downcoded

QPA certificationmixed

QPA certification

Initial notice must certify that each QPA was determined in compliance with applicable rules

inv-14: Initial payment disclosure requirements — Include QPA for each item/service and certifications/explanations if downcoded

Required QPA disclosureInclude the applicable QPA for each item or service with the plan's initial payment or notice of denial

Downcoding explanationIf QPA is based on a downcoded service code or modifier, statement explaining that the billed code/modifier was downcoded and why

Alternate QPA amount when downcodedState the amount the QPA would have been had the service code or modifier not been downcoded

QPA certificationA certification that the plan determined the QPA applies and that each QPA was calculated in compliance using a good‑faith, reasonable interpretation of applicable rules

Contact info for negotiations

How Providers and Plans Initiate and Participate in Federal IDR

Note

Initiation of Federal IDR

Either party may initiate the Federal IDR Process by submitting a Notice of IDR Initiation to the other party and to the Departments within 4 business days after the close of the 30-business-day open negotiation period (i.e., beginning on the 31st business day after the start of open negotiation). For claims subject to a 90-calendar-day cooling-off period, initiation may occur during the 30-business-day period following that cooling-off period. The Notice of IDR Initiation must be furnished to the Departments through the Federal IDR portal (https://www.nsa-idr.cms.gov) and must include the initiating party's preferred certified IDR entity. The initiation date of the Federal IDR Process is the date the Departments receive the Notice (the portal displays that date). A party may not initiate Federal IDR if it knows or reasonably should have known that the provider or facility obtained proper notice and consent to waive surprise billing protections.

Note

Selection of Certified IDR Entity

After a Notice of IDR Initiation, the initiating party supplies its preferred certified IDR entity. The non-initiating party may accept that preferred entity or object and propose another certified IDR entity. A lack of response from the non-initiating party within 3 business days is deemed acceptance of the initiating party's preferred certified IDR entity. If the parties cannot agree, the Departments will randomly select a certified IDR entity on the parties' behalf; the Departments will do so no later than 6 business days after initiation. Once contingently selected, the certified IDR entity must, within 3 business days of contingent selection, attest it has no conflict of interest and determine whether the Federal IDR Process applies, thereby finalizing selection.

Key Terms Used in This Guidance

inv-31: OON provider — Out-of-network (OON) provider

DefinitionOut‑of‑network (OON) provider: a physician or other health care provider acting within scope of practice who is not in‑network; includes providers of air ambulance services (see Appendix A)

Context under NSAOON providers may generate surprise bills when patients lack opportunity to select in‑network providers (e.g., emergencies)

Relevance to Federal IDRPayment disputes involving OON providers for qualified IDR items/services may be subject to the Federal IDR Process unless excluded by law or All‑Payer Model agreements

inv-32: QPA — Qualifying Payment Amount (QPA)

Core definitionQualifying Payment Amount (QPA): generally the median of contracted rates recognized by the plan for the same or similar item/service in the same specialty/facility type and geographic region, increased for inflation

Operational Rules for Batching, Bundling, and Billing

inv-16: Batching timeframe (duplicate placement for operational emphasis)

Batching timeframe (operational)Operationally, only items furnished within the same 30‑business‑day window and meeting open negotiation timing should be submitted together as a batch

Verification stepsEnsure same billing entity (NPI/TIN), same payer, related condition, and aligned open negotiation periods before batching

Portal submission noteBatched disputes must be identified as batched (or bundled) in the Notice of IDR Initiation and include service/place‑of‑service codes and dates for all items

inv-38: Batched items or services (operational implications)

Operational definition of batched itemsMultiple qualified IDR items/services considered jointly as one determination when statutory criteria are met; certified IDR entities may issue different determinations per item within a batch

Document Updates and Effective Dates

December 2023guidance updateLatest

Guidance document updated (December 2023) as an update to the March 2023 guidance; guidance is effective upon publication for items and services furnished on or after October 25, 2022 for plan/policy years beginning on or after January 1, 2022.

March 2023previous guidance

Prior guidance referenced as March 2023 version that was subsequently updated by the December 2023 publication.

Policy Summary

PayerMedicare

PolicyFederal IDR Process guidance for certified IDR entities (December 2023 update)

Policy CodePolicy N/A

Change TypeAdministrative update (guidance clarification)

Effective DateDecember 2023 (update to March 2023 Guidance) as written

Next Review DateN/A

SourceLink

On This Page

Once certified IDR entity selection is finalized, each party must submit its offer (dollar amount and percentage of the QPA, required contact and QPA information, and other specified data) no later than 10 business days after finalization, using the Federal IDR portal and following the certified IDR entity’s submission instructions.

If a party fails to submit an offer or to pay required fees by the deadlines, the certified IDR entity will select the other party's offer as the final payment amount; offers not accompanied by required fees will not be considered.

The certified IDR entity has 30 business days from the date its selection was finalized to choose one party's offer and notify the parties and the Departments; the determination is binding absent fraud or intentional misrepresentation.

Certified IDR entities must select an offer within 30 business days of finalization and issue a written decision explaining the rationale and the weight given to the QPA and any additional information considered.

Effect of determination: the certified IDR entity’s selected OON payment does not change patient cost‑sharing; payment to the prevailing party is due within 30 calendar days after determination; the certified IDR entity must refund the prevailing party's IDR entity fee within 30 business days after determination; non‑prevailing party generally bears the certified IDR entity fee (see batched rules).

Certified IDR entities must submit monthly reports including: QPA versus OON rate comparisons, counts of notices and offers (amount and percent of QPA and submitting party), provider/facility size, air ambulance vehicle type, item/service codes, geographic region or point of pick‑up, rationale for selected offer, party identifying information, elapsed days between selection and payment, counts of determinations exceeding QPA, administrative fees collected, and certified IDR entity fees.

Parties must exhaust the 30‑business‑day open negotiation period before initiating Federal IDR; the Notice of IDR Initiation must be submitted within 4 business days after the close of open negotiation; initial payment or denial must be sent by the plan/issuer within 30 calendar days and include QPA information and downcoding explanations when applicable; parties must comply with No Surprises Act balance‑billing restrictions.

Step 5 — Submission of offers: Parties must submit offers no later than 10 business days after certified IDR entity selection is finalized; administrative and certified IDR entity fees are collected upon offer submission and offers without required fees will not be considered.

Step 6 — Continuing negotiations and agreement: Parties may continue negotiating after initiation; if they reach agreement, the initiating party must notify the Departments and the certified IDR entity within 3 business days of the agreement.

Step 7 — Certified IDR entity determination and payment: The certified IDR entity has 30 business days from the date its selection was finalized to select one offer and notify parties and Departments; any amount due must be paid within 30 calendar days after the determination; the certified IDR entity must refund applicable fees within 30 business days after determination.

Step 8 — Extensions and extenuating circumstances: Parties may request extensions for time periods (other than payment timelines) for extenuating circumstances at the Departments' discretion; requests do not pause timelines unless granted.

Include contact information to initiate open negotiation (phone and email) as part of the initial payment/denial notice

inv-15: Initial payment disclosure requirements — Initial payment must include applicable QPA and explanations for downcoding when patient cost sharing is based on QPA

Initial payment must include QPA when cost‑sharing based on QPAWhen patient cost sharing is based on the QPA, the plan must include the applicable QPA with its initial payment or notice of denial

Downcoding disclosure requiredIf the QPA is based on a downcoded service code or modifier, the notice must explain the downcoding and list altered/added/removed codes or modifiers

Certification of QPA methodologyThe notice must certify that the plan has determined the QPA applies and that the QPA was determined in compliance with applicable statutes and regulations

Initiation contact detailsProvide contact information (telephone and email) for the office to initiate open negotiation

inv-16: Batching timeframe — Items must be furnished within same 30-business-day period and have a 30-business-day open negotiation period that ended within 4 busines...

Furnishing window for batchingItems/services must have been furnished within the same 30‑business‑day period to be eligible for batching

Open negotiation alignmentThe batched items must have had a 30‑business‑day open negotiation period that ended within 4 business days of IDR initiation (or expired during the same 90‑day cooling off period)

Common payer/provider criteriaBatched items must be billed by the same provider/TIN/NPI and payable by the same plan, issuer, or FEHB carrier

inv-17: Offers expressed relative to QPA — Offers must be reported as dollar amount and as percentage of the QPA

Dollar and percent reportingEach offer must be reported as a dollar amount and as a percentage of the QPA when submitted to the certified IDR entity

Offer content requirementOffers must include contact info, QPA info, and specified data as part of the submission

Monthly reporting of offersCertified IDR entities must report offers (amount and percent of QPA) and indicate which party submitted each offer in monthly reports

inv-18: QPA disclosure when downcoded — Plan must state amount that would have been the QPA had the service code or modifier not been downcoded

Statement of alternate QPA if downcodedPlan must state the amount that would have been the QPA had the service code or modifier not been downcoded

Explanation of downcoding specificsProvide an explanation of why the claim was downcoded, including which codes or modifiers were altered, added, or removed

Inclusion in initial noticeThis disclosure is required as part of the initial payment or notice of denial when the QPA is based on a downcoded code or modifier

Billing Rule

Offers, Fees, and Timelines

Offers, Fees, and Timelines: Parties must submit offers no later than 10 business days after finalization of certified IDR entity selection. Each party must pay the certified IDR entity fee and the administrative fee by the time it submits its offer; an offer is not considered received until both fees are paid. Certified IDR entities may invoice administrative fees at selection but must collect administrative fees by the time offers are submitted. The certified IDR entity holds collected certified IDR entity fees in trust or escrow. Certified IDR entities have 30 business days from the date selection is finalized to select one of the offers and issue a written decision (through the Federal IDR portal) notifying both parties and the Departments and explaining the rationale and weight given to the QPA and other information. Any amount due pursuant to the certified IDR entity's determination must be paid no later than 30 calendar days after the determination. The certified IDR entity must refund the prevailing party's certified IDR entity fee within 30 business days after the determination.

Offers due: within 10 business days after certified IDR entity selection is finalized
Certified IDR entity fee: must be paid by each party at time of offer submission; held in trust/escrow
Administrative fee: may be invoiced at selection but must be collected by offer submission
Certified IDR entity decision timeline: 30 business days from finalization of selection
Post-determination payment: any amount due paid within 30 calendar days after determination
Refunds: prevailing party's certified IDR entity fee refunded within 30 business days after determination

Note

Initiation and Open Negotiation Steps

Initiation and Open Negotiation Steps: Before initiating Federal IDR, parties must exhaust a 30-business-day open negotiation period. Either party may begin that open negotiation within 30 business days after the provider receives the plan's initial payment or notice of denial. The open negotiation is initiated by a written Open Negotiation Notice that identifies the item(s)/service(s), claim number(s), provider name, and NPI. If no agreement is reached by the end of the 30-business-day open negotiation, either party may submit a Notice of IDR Initiation within 4 business days after the close of open negotiation. The plan must have provided an initial payment or a notice of denial within 30 calendar days of claim submission; that initial payment must include the applicable QPA and related certifications and explanations (including downcoding explanations when applicable).

Provider submits claim → plan issues initial payment or denial within 30 calendar days
Open negotiation: 30 business days; initiated by Open Negotiation Notice (includes claim details, provider name, NPI)
If no agreement: Notice of IDR Initiation filed within 4 business days after open negotiation ends

Denial Risk

Fee collection and consequence of nonpayment

Fee collection and consequences of nonpayment: The certified IDR entity must collect the administrative fee from both parties and remit it to the Departments. Administrative fees may be invoiced at time of selection but must be collected by the time offers are submitted. Each party must also pay the certified IDR entity fee by the time of offer submission; the certified IDR entity will not consider an offer received until both fees from that party are paid. If a party fails to submit an offer by the deadline, the certified IDR entity will select the other party's offer as the final payment amount. If a party's offer is not considered received because fees were unpaid, the certified IDR entity will select the other party's offer. For batched claims, a single administrative fee is collected per party and the certified IDR entity may allocate the certified IDR entity fee to the non-prevailing party as described in the batched-claims rules; if parties settle or withdraw before determination, half of each party's certified IDR entity fee will be returned unless directed otherwise.

Administrative fee: collected by certified IDR entity and remitted to Departments; must be collected by offer submission
Certified IDR entity fee: must be paid by both parties by offer submission; retained from non-prevailing party
Nonpayment consequence: unpaid fees mean offer not received → other party's offer selected
Batched claims: single administrative fee per party; certified IDR entity fee allocation rules apply
Settlement/withdrawal: typically return half of each party's fee unless parties agree otherwise

Billing Rule

Post-determination payment timeline

Post-determination payment timeline: After the certified IDR entity issues its written decision, any amount due from one party to the other must be paid no later than 30 calendar days after the determination. The certified IDR entity must refund the prevailing party's certified IDR entity fee within 30 business days after the determination. Determinations are legally binding except in cases of fraud or intentional misrepresentation of material facts to the certified IDR entity. Extensions to timelines (except payment deadlines) may be requested and granted by the Departments for extenuating circumstances.

Payment due: within 30 calendar days after certified IDR entity determination
Fee refund: certified IDR entity refunds prevailing party's fee within 30 business days after determination
Finality: determinations are binding unless fraud or intentional misrepresentation is shown

Plan must calculate QPA using a good‑faith, reasonable interpretation of applicable statutes and regulations

Use in processQPA is disclosed with initial payment/notice of denial and is used as a primary consideration by certified IDR entities

inv-33: Qualified Payment Amount (QPA) - disclosure and downcoding explanation

Disclosure requirementInitial payment or notice of denial must include the QPA for each disputed item/service when cost sharing is based on the QPA

Downcoding handlingIf the QPA is based on a downcoded service code/modifier, the plan must explain the downcoding and provide the QPA that would have applied absent the downcoding

Certification of complianceThe plan must certify that the QPA was determined in compliance with applicable rules and statutes

inv-34: Notice of IDR Initiation — Formal submission to the Departments and the other party via the Federal IDR portal to start the Federal IDR Process when open negotiations fail

Notice of IDR Initiation actionFormal submission to the Departments and the other party via the Federal IDR portal to start the Federal IDR Process when open negotiations fail

Timing to submitMust be submitted within 4 business days after the close of the 30‑business‑day open negotiation period (or within 30 business days after a cooling off period, if applicable)

Required contentMust include initiating party type, contact info for both parties, identification of items/services (including QPA and service/place‑of‑service codes), date of initial payment/denial, and preferred certified IDR entity

inv-35: QPA methodology summary — median of contracted rates, inflation adjustment, good faith calculation

Method summaryQPA is generally the median of contracted rates for same/similar item/service in same specialty/facility type and geographic region, adjusted for inflation

Calculation standardPlans must calculate the QPA using a good‑faith, reasonable interpretation of applicable statutes and regulations post‑TMA III

Role in determinationCertified IDR entities must consider the QPA and may give weight to additional permitted circumstances when selecting an offer

inv-36: Cooling Off Period — 90-calendar-day restriction after a payment determination

DefinitionCooling Off Period: a 90‑calendar‑day period following a payment determination during which the initiating party may not submit a subsequent Notice of IDR Initiation for the same or similar item/service against the same party

Exception timingIf the open negotiation period for later items/services expires during the cooling off period, a Notice of IDR Initiation for those items may be submitted within 30 business days after the cooling off period ends

Effect on initiation windowStandard initiation window (4 business days) is replaced by the 30‑business‑day period for items subject to the cooling off exception

inv-37: Six-year recordkeeping requirement — Certified IDR entities must retain records for six years

Record retention periodCertified IDR entities must retain records of all claims and notices associated with the Federal IDR Process for six years

Availability of recordsRecords must be available to the parties to the dispute or to state/Federal oversight agencies unless disclosure is prohibited by law

Reporting cadence linkRecordkeeping supports monthly mandatory reporting obligations submitted through the Federal IDR portal

inv-38: Batched items or services — Definition and statutory considerations for batching

Definition of batched itemsBatched items or services: multiple qualified IDR items/services considered jointly as one payment determination when statutory criteria (same biller/ NPI/TIN, same payer, related to a similar condition) are met

Timing criteriaQualified items must have been furnished within the same 30‑business‑day period and have aligned open negotiation timing as required for batching

Statutory complianceBatched claims must satisfy regulatory citations referenced in Appendix A and the statutory requirement that items be related to treatment of a similar condition

inv-39: Bundled arrangement — Definition and examples (e.g., DRG)

DefinitionBundled arrangement: billing or initial payment/denial under a single service code that represents multiple items or services (e.g., a DRG)

Treatment under batching rulesBundled arrangements are subject to the rules for batched determinations, but certified IDR entity and administrative fees are the same as for single determinations

ExamplesDRG is an example of a single service code representing multiple items/services billed or paid as a bundle

inv-40: Certified IDR entity — Definition and certification overview

Role and definitionCertified IDR entity: an entity certified by the Departments to conduct Federal IDR determinations that meets the CFR certification criteria

Attestation requirementsAfter selection, the certified IDR entity must attest within 3 business days that it has no conflicts of interest or notify the Departments if it cannot attest

Decision timelineThe certified IDR entity has 30 business days from finalization of selection to choose one party's offer and issue a written determination

inv-41: IIHI — Individually identifiable health information (IIHI)

Definition of IIHIIndividually identifiable health information (IIHI): information including demographic data that relates to health or payment and identifies the individual or can reasonably identify them

ScopeIIHI includes information about past, present, or future health, provision of health care, or payment for health care tied to an individual

Privacy implicationIIHI is subject to privacy protections and record disclosure limits under state and Federal law

inv-42: QPA (alternate ref) — QPA definition and methodology cross-reference

QPA definition (alternate ref)QPA: generally the median of contracted rates recognized by the plan for same/similar item/service in same specialty/facility type and geographic region, increased by inflation

Statutory referencesMethodologies for QPA calculation are specified across Treasury, DOL, and HHS regulations and FAQs (post‑TMA III guidance)

Disclosure and useQPA must be disclosed in initial notices and is a primary factor considered by certified IDR entities

inv-43: Recognized amount — Definition and hierarchy for recognized amount determination

Recognized amount hierarchy'Recognized amount' is determined by reference to an applicable All‑Payer Model Agreement; if none, by specified state law; if neither, the lesser of billed amount or the QPA

Interaction with QPAWhen no All‑Payer Model Agreement or specified state law applies, the QPA serves as the ceiling for the recognized amount calculation (subject to lesser of billed amount and QPA)

Applicability notePlans must follow recognized amount rules when an All‑Payer Model Agreement or specified state law applies

inv-44: certified IDR entity — definition cross-reference

Certified IDR entity definition (xref)Entity certified by Departments to conduct IDR determinations under cited CFR sections and meeting certification criteria

ResponsibilitiesConduct binding determinations, collect and remit administrative fees as required, and report monthly data to Departments

Conflict and removalEntities must attest absence of conflicts and notify Departments within 3 business days if they cannot; Departments may revoke certification for cause

inv-45: open negotiation period — Definition and timing

Open negotiation period definitionOpen negotiation period: a 30‑business‑day period that parties must exhaust prior to initiating Federal IDR, beginning when the open negotiation notice is first sent

Timing to initiate IDR after open negotiationEither party may initiate Federal IDR by submitting a Notice of IDR Initiation within 4 business days after the close of the open negotiation period (or within 30 business days after a cooling off period when applicable)

One notice per item/serviceThe initiating party should use one Open Negotiation Notice per out‑of‑network item or service unless batching is permitted

inv-46: QPA notice — QPA disclosure and certification requirements in initial notices

QPA notice contentInitial payment/denial notice must include the QPA for each item/service, a certification that the QPA applies and was determined in compliance, and contact information to initiate open negotiations

Downcoding statement when applicableIf the QPA is based on a downcoded service code or modifier, the notice must explain the downcoding and provide the QPA absent the downcoding

PurposeQPA notices enable parties to begin the 30‑business‑day open negotiation period and preserve rights to initiate Federal IDR if negotiations fail

Fee allocation impactFor batched claims, fee allocation depends on which party prevails on more items; if tied, fee is split; collect single administrative fee per party

Reporting and documentationParties should provide itemized service codes, dates, locations, and the QPA for each item to support batched consideration

inv-39: Bundled arrangement (operational implications)

Operational definition of bundled arrangementBundled arrangement: billing or payment under a single service code representing multiple items/services (e.g., DRG); treated under batched determination rules

Fee parityCertified IDR entity and administrative fees for bundled arrangements are the same as for single determinations

Submission guidanceIf a bundled payment or denial was used, Notice of IDR Initiation or Open Negotiation Notice should indicate that items are bundled and include the single service code