By Barbara Rubel, MBA, FRBMA
MSN Senior VP, Marketing & Client Services
The Federal Independent Dispute Resolution (IDR) process, created under the No Surprises Act (NSA), provides out-of-network providers and payers with a formal pathway for resolving payment disputes for eligible claims when negotiations fail. The Federal IDR Operations Final Rule was issued on May 28, 2026, and is intended to make the process for resolving out-of-network payment disputes more workable, less administratively burdensome, and less confusing. The Final Rule takes effect on August 3, 2026, and it appears the Federal IDR process is here to stay, albeit with an extended period of adopting to the changes. An important footnote is the new administrative fee applies to disputes initiated on or after June 11, 2026.
Administrative Fee Reduction
The administrative fee for initiating a dispute that is required for both parties to the dispute has been reduced from $115 to $15 per party per dispute. This change is designed to make the IDR process more accessible and economical for all parties involved.
"Cooling Off” Period
The NSA establishes a “cooling off period” after a provider has received an IDR determination for disputes with the same payer, for the same items or services, and for the same encounter or CPT® codes.
This period, which has been reduced from 90 days to 30 days, is the time providers must wait before they can submit additional IDR disputes.
Batching Methodology Changes
Batching similar claims for a payer or plan sponsor into one larger group is essential to making the IDR process more efficient and more cost-effective.
The Final Rule has increased the 25-line-item cap on a batch to 50-line items provided the following batching criteria are met and batched claims generally must involve the same payer.
More flexibility in meeting the statutory requirement that batched claims “relate to the treatment of a similar condition” has been included and the specific batching criteria is:
- Services from a single patient encounter (same or consecutive dates of service and billed on the same claim form).
- Services that are billed under comparable codes but from different coding terminologies.
- Certain anesthesiology, radiology, pathology, and laboratory services within the same Category I CPT® code section.
New Federal IDR Registry
A Federal IDR Registry, yet to be created, was announced and will require payers to submit information about their legal entities, including entity names, registration identification numbers, etc. and contact information for the correct entity. This will be useful to providers for evaluating claim eligibility (for example, if remittance advice messages do not include the required information).
Standardized Communication Requirements
Arguably one of the most fundamental challenges with the IDR process has been the ability to accurately identify claims that are eligible for the Federal IDR process given the limited and sometimes conflicting information that has been provided by payers to providers. The Final Rule adds several communications that payers must provide to providers and certified IDR Entities (IDREs) which should help improve a provider’s ability to evaluate eligibility quickly and accurately.[1]
Use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs)
A common occurrence has been for providers to file IDR disputes only to learn later that the claims were ineligible.
Under the Final Rule, payers are required to include CARC and RARC codes and the business name (i.e., legal entity of both the payer and the plan sponsor if possible) in both paper and electronic remittance advice communications to out-of-network providers for routing and eligibility determinations. This should allow providers to make more accurate eligibility assessments on day one.
Unfortunately, rather than immediately requiring available codes that indicate NSA eligibility (e.g., N860, which unambiguously indicates NSA applicability) and prohibiting use of ambiguous codes (e.g., N830, which indicates the claim could be subject to federal or state IDR processes), HHS, DOL and Treasury (“the Departments”) have opted to work through the HHS-approved X12 committees that develop CARC and RARC codes to develop new codes or to modify existing codes. This will most likely mean implementation could take many months.
Eligibility Information. Within three days of receipt of a provider’s notice of IDR initiation, the Final Rule now requires that payers send an IDR initiation response that confirms or updates eligibility information. The goal is for the IDRE to determine eligibility within five business days of initiation of the dispute.
Improved Certified IDRE Selection. Providers have struggled with the IDR process when payers wait until the eleventh hour to submit their preferred certified IDRE. Such a delay gives no opportunity to object with the result being the payer’s (more favorable) certified IDRE is selected.
Key improvements to the Certified IDRE selection process include:
- More structured information exchange during the open negotiation period, the IDR initiation, and the certified IDRE selection.
- Notices and communication will move through the Federal IDR portal rather than through separate proprietary systems.
Eligibility determinations must be made within five business days after final selection of the certified IDRE. - The parties must provide any additional information that is needed by the certified IDRE within five business days of the request.
- Payers must register and obtain an IDR registration number so providers can identify the correct payer and coverage type when initiating a dispute and selecting a certified IDRE.
Summary
Some changes such as a reduction in the administrative fee will be almost immediate while other more impactful changes such as use of IDR-specific CARCs and RARCs will not take effect for many months, at best. The new process requirements for use of the “to be created” Federal IDR portal will take effect 90 to 150 days after the functionality is available. The Departments have stated they expect this functionality to be available within 24 months of the Final Rules taking effect. There will be a phased approach to implementation and guidance specifying a) when each capability is available and b) when compliance with each requirement becomes mandatory will be issued. An optimistic date for the availability of the new functionality is 12 months so the earliest effective date could be 15 months.
In addition, a commitment to meaningful enforcement that requires providers, payers and certified IDREs to conform to the processes and the timelines has been lacking. For example, the response from the Departments was we will “use existing process to enforce requirements” when asked for enforcement to ensure payers would follow the new requirements for use of CARC and RARC codes in remittance advice communications. The same response was given to the question of whether or when enforcement action will be taken against payers who do not make required payments to providers within 30 days of an IDR determination.
For those organizations that choose to initiate an IDR dispute, the most impactful changes of this Final Rule are the reduction in the administrative fee, the new CARC and RARC requirements, the 50-line-item batching limit, the five-day eligibility review deadline, and the payer registration system.
[1] The 2026 fixed fee (single determinations) range is from $425 to $800 with an average of $565 and the 2026 fixed batch fees range from $625 to $1,150 with an average of $808.
Barbara Rubel
MBA, FRBMA
Senior Vice President, Marketing & Client Services
Barbara has been a leader with MSN Client Services since 1998. Her extensive background in strategic planning, market research, healthcare marketing and managed care negotiations provides a wealth of information to support MSN Clients.
Barbara has also been highly involved in industry organizations, serving as President of the Radiology Business Management Association (RBMA), the Georgia RBMA, and the Florida RBMA. In addition, she chaired the influential RBMA Federal Affairs Committee and the RBMA Technology Task force and was a member of the RBMA Data Committee. Her work on behalf of radiology has earned her the RBMA Special Recognition Award (2010), the RBMA Global Achievement Award (2013), and she is a Fellow of the RBMA.
