How long does a health plan have to pay an IDR award?
Verdict Consulting Group Research · Updated
Answer
Thirty calendar days. Federal regulations require the plan or issuer to pay the selected offer, less the initial payment and any patient cost sharing, directly to the provider within 30 calendar days after the certified IDR entity's determination. If the selected offer is below what was already paid, the provider owes the plan the difference on the same timeline.
Detail
The rule
| Item | Requirement | Source |
|---|---|---|
| Deadline | Not later than 30 days after the determination | 42 U.S.C. 300gg-111(c)(6) |
| Day count | 30 calendar days | 45 CFR 149.510(c)(5)(ix); CMS |
| Amount owed | Selected offer, less the initial payment and cost sharing paid or owed | 45 CFR 149.510(c)(5)(ix) |
| Overpayment | Provider pays the difference to the plan within 30 calendar days | 45 CFR 149.510(c)(5)(ix) |
The same 30-calendar-day deadline applies when the parties settle after IDR is initiated, counted from the date the agreement is reached.
Related questions
Whether a provider can go to court over a late or missing payment depends on the circuit. See Can a provider sue to enforce an IDR award? and What happens if a health plan does not pay an IDR award?.
Read the analysis
Sources
- Electronic Code of Federal Regulations — 45 CFR 149.510 — Independent dispute resolution process ()
- Legal Information Institute, Cornell Law School — 42 U.S. Code § 300gg-111 — Preventing surprise medical bills ()
- Centers for Medicare & Medicaid Services — About Independent Dispute Resolution ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.