The No Surprises Act (NSA) Independent Dispute Resolution (IDR) process is a federal arbitration system that allows healthcare providers to challenge underpaid or denied out-of-network claims by insurers through a structured process involving open negotiation, formal dispute filing, and binding “baseball-style” arbitration.
In 2024, there were approximately 1.4 million+ disputes filed, more than doubling from the year before. It’s a clear sign that providers are increasingly relying on this process to recover payment.
If you’re already dealing with underpaid or denied claims, the NSA attorneys at Kotlar Cohen can help you evaluate your options and take the next step.
Here is the NSA IDR process explained. Contact Kotlar Cohen today to see what we can do for you.
What Should You Do After an Insurer Underpays You?
You’ve already done the hard part. You treated the patient, documented the care, and submitted the claim. Then the insurer responds, and the number doesn’t make sense. It’s lower than expected. Sometimes much lower. In other cases, the claim is denied entirely.
Before the No Surprises Act, you might have billed the patient for the difference. That option is gone. Now, the responsibility shifts to you. If you want to recover the full value of your services, you must go through a structured federal IDR arbitration process.
That process is called Independent Dispute Resolution (IDR). At first glance, it looks straightforward. It’s actually deadline-driven, technical, and easy to get wrong if you don’t understand how it works in practice.
Here is how to file IDR claim against an insurance company. This guide walks you through it step by step—so you know not just what to do, but how to do it correctly. It’s worth your time, since providers win 86%+ of disputes. In addition, the average winning offer is 4x the Qualifying Payment Amount (QPA).
The NSA IDR Process Explained
The No Surprises Act (NSA) Independent Dispute Resolution (IDR) process is a federal system that allows healthcare providers to challenge underpaid or denied out-of-network claims. It begins with mandatory negotiation and, if unresolved, moves to binding arbitration, where a neutral third party decides the final payment amount.
The federal government created this process to resolve payment disputes between healthcare providers and insurance companies. It exists for one simple reason: to take patients out of the middle of billing issues.
Instead of patients being stuck with unexpected bills, providers and insurers now negotiate and if needed, go to arbitration. At the center of this system is something called “baseball-style arbitration,” meaning the arbitrator doesn’t split the difference. They must choose one side’s offer in full.
That detail matters more than most providers realize. It changes how you approach the entire process because you’re not just submitting a number. You’re building a case.
How the NSA IDR Process Works (Step-by-Step)
The IDR process typically goes through three phases: negotiation, escalation, and resolution. Each phase of the IDR process has strict deadlines and requires specific documentation. Each one also gives you an opportunity to strengthen your position. Let’s walk through what happens after an underpayment or denial.
Step 1: The Insurer Issues a Payment (or Denial)
The IDR process starts after you submit a claim. The insurer has about 30 days to respond. Most insurers don’t simply “process” the claim. They evaluate it through their own internal pricing framework. It’s usually anchored to the Qualifying Payment Amount (QPA), which is their version of a median in-network rate.
In theory, it’s supposed to reflect market rates. In practice, it often doesn’t. That’s why disputes often begin here.
After the evaluation, the insurer will either make an initial payment or issue a denial. When you get the response, it could be:
- A payment that is significantly lower than your expected reimbursement
- A partial payment with unexplained reductions
- A denial based on technical or documentation-related reasons
At this point, many providers assume there’s been a mistake. Sometimes there has, but more often it’s intentional. Insurers operate on a system that allows them to anchor payments low, rely on internal benchmarks, and shift the burden to the providers to challenge the amount.
For healthcare providers, this moment isn’t just administrative. It’s a crucial decision: accept the payment or challenge it.
If you choose to challenge it, the clock starts ticking. This is where you need to know how to file an IDR claim against the insurance company.
Step 2: Open Negotiation (30 Business Days)
Before you can go to arbitration, you’re required to negotiate. You must formally initiate an open negotiation period within 30 business days of receiving the payment or denial.
Initiating negotiation requires more than sending an email. The notice must be properly formatted, include the correct claim details, and be delivered to the right party (the NIP) through the correct method. If your negotiation notice is incomplete or improperly filed, it can compromise your entire case, even if everything else is done correctly.
Once it starts, the negotiation lasts another 30 business days. The idea behind the 30-day period is to resolve disputes relatively quickly. It doesn’t usually happen that way, unfortunately.
Most insurers will respond by
- Standing by their initial payment
- Anchoring heavily to the QPA
- Using this period to delay rather than meaningfully negotiate
Once the period is active, track everything. Document all of it. How the insurer behaves during negotiation becomes part of your case.
This step is less about reaching an agreement and more about setting up your case. If your negotiation notice is weak, incomplete, or improperly formatted, it can hurt you later. The IDR process has strict procedural requirements, and failing to follow them can disqualify your claim entirely.
Put simply, this step is your first move in a longer strategy.
Step 3: Initiating IDR (The 4-Day Window)
If the open negotiation period ends without an agreement, the next step is to formally escalate the dispute. At this point, the process shifts from negotiation to arbitration.
To continue, you must start the IDR process within 4 business days of the negotiation period ending.
Initiating IDR requires you to:
- Submit a Notice of IDR Initiation through the federal portal
- Send the same notice to the insurer
- Include key details about the claim (dates of service, payment amount, etc.)
This is one of the tightest deadlines in the entire process. If you miss the 4-day window:
- You lose the ability to take the claim to IDR
- The insurer’s payment effectively stands
There’s very little flexibility here, which is why timeline tracking is critical. Be ready to act before negotiation ends, not after. Also, make sure your documentation is already organized and confirm that the claim is eligible before filing.
The moment the negotiation period closes without resolution, the clock is running. Do not wait to see how things shake out. The filing should be ready to go before negotiation ends, so that when the window opens, you are moving immediately rather than scrambling to prepare.
Step 4: Selecting the Arbitrator
Once the dispute is initiated, the next step is deciding who will resolve it. Under the No Surprises Act, disputes are handled by certified IDR entities—federal government-approved independent third-party organizations that serve as arbitrators.
After filing, both parties have about 3 business days to agree on an IDR entity. Each side can propose or object to a selection. If no agreement is reached, the government assigns one at random.
At first glance, this step can feel like a procedural step. It’s not. IDR entities are not identical. They review evidence, apply judgment, and interpret the same rules differently. In fact, outcomes can vary significantly depending on the arbitrator, with some entities ruling for providers far more often than others.
You should be prepared to propose an IDR entity quickly and watch for last-minute objections from insurers. If you don’t respond in time, the selection may default to the other side.
This is also where experienced representation makes a difference. Knowing which IDR entities have a track record of ruling in favor of providers, and which to push back on, is not something that comes from reading the rules. It comes from having been through the process repeatedly.
What Happens Once Arbitration is Live
Once your dispute is filed and an arbitration company is selected, expect your inbox to fill up fast. Insurers routinely send large volumes of correspondence once a case goes live, and not all of it is legitimate.
Much of it is designed to intimidate. The goal is to pressure providers into pulling their IDR filing from the federal system entirely. If that happens, and the original Explanation of Benefits is now out of date, you lose the ability to refile. The insurer wins without the arbitrator ever weighing in.
Not every piece of correspondence can be ignored, however. Mixed in with the noise are things that actually require a response, including post-arbitration negotiation notices, questions about your method of delivering the open negotiation notice, and requests from the arbitrator itself.
Every piece needs to be reviewed quickly so nothing important gets missed. Knowing the difference between an intimidation tactic and a deadline is the kind of thing that can make or break your case.
Step 5: Submitting Your Offer and Evidence
Once the IDR entity is selected, both sides move quickly into the most important part of the process: making their case. You have 10 business days to submit your payment offer and supporting documentation.
At a minimum, your submission should include:
- The amount you’re requesting
- An explanation of how you arrived at that number
- Supporting materials (billing data, market comparisons, clinical context)
The insurer will submit their own offer and justification at the same time. From this point forward, the arbitrator is working off what both sides provide, nothing more. This step is where the dispute is decided. The IDR process doesn’t include a hearing or back-and-forth argument. The arbitrator reviews the submissions and chooses one side.
That means that if your submission is incomplete, you lose ground. If you miss the deadline, the arbitrator may default to the other side’s offer. There’s very little room for correction after this step.
Don’t rely on your billed charges; explain the value behind them. Address the insurer’s likely position (especially the QPA) and make your argument clear and easy to follow. This process isn’t just submitting numbers; it’s helping the arbitrator understand why your number is the stronger one.
Step 6: The Arbitration Decision
Once both sides submit their offers and evidence, the arbitrator reviews everything and makes a final decision. Under the No Surprises Act, the IDR entity has about 30 business days to select one of the two offers and issue a written determination.
At this stage, there are no hearings, calls, or back-and-forth discussions. The arbitrator:
- Reviews both submissions
- Weighs the evidence (including the QPA and supporting materials)
- Selects one offer in full
Because the arbitrator must choose one side, the outcome depends heavily on how each offer is positioned. If your offer is well-supported and reasonable, you increase your chances of winning. If it’s too aggressive without justification, the arbitrator may default to the insurer’s number.
There’s no opportunity to adjust your position after submission. The decision is based entirely on what was already filed.
Step 7: Payment (and the Reality of Enforcement)
After the arbitrator issues a decision, the process moves into the final stage: payment. Under the No Surprises Act, the losing party is required to pay the determined amount within 30 days.
At this point, the arbitrator’s decision is binding. The insurer must issue payment based on the selected offer, and the dispute is considered resolved from a procedural standpoint.
In practice, this step doesn’t always go as smoothly as it should. Providers may encounter:
- Delayed payments
- Partial payments
- Situations where payment doesn’t come at all
While the law sets a clear deadline, enforcement can be less straightforward. Providers may need to follow up, escalate, or pursue additional steps to secure payment. For that reason, you should track the 30-day deadline closely. Document any delays or discrepancies so if you do need to follow up, you have evidence.
Winning the arbitration is not the finish line. Payment still has to be collected, and insurers do not always move quickly even when they are legally required to. Having counsel who tracks the 30-day deadline, follows up with the carrier, and applies pressure when payment is delayed is the difference between a determination that pays out and one that sits unresolved.
Why Providers Still Struggle with the IDR Process
On paper, the IDR process is structured and predictable. In reality, it creates new challenges for providers.
First, the timeline is unforgiving. Each step has strict deadlines, and missing one can invalidate your claim. Second, the process is documentation-heavy. You’re not just submitting claims, you’re building legal-grade arguments. Third, insurers understand the system. They use it strategically, relying on technical rules and procedural gaps to reduce payouts.
Common Mistakes That Cost Providers Money
Most losses in IDR don’t result from execution errors but from a weak case.
The most common mistakes include:
- Missing the 4-day filing window
- Failing to properly initiate negotiation
- Submitting incomplete documentation
- Relying too heavily on billed charges
- Filing claims that aren’t eligible
Each of these errors is avoidable, but only if you understand the process in detail.
FAQs: NSA IDR Process Explained
How long does the IDR process take?
From start to finish, the process typically takes several months, depending on timelines and delays.
What is the QPA?
The Qualifying Payment Amount is the insurer’s median in-network rate. It’s used as a reference point, but it can be challenged.
What counts as “credible information”?
Anything that helps demonstrate the value of your services, including:
- Case complexity
- Provider expertise
- Market data
Can you batch claims?
Yes. If claims involve similar services, batching can reduce costs and improve efficiency.
What happens if the insurer doesn’t pay?
That’s where things get more complicated. You may need to escalate or take additional steps to enforce your IDR award.
When Should You Bring in Legal Help?
At a certain point, IDR stops being administrative and becomes strategic. That point usually comes when:
- You’re dealing with repeated underpayments
- The volume of disputes increases
- Claims become higher value or more complex
- Payments are delayed even after you win
At that stage, how you handle the process directly impacts your revenue.
How Kotlar Cohen Helps Healthcare Providers Navigate IDR
Kotlar Cohen represents healthcare providers, not insurers or patients. Our team includes board-certified trial attorneys with decades of experience handling complex disputes.
We approach IDR as advocacy on your behalf, not as a dry administrative process.
When you work with the attorneys at Kotlar Cohen, we prepare a strong case for you by:
- Selecting the right claims to pursue
- Building strong, evidence-backed submissions
- Managing deadlines and filings
- And addressing what happens after the decision
The IDR process was designed to protect patients, but for providers, it created a new challenge. Getting paid is no longer automatic; it’s a lengthy and time-consuming process.
It’s structured and technical, but when it’s handled correctly, it works. You’ve already delivered the care, now let’s make sure you’re paid for it. Contact Kotlar Cohen’s NSA attorneys today about the IDR process before your deadlines pass.
