Free No Surprises Act IDR calculator
Is this claim eligible for IDR, and would a dispute pay?
Enter what the remittance says. The checker tests eligibility, counts your 30 business days, and estimates what a federal IDR dispute could add.
Free. No sign-up, no patient information, and nothing you type leaves your browser.
01Eligibility
What makes a claim eligible for federal IDR
Under the No Surprises Act, a provider can take an out-of-network payment to federal independent dispute resolution (IDR) when every one of these holds. The checker tests each one, says which pass, and asks about the ones a remittance cannot answer.
- 01
The plan is covered. Self-funded and fully insured employer plans, individual market plans, and federal employee plans. Not Medicare, Medicaid, TRICARE, VA, workers’ compensation, auto or liability coverage.
- 02
The clinician is out of network with that payer. An in-network claim is paid at the contract rate.
- 03
The care was protected: emergency care, non-emergency care at an in-network hospital, outpatient department or surgery center, or air ambulance.
- 04
No valid waiver applies. A patient can waive protections for some scheduled care, never for anesthesia, radiology, pathology, lab, assistant surgeons, hospitalists, intensivists, neonatology or emergency care.
- 05
The federal process applies, not a state’s own. Self-funded and federal employee plans use the federal process everywhere; some states run their own process for insured plans.
- 06
The window is open. The open negotiation notice must reach the payer within 30 business days of its payment or denial.
- 07
The denial is one IDR can decide. A payment of nothing because of cost sharing can be disputed; a medical necessity or coverage denial goes to appeal, and a billing error is corrected and resubmitted first.
Qualify
- Emergency services at any facility, including care after stabilization
- Out-of-network care at an in-network hospital, outpatient department, or surgery center
- Patients on employer, individual market, or federal employee plans
Don’t qualify
- Medicare, Medicaid, and TRICARE
- Office visits
- In-network claims paid under a contract
- Scheduled care where the patient signed a consent waiver
- Coverage or medical necessity denials (those go to appeal)
02The method
How the estimate is worked out
In federal IDR each side sends one final offer and a certified IDR entity picks one of them. CMS publishes every decided line item. From the July to December 2025 public use files, the checker takes, for each kind of service, line items where both sides made an offer (2,391,454 in all): how often the entity picked the provider’s offer, and what the winning provider offers were as a share of the payer’s qualifying payment amount (QPA), the payer’s median in-network rate.
For each service line, the estimate is that share of the QPA, capped at the billed charge, less what the payer already allowed, weighted by how often providers won. The range runs from the lower quarter to the upper quarter of past winning offers. Where you have no QPA, the payer’s allowed amount stands in for it, or its payment when that is all there is; a payer’s first payment is normally worked out from its QPA, but it is a stand-in, and the answer says so.
Then the costs. Each party pays a $15 federal administrative fee per dispute, which is never returned, and the certified IDR entity’s fee up front, $425 to $800 for a single claim in 2026 (CMS list as of August 31, 2026); the side that wins gets the entity fee back. The checker uses the middle fee and puts it at risk at the odds of losing. A claim counts as worth disputing when it would likely leave the practice at least $100 better off after those fees. Because the fees are paid once per dispute, it also says how many similar lines, batched against the same payer, would make a dispute worth it: up to 50 line items for negotiations opened on or after November 1, 2026.
| Kind of service | Codes | Line items decided | Decided for the provider | Median winning provider offer, % of QPA | Middle half of winning offers |
|---|---|---|---|---|---|
| Emergency and critical care visits | 99281 to 99285, 99291, 99292 | 808,002 | 84.5% | 369% | 238% to 638% |
| Radiology | 70010 to 79999 | 387,503 | 89.0% | 472% | 287% to 738% |
| Pathology and laboratory | 80047 to 89398 | 374,568 | 79.0% | 526% | 289% to 974% |
| Other visits and medicine | 90281 to 99607 | 327,798 | 83.4% | 746% | 332% to 2,201% |
| Anesthesia | 00100 to 01999 | 169,364 | 80.0% | 435% | 268% to 1,054% |
| Surgery | 10021 to 69990 | 132,024 | 84.4% | 2,286% | 648% to 7,009% |
| Other services | HCPCS and other codes | 192,195 | 78.4% | 464% | 209% to 1,027% |
Spectare Health’s analysis of the CMS federal IDR public use files, out-of-network emergency and non-emergency line items, air ambulance left out. Entity fees from the CMS list of certified IDR entities. National figures for all federal disputes, not our results, and not a guarantee of any result. Updated October 2026. More on the process: CMS: IDR Gateway, CMS: final rule timeline.
03FAQ
Questions about IDR eligibility and cost
What practices ask about eligibility, deadlines and fees before they file. For how Spectare works and what it costs, see the home page.
How Spectare worksSomething else? Email us and we’ll answer within a day.
01Which claims are eligible for federal IDR?
Out-of-network claims for emergency care, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgery center, and for air ambulance, under self-funded employer plans, fully insured employer plans, individual market plans and federal employee plans. The claim must not be one a state’s own dispute process takes, no valid notice-and-consent waiver may apply, and the open negotiation notice must reach the payer within 30 business days of its payment or denial. Medicare, Medicaid, TRICARE, VA, workers’ compensation and in-network claims are not eligible.
02How long do I have to dispute an out-of-network underpayment?
Thirty business days from the day you receive the payer’s initial payment or notice of denial to send the open negotiation notice. If 30 business days of negotiation do not settle it, you have 4 business days to initiate the federal IDR dispute. Business days leave out weekends and federal holidays.
03What does a federal IDR dispute cost?
Each party pays a $15 federal administrative fee for disputes initiated on or after June 11, 2026, and it is not refunded. Each party also pays the certified IDR entity’s fee up front, $425 to $800 for a single claim in 2026 depending on the entity, and the side that wins gets that fee back. A batch of claims pays one batched fee.
04How does the checker estimate what a dispute could add?
From the CMS federal IDR public use files for July to December 2025, it takes, for each kind of service, how often the arbiter chose the provider’s offer and what winning provider offers were as a share of the payer’s qualifying payment amount (QPA). The estimate is that share of the QPA, capped at your billed charge, less what the payer already allowed, weighted by how often providers won. When you have no QPA, the payer’s allowed amount, or its payment, stands in for it.
05Why might a small claim not be worth disputing on its own?
The fees are paid once per dispute, not per claim. A low-dollar line can add less than the fees put at risk, but similar lines against the same payer can be batched into one dispute, up to 50 line items for negotiations opened on or after November 1, 2026. The checker says how many similar lines would make a dispute worth filing.
06Is the result a guarantee?
No. Every figure is an estimate from public data on past decisions, and past decisions do not predict any one dispute. The eligibility rules are the federal rules as published, simplified for a quick check; some answers turn on facts only the plan or the practice has. It is not legal advice.
07Do I need to enter patient information?
No. The checker needs only the plan type, the setting, the dates, the service codes and the amounts. It runs in your browser and sends nothing anywhere.
04Free claims review
Find out what your claims could be worth.
Send us 90 days of remittance files. Within 24 hours you get a written list of every eligible claim, the deadlines still open, and the recovery we expect. It’s free, and the list is yours whether or not you hire us.
- 01Every eligible claim, and why it qualifies
- 02The deadlines still open on each one
- 03The recovery we expect, before you commit to anything
No patient information is needed for the first conversation.
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