The No Surprises Act gives out-of-network providers a way to contest low payments for services it covers, mainly emergency care and non-emergency care at in-network facilities. The process is strict about deadlines, so it helps to see it as a sequence.
Step 1: The initial payment or denial
The clock starts when you receive the plan's initial payment or notice of denial for the out-of-network service. Plans often pay at or near the qualifying payment amount (QPA), which must be disclosed with the payment. See what the QPA is and why it is not the final word.
Step 2: Open negotiation (30 business days)
- Send the open negotiation notice within 30 business days of receiving the initial payment or denial, using the federal standard notice.
- Negotiation then runs for 30 business days from the day the notice is sent.
- Many disputes settle here. Keep a record of every offer and response.
Step 3: Start federal IDR (4 business days)
If open negotiation ends without agreement, either party may start IDR within 4 business days after the negotiation period ends, through the federal IDR portal, and send notice to the other side.
Step 4: Select the IDR entity and confirm eligibility
- The parties have 3 business days to jointly choose a certified IDR entity; if they don't, the Departments select one.
- The entity checks that the dispute is eligible: the plan must be subject to the federal process (some state-regulated plans follow a state process instead, and Texas has its own), and the service must be covered by the law.
Step 5: Pay the fees
- Administrative fee: paid by each party to the federal government, non-refundable.
- IDR entity fee: paid by each party up front; the prevailing party's fee is refunded.
These amounts are set by CMS and change, so check the current figures before filing.
Step 6: Submit offers and evidence (10 business days)
Each side submits a payment offer and supporting information within 10 business days of the entity's selection. The entity must consider the QPA and other relevant information, such as:
- The provider's training, experience and quality outcomes
- Patient acuity and the complexity of the service
- Market share of the provider and the plan
- Prior good-faith efforts to contract and past contracted rates
Specific, claim-level evidence wins more often than generic arguments.
Step 7: The decision (30 business days)
The IDR entity chooses one of the two offers, with no splitting, generally within 30 business days of its selection. This "baseball-style" format rewards realistic, well-supported offers.
Step 8: Payment (30 calendar days)
If the provider's offer is selected, the plan must pay the amount owed within 30 calendar days of the decision.
What changed in 2026
The Departments finalized an IDR operations rule on May 28, 2026. As reported at the time, it:
- Cut the per-party administrative fee from $115 to $15, which makes disputing smaller claims more worthwhile.
- Expanded batching, so more similar claims can be resolved in one dispute, within set limits.
- Requires payers to use standardized claim codes when communicating about out-of-network services, which helps show earlier whether a claim qualifies.
- Introduces a centralized IDR gateway, rolling out in phases from 2026, for starting and tracking disputes.
Check the effective dates for each change on the CMS No Surprises Act site before relying on them.
Two rules that catch people out
- Cooling-off period: after a decision, the party that started IDR can't file a new dispute on the same item or service with the same party for 90 calendar days, though claims from that period can be filed after it ends.
- Batching: similar claims can be grouped into one dispute only when they meet the batching rules (same plan, same or similar service, within the allowed time window).
Where most providers lose
Not on the merits, but on the calendar: missed notice windows, disputes filed for ineligible plans, or evidence that doesn't speak to the specific claim. A tracking system that starts the clock the day the remittance posts prevents most of that.
RAS runs this process for out-of-network physicians for 10% of the IDR award, charged only when we win. See our No Surprises Act service, the worked fee example, and the open negotiation timeline.
Rules here reflect the federal process as generally applied; regulations and fees change, so confirm current requirements on the CMS No Surprises Act site before filing.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.