What makes a dispute ineligible for federal IDR?
Verdict Consulting Group Research · Updated
Answer
A dispute is ineligible if it does not involve a qualified IDR item or service, for example because a specified state law, an All-Payer Model Agreement, Medicare or Medicaid governs payment, or if open negotiation, timing, batching or cooling-off rules were not met. Certified IDR entities found 355,804 disputes ineligible from April 15, 2022 to December 31, 2024.
Detail
Common grounds for ineligibility
The Departments list these in the preamble to the Federal IDR Operations rule (91 FR 33902):
| Ground | Example |
|---|---|
| Not a qualified IDR item or service | Payment governed by Medicare, Medicaid or another program outside the surprise-billing protections |
| State process applies | A specified state law or All-Payer Model Agreement determines the payment amount |
| Improper batching or bundling | Batching claims paid by different plans or issuers |
| Open negotiation not completed | Initiating before the 30-business-day period ends |
| Late initiation | Initiating more than 4 business days after open negotiation ends |
| Cooling-off period | Re-filing against the same party within 90 calendar days of a determination |
The numbers
| Measure | Figure | Period | Source |
|---|---|---|---|
| Eligibility challenged by non-initiating party | 976,721 disputes | Apr 15, 2022 – Dec 31, 2024 | 91 FR 33902 |
| Found ineligible | 355,804 disputes | Apr 15, 2022 – Dec 31, 2024 | 91 FR 33902 |
| Share found ineligible | About 19% | Jul 1 – Dec 31, 2025 | CMS |
| Eligibility challenged | 42% of initiated disputes | Jul 1 – Dec 31, 2025 | CMS |
CMS reports that since the fourth quarter of 2024, the most frequent reasons for ineligibility have been an incomplete cooling-off period and disputes falling under a specified state law or All-Payer Model Agreement.
Read the analysis
Sources
- Federal Register — Federal Independent Dispute Resolution Operations, 91 FR 33900 ()
- Centers for Medicare & Medicaid Services — Supplemental Background on Federal IDR Public Use Files, July 1 – December 31, 2025 ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.