{"id":8272,"date":"2026-02-26T07:49:07","date_gmt":"2026-02-26T07:49:07","guid":{"rendered":"https:\/\/skillup.online\/blog\/?p=8272"},"modified":"2026-03-10T11:34:41","modified_gmt":"2026-03-10T11:34:41","slug":"the-importance-of-understanding-the-no-surprises-act-nsa-independent-dispute-resolution-idr-process","status":"publish","type":"post","link":"https:\/\/skillup.online\/blog\/the-importance-of-understanding-the-no-surprises-act-nsa-independent-dispute-resolution-idr-process\/","title":{"rendered":"The Importance of Understanding the No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process"},"content":{"rendered":"
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Surprise billing may feel like a\u00a0patient\u00a0problem, but the ripple effects hit everyone working in healthcare. Confusion, denied claims, delayed payments\u2014one disagreement between a provider and a health plan can slow down entire workflows.<\/span><\/p>\n

That\u2019s exactly why the No Surprises Act (NSA) introduced the Independent Dispute Resolution (IDR) process. If you understand how IDR works, you\u2019re better equipped to protect your organization, reduce friction, and keep revenue moving.<\/span>\u00a0<\/span><\/p>\n

How the IDR Process Works<\/span><\/b>\u00a0<\/span><\/h2>\n

\"IDR<\/a><\/p>\n

The IDR process follows a clear, step-by-step structure:<\/span>\u00a0<\/span><\/p>\n

    \n
  1. Open Negotiation Period(30business\u00a0days)<\/span><\/b>
    \nAfter an out-of-network provider\u00a0submits\u00a0a claim for services provided, the health plan reviews and\u00a0adjudicates\u00a0the claim. If the provider disagrees with the amount reimbursed or denial of payment for services provided, either the provider or health plan may\u00a0initiate\u00a0the Open Negotiation Period. This is a\u00a030-business\u00a0day period for both sides to\u00a0attempt\u00a0to\u00a0reach an agreement\u00a0on a payment amount\u00a0for the services provided.\u00a0Notice of the Open Negotiation Period must be sent by the initiating party to the non-initiating party within 30 business days of the\u00a0initial\u00a0denial or payment of the claim.<\/span>\u00a0<\/span><\/li>\n
  2. Initiation of IDRProcess(within 4 days of negotiation ending)\u00a0<\/span><\/b>
    \nIf\u00a0the payment\u00a0negotiations fail, either party may\u00a0initiate\u00a0the\u00a0IDR\u00a0process, within 4 days of the end of the Open Negotiation Period. The initiating party will\u00a0provide notice to the non-initiating party\u00a0and\u00a0select an\u00a0Independent Dispute Resolution\u00a0Entity (IDRE) to review, and\u00a0determine\u00a0the payment amount for, the service or item being disputed. If the parties cannot agree on an IDRE, one will be appointed.<\/span>\u00a0<\/span><\/li>\n
  3. Fees, Offers & Evidence Submission (10 business days)<\/span><\/b>
    \nIf the IDRE\u00a0determines\u00a0the\u00a0disputed\u00a0items\/services\u00a0are eligible for the Federal NSA process,\u00a0each\u00a0party\u00a0has 10 business\u00a0day\u00a0to pay\u00a0an\u00a0administrative fee (currently $115) and IDRE\u00a0fee\u00a0(varies per entity).\u00a0Each\u00a0party must also\u00a0submit\u00a0a Notice of Offer Form within\u00a010\u00a0business\u00a0days\u00a0of the IDRE\u2019s acceptance of the dispute. The offer form is where each party states what they believe to be fair and\u00a0accurate\u00a0payment for the disputed items or services provided. If either party\u00a0fails to\u00a0submit\u00a0payment for the fees\u00a0and\/or offer\u00a0timely, a default judgment will be issued in favor of the lone party that did. If both parties\u00a0fail to\u00a0submit\u00a0the fees and\/or\u00a0offer\u00a0timely, the dispute will be dismissed.<\/span>\u00a0<\/span><\/li>\n
  4. IDRE Determination (30 business days)<\/span><\/b>
    \nThe IDRE has 30 business days to\u00a0determine\u00a0the prevailing party and payment amount. Payment of the\u00a0adjudicated\u00a0amount must be made by the unsuccessful party within 30 business days. The prevailing party is refunded their IDRE fee within 30 business days.<\/span>
    \n\u00a0<\/span><\/li>\n<\/ol>\n

    Circumstances or Factors for Qualified Items and Services<\/span><\/b>\u00a0<\/span><\/h2>\n

    \"What<\/a><\/p>\n

    The\u00a0circumstances or factors for qualified items and services\u00a0are sets of facts that are presented by the parties and reviewed by the IDRE.\u00a0The factors are different for qualified non-air ambulance items and\u00a0services\u00a0and qualified air ambulance items and services.\u00a0<\/span><\/p>\n

    Below are the six factors for qualified non-air ambulance items and services:<\/span><\/b>\u00a0<\/span><\/h4>\n
      \n
    1. The level of training, experience, and quality and outcomes measurements of\u00a0the provider or facility that\u00a0furnished\u00a0the qualified IDR item or service.<\/span>\u00a0<\/span><\/li>\n
    2. The market share held by the provider or facility or that of the plan in the geographic region in which the qualified IDR item or service was provided.<\/span>\u00a0<\/span><\/li>\n
    3. The acuity of the participant, beneficiary, or enrollee receiving the qualified IDR item or service, or the complexity of\u00a0furnishing\u00a0the qualified IDR item or service to the participant, beneficiary, or enrollee.<\/span>\u00a0<\/span><\/li>\n
    4. The teaching status, case mix, and scope of services of the facility that\u00a0furnished\u00a0the qualified IDR item or service (only applicable if one of the parties is a facility).<\/span>\u00a0<\/span><\/li>\n
    5. Demonstration of good faith efforts (or lack thereof) made by the provider or facility or the plan to enter into network agreements with each other, and, if applicable, contracted rates between the provider or facility, as applicable, and the plan during the\u00a0previous\u00a0four plan years.<\/span>\u00a0<\/span><\/li>\n
    6. Additional\u00a0information relevant to the\u00a0submitted\u00a0Qualified\u00a0Payment\u00a0Amount QPA.<\/span>\u00a0<\/span><\/li>\n<\/ol>\n

      Keys for\u00a0Healthcare Providers\u00a0to Prevail<\/span><\/b>\u00a0<\/span><\/h2>\n

      \"How<\/a><\/p>\n

      The Open Negotiation Period and IDR process are often\u00a0initiated\u00a0by the non-contract provider, as they are the party that is not in agreement with the denial or amount of reimbursement received, for the items or services provided. To support their requested payment amount, providers must\u00a0submit\u00a0documentation that:<\/span>\u00a0<\/span><\/p>\n