Hospital-based specialties can’t choose their patients’ networks, and the Act says their services can never be waived. That makes your out-of-network claims some of the most reliably eligible for federal IDR.
| Number | Where to look | Why it can go to IDR | Source |
|---|---|---|---|
| 1 | Ancillary services at in-network facilities | Anesthesia, radiology, pathology, neonatology, lab and imaging, assistant surgeons, hospitalists and intensivists are always protected, whatever the patient signed. | CMS guide, p. 7 |
| 2 | Every ED professional claim | Emergency physicians’ claims are protected, and plans can’t deny them based solely on the final diagnosis or for lack of prior authorization. | CMS guide, p. 5 |
| 3 | Facilities with no in-network option | If no in-network clinician in your specialty is available at the facility, your service counts as ancillary by definition and can’t be waived. | CMS guide, p. 7 |
| 4 | Self-funded plans in states with their own law | State surprise-billing laws generally don’t reach self-funded employer plans, and some cover one specialty but not another. Federal IDR fills the gap. | CMS guide, p. 9 |
| 5 | Batched disputes | Similar services for the same plan within a 30-business-day window can be filed together, which keeps per-dispute fees in proportion to claim size. | 45 CFR § 149.510 |
| Have a claim like one of these? Run it through our eligibility check. It takes a couple of minutes and asks for no patient details. Check a claim → | |||
In CMS’s own examples for hospital-based specialties, the plan’s qualifying payment amount (QPA) falls well short of the provider’s charge. That gap is what open negotiation and IDR settle.
Read why the QPA isn’t a cap →Eligibility screening and batching, offer strategy against the QPA, open negotiation, arbitration and award tracking to payment.
Learn more →Know what your out-of-network position is worth before you renew, renegotiate or leave a network.
Learn more →Model the revenue effect of payer mix, facility contracts and coverage arrangements across your sites.
Learn more →Claims and remittance files are enough to size the opportunity. We ask for the rest only for claims we plan to file. We sign a business associate agreement before any claim data is shared.
No. These are ancillary services under the No Surprises Act, and a notice-and-consent waiver can never apply to them at an in-network facility. A signed form doesn’t count, so the claim stays payable by the plan and can go to IDR.
Often, yes. Federal rules allow batching of similar services billed by the same provider or group to the same plan within a 30-business-day period, which spreads the administrative fee across claims.
Often. State laws generally apply to fully insured plans issued in that state, not to self-funded employer plans, and some cover only certain specialties. Each claim needs a check on plan funding type and service.
No. The QPA is the plan’s median contracted rate and one factor the arbitrator weighs. After the TMA litigation, arbitrators must consider all statutory factors without giving the QPA special weight.
Based on the CMS No Surprises Act guidance and 45 CFR Part 149. Educational, not legal advice. Equavis Health isn’t a certified IDR entity.
Send us a year of remittances and we’ll show you which claims qualify, how to batch them, and what they’re likely to recover.