When a health plan underpays an out-of-network claim, the fix depends on which rules govern that claim. For most emergency and facility-based care, the No Surprises Act gives you a defined route: open negotiation, then federal independent dispute resolution (IDR). For other claims it’s a state process or the plan’s own appeals. The steps below take you from the remit to the right one.
1. Confirm it’s really an underpayment
Before disputing anything, read the remit closely. Note:
- The allowed amount — what the plan decided to pay.
- The QPA — the plan’s median in-network rate for the service, which it must disclose for claims covered by the No Surprises Act. See what a QPA is.
- Codes and modifiers — whether any were changed from what you billed.
- The plan type — fully insured, self-funded, or a government program.
- The date — your deadlines usually run from the date you received the payment or denial.
Many apparent underpayments turn out to be coding or eligibility problems, and those are fixed differently from a disagreement over the rate.
2. Work out which rules apply
| Situation | Usually governed by | Route |
|---|---|---|
| Emergency care, out-of-network | No Surprises Act, or a state law where one applies | Open negotiation → federal or state IDR |
| Non-emergency care by an out-of-network provider at an in-network facility, without valid patient consent | No Surprises Act, or state law | Open negotiation → federal or state IDR |
| Out-of-network air ambulance | No Surprises Act | Open negotiation → federal IDR |
| Out-of-network care the Act doesn’t protect, such as elective care at an out-of-network facility | Plan terms and state law | Plan appeal; patient billing may be permitted |
| Medicare, Medicaid, TRICARE | Their own program rules | Not federal IDR |
Two complications worth knowing:
- State law. Some states run their own surprise-billing dispute processes. Where a state law applies to the claim, it generally takes the place of the federal process. See federal vs. state IDR and our state guides.
- Self-funded plans. State surprise-billing laws generally can’t regulate self-funded employer plans governed by ERISA, unless the state offers an opt-in and the plan has elected it. So the same service can go to a state process under one patient’s plan and to federal IDR under another’s.
3. Fix coding and coverage problems first
If the plan changed a code or modifier, bundled services together, or denied coverage outright, that dispute usually belongs in the plan’s appeals process or a corrected claim, not in IDR. IDR decides the right payment amount for a service. It isn’t the forum for arguing over what the service was.
One overlap: if the plan based the QPA on a downcoded service code or modifier, it must say so on the remit and explain why. Check for that statement.
4. Start open negotiation — in writing, on time
For claims covered by the No Surprises Act, open negotiation is mandatory before IDR.
- Send the plan an open negotiation notice within 30 business days of receiving the initial payment or notice of denial.
- The negotiation period then runs for 30 business days.
- Put your counter-offer and its basis in writing, and keep proof of when you sent it.
A meaningful share of disputes settle here, and a settlement is a recovery like any other — often the fastest and cheapest one. More in our guide to open negotiation.
5. Initiate IDR if negotiation fails
If open negotiation doesn’t resolve the claim, either party has 4 business days after the negotiation period ends to initiate federal IDR. That window is short and unforgiving: miss it and the dispute is generally lost.
In IDR, each side submits an offer and a certified IDR entity picks one. Build yours on the factors the entity is allowed to weigh — patient acuity, service complexity, your training and experience, and the parties’ contracting history — not on billed charges or Medicare rates, which it may not consider. Check eligibility first with our federal IDR eligibility checklist.
Qualifying claims can often be batched, which makes disputing a run of smaller underpayments practical.
6. Collect the award
If the IDR entity selects your offer, the plan must pay within 30 calendar days of the determination. Track it. Late or missing award payments are common enough that following up is part of the job, not an exception.
7. Look for the pattern
One underpaid claim is a dispute. The same payer underpaying the same service month after month is a pattern — and patterns are worth more than any single claim. Track outcomes by payer and service. They tell you where to push, what a fair rate looks like, and whether you have leverage to negotiate a contract.
A payment integrity audit does this systematically across past claims, including ones still inside their dispute windows.
Mistakes that cost providers money
- Missing the 30-business-day window to start open negotiation. It’s the most common reason recoverable claims are lost.
- Balance billing the patient for a protected service. For services the No Surprises Act covers, the patient owes only in-network cost-sharing.
- Taking a coding dispute to IDR. Fix the code first, through an appeal or corrected claim.
- Anchoring the IDR offer to billed charges or a Medicare multiple. The IDR entity can’t consider either.
- Treating each claim in isolation and never noticing a payer’s pattern.
When to get help
If you’re seeing regular out-of-network underpayments and nobody owns the deadline calendar full time, that’s usually the point at which outside help pays for itself. If you’re comparing options, our guide to choosing an NSA and IDR vendor lists the questions worth asking.
Or send us a sample of recent out-of-network remits and we’ll tell you which claims are eligible and what we’d do with them. We charge only on the increase we recover, and nothing if we don’t. Get in touch.
This guide is general information, not legal advice. Confirm current requirements at cms.gov/nosurprises.