No Surprises Act & IDR Glossary

Administrative fee

A non-refundable fee each party pays to the federal government for every federal IDR dispute, separate from the certified IDR entity's fee.

All-Payer Model Agreement

An agreement between a state and CMS that sets payment rates across payers (Maryland's is the best-known example). Where one applies, it determines the out-of-network amount instead of federal IDR.

Balance billing

Billing a patient for the difference between a provider's charge and what the health plan paid. The No Surprises Act prohibits it for protected services unless valid notice and consent was obtained.

Batched determination

A single IDR dispute covering multiple qualified items or services that meet the batching criteria: generally the same provider or facility, the same plan, the same or similar service codes, and a limited time window. Batching criteria

Business day

Monday through Friday, excluding federal holidays. Most federal IDR deadlines are counted in business days, not calendar days. Every IDR deadline

Certified IDR entity (IDRE)

An independent organization certified by the Departments to decide federal IDR disputes. It reviews both parties' offers and supporting information and selects one offer.

Cooling-off period

The 90 calendar days after an IDR determination during which the party that initiated the dispute can't bring a new dispute against the same party for the same item or service.

Explanation of benefits (EOB)

The statement a health plan issues describing how a claim was processed and paid. With remittance advice, it's the starting document for any out-of-network payment dispute.

Good faith estimate (GFE)

An estimate of expected charges that providers must give uninsured and self-pay patients for scheduled services under the No Surprises Act.

Independent dispute resolution (IDR)

The federal process for resolving out-of-network payment disputes between providers or facilities and health plans. Each side submits an offer and a certified IDR entity picks one. It's often called baseball-style arbitration. Federal IDR submission

Initial payment

The plan's first payment on an out-of-network claim, due within 30 calendar days of receiving a clean claim. Receiving it (or a notice of denial) starts the 30-business-day window to open negotiation.

No Surprises Act (NSA)

The federal law, in effect since January 1, 2022, that protects patients from surprise out-of-network bills for emergency care, certain non-emergency care at in-network facilities, and air ambulance services. It also created open negotiation and federal IDR to settle payment between providers and plans. Provider's guide to the NSA

Notice and consent

The process by which a patient can waive No Surprises Act balance-billing protections for certain non-emergency services. It isn't available for emergency services or for ancillary services such as anesthesiology, radiology, pathology and neonatology.

Notice of IDR initiation

The notice filed through the Federal IDR portal, and sent to the other party, that starts a federal IDR dispute. It's due within 4 business days after the open negotiation period ends.

Open negotiation

The mandatory 30-business-day period in which the provider and plan try to agree on payment before either can initiate federal IDR. Open negotiation guide

Open negotiation notice

The standard notice that starts open negotiation. It must be sent within 30 business days of receiving the initial payment or notice of denial.

Out-of-network rate

The total amount a plan pays for a protected out-of-network service. It's set by a state law or All-Payer Model where one applies, otherwise by agreement in open negotiation or by an IDR determination.

Patient-provider dispute resolution (PPDR)

A separate federal process that lets uninsured or self-pay patients dispute a bill that is substantially higher than their good faith estimate. It isn't the same as provider-plan IDR.

Qualifying payment amount (QPA)

Generally, the plan's median contracted rate for the same or similar service in the same geographic region, adjusted for inflation. Plans must disclose it with the initial payment, and IDR entities must consider it alongside other factors. QPA explained

Recognized amount

The amount a patient's cost-sharing for a protected service is based on. Where no state law or All-Payer Model applies, it's generally the lesser of the QPA and the billed charge.

Specified state law

A state law that sets the out-of-network payment amount for a given plan, provider and service. Where one applies, the state's process governs the claim instead of federal IDR. Federal vs. state IDR

General information, not legal advice. Confirm current rules at cms.gov/nosurprises.