After an out-of-network claim is adjudicated, confirm that the service qualifies as a covered IDR item (generally emergency services, certain non-emergency services at in-network facilities, and air ambulance services from non-network providers).
Initiate a 30-business-day open negotiation period by sending the payer a written notice specifying the claim, the amount requested, and supporting rationale; document the negotiation attempt thoroughly.
If open negotiation fails within 30 business days, initiate a federal IDR dispute through the CMS IDR portal within 4 business days after the end of the open negotiation period.
Select a certified IDR entity from the approved list or allow the parties to jointly select one; if no joint selection is made within the required window, CMS assigns an entity.
Submit your offer amount and supporting documentation to the certified IDR entity, including any relevant information about the qualifying payment amount (QPA) and why your offer is appropriate.
The IDR entity selects one of the two parties' offers (baseball-style arbitration); implement the selected payment within the required timeframe and update your AR accordingly.
Known gotchas
The 4-business-day window to initiate IDR after failed open negotiation is a hard deadline; missing it forfeits the right to federal IDR for that claim.
Batching is permitted for substantially similar claims (same provider, same plan, same or similar service code, same IDR entity) which can significantly reduce per-claim IDR fees.
The qualifying payment amount (QPA) — essentially the median in-network rate — is the presumptive correct payment; your offer documentation must provide credible justification to deviate from QPA or the IDR entity is likely to select the QPA-aligned offer.
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp