No Surprises Act IDR Services for Pain Management Practices

Which pain management claims qualify for IDR?

The No Surprises Act covers emergency services and non-emergency services that an out-of-network provider performs at an in-network facility, such as a hospital outpatient department or an ambulatory surgery center. For pain practices, that usually means procedures performed by an out-of-network physician at an in-network ASC or hospital.

Claims covered by a state surprise billing law, such as New Jersey's out-of-network law for state-regulated plans, may follow the state process instead. We identify which process applies to each claim.

How does the federal IDR process work?

Federal IDR runs on fixed deadlines. After the plan's initial payment or denial, the provider has 30 business days to start open negotiation, which lasts 30 business days. If it fails, either side has 4 business days to initiate IDR, and a certified IDR entity then picks one of the two final offers.

• The plan sends an initial payment or denial, usually within 30 calendar days of receiving the claim
• The provider has 30 business days from that payment or denial to start open negotiation
• Open negotiation lasts 30 business days
• If negotiation fails, either party has 4 business days to initiate federal IDR
• Each side submits a final payment offer and supporting information to the certified IDR entity
• The IDR entity picks one of the two offers, and the non-prevailing party pays the IDR entity fee
• The plan must pay any amount owed within 30 calendar days of the decision