A detailed walkthrough of both processes — timelines, deadlines, statutory factors, and what distinguishes winning cases from losing ones.
New York enacted the nation's first surprise billing law in 2015 under Financial Services Law Article 6 and Insurance Law § 3241 — seven years before the federal No Surprises Act. NY IDR operates through the DFS and is governed by 23 NYCRR 400. It is generally more favorable to providers than the federal process.
The provider submits the claim to the health plan. Under Insurance Law § 3224-a, the insurer must pay or deny within 30 days for electronic claims and 45 days for paper claims. The insurer pays what it "determines is reasonable" — which is typically the QPA or a similarly low figure.
For emergency services where the health plan and hospital had a prior participating agreement, Financial Services Law § 605(e) requires the health plan to initially pay at least 25% more than the prior contracted rate, adjusted annually by the medical consumer price index (CPI). This is a mandatory floor.
Authority: Insurance Law § 3224-a; Financial Services Law § 605(e); 23 NYCRR 400.5
Unlike the federal NSA, which requires IDR filing within 4 business days after the 30-day open negotiation period, New York IDR allows providers to file a dispute within 3 years of the date the health plan made the original payment. This is the single most important procedural difference between the two frameworks.
This means claims that were underpaid in 2022, 2023, or 2024 — and were written off by your practice as uncollectible — may still be eligible for NY state IDR if they involve fully insured New York health plans. This multi-year claim recovery window cannot be waived by contract or policy terms.
Authority: 23 NYCRR 400 / Financial Services Law § 605; DFS FAQ Q-2 (time limits on IDR submissions)
The provider submits the dispute through the DFS portal at dfs.ny.gov. The submission must include the Surprise Bill Certification Form (where applicable), the claim details, the health plan's initial payment, and the provider's proposed amount.
The DFS portal assigns the dispute to a certified IDRE (Independent Dispute Resolution Entity). Under 23 NYCRR 400.5(k), each health plan must designate an officer responsible for overseeing IDR compliance. Health plans are required to post their designated contact information publicly.
Authority: Financial Services Law Article 6; Insurance Law § 3241; 23 NYCRR 400.5; DFS IDR portal: dfs.ny.gov
The IDRE notifies both parties and sets a deadline for submission of final offers and supporting documentation. Under 23 NYCRR 400.7, each party may submit any information it deems relevant. The IDRE must consider this information under 23 NYCRR 400.8. This is where the case is won or lost.
What to include in the provider's submission: (1) FAIR Health 80th percentile data for the specific CPT code and geographic area; (2) Provider credentials, board certifications, subspecialty training; (3) Case complexity documentation from operative report; (4) Prior payment amounts from this health plan for same services (if higher); (5) Regional market rate comparisons; (6) Patient acuity documentation.
Authority: 23 NYCRR 400.7; 23 NYCRR 400.8; Financial Services Law § 604
The IDRE selects one of the two offers — "baseball-style" arbitration — and issues a written determination. Unlike the federal process, the NY standard expressly includes the 80th percentile of UCR as calculated by FAIR Health as a factor. All factors carry equal weight; no single factor is determinative.
Factors the IDRE must consider under Financial Services Law § 604: The 80th percentile of UCR (FAIR Health); median rate paid by the health plan to similarly qualified participating providers for the same/similar services in the same region; the provider's training, experience, and specialty; patient acuity and case complexity; geographic region; circumstances of the case; and any other relevant information submitted by the parties. The insured's cost-sharing cannot increase based on the determination (DFS FAQ Q-9).
Authority: Financial Services Law § 604; 23 NYCRR 400.7-400.8; DFS guidance FAQ Q-8
Following the IDRE determination, the health plan must pay the awarded amount within 30 days. The determination is binding on both parties. If the health plan fails to pay, legal enforcement remedies are available.
In 2025, CMS released guidance creating a formalized process for requesting reopening of closed disputes if a certified IDR entity committed a specific type of procedural error. This provides an additional avenue for providers who received adverse determinations due to IDRE error — not merely disagreement with the outcome.
The federal No Surprises Act (P.L. 116-260, effective January 1, 2022) established the federal IDR process administered by HHS/CMS. It applies to self-funded ERISA plans and situations where NY state law provides less protection. The federal process has strict deadlines that differ significantly from NY state IDR.
Within 30 days of receiving the claim, the health plan makes an initial payment based on its Qualifying Payment Amount (QPA) — defined as the plan's 2019 median in-network rate for the service in the relevant market, indexed for inflation by CPI. The QPA routinely understates actual market value for OON services.
The QPA calculation has been the subject of extensive litigation (Texas Medical Association I-IV). The 5th Circuit is currently reconsidering the ghost rates methodology en banc (as of April 2026). Ongoing litigation means QPA calculations from many payers may be lower than lawfully required.
Authority: 42 U.S.C. § 300gg-111(a); 45 C.F.R. § 149.140
Either party initiates a 30 business day open negotiation period. Both parties must negotiate in good faith. If the parties reach agreement, IDR is unnecessary. If negotiations fail, the clock starts on the 4-business-day IDR filing window.
Good faith negotiation correspondence during this period creates the factual record that strengthens your IDR submission. Document every communication, offer, and response from the payer. Prior payment history and written representations from the payer during this period are admissible as credible information in arbitration.
Authority: 42 U.S.C. § 300gg-111(b)(1); 45 C.F.R. § 149.510(b)(1)
The initiating party (almost always the provider) must file the IDR request through the federal portal at cms.gov/nosurprises within 4 business days after the open negotiation period ends. This is the most commonly missed deadline in the entire process and results in permanent forfeiture of the claim.
The parties then have 3 business days to agree on a certified IDR entity. If no agreement is reached, HHS assigns one within 6 business days. This is why strategic selection of the IDR entity matters — we track performance data for certified IDR entities and select strategically where possible.
Authority: 42 U.S.C. § 300gg-111(b)(2); 45 C.F.R. § 149.510(b)(2); CMS Federal IDR portal
Within 10 business days of IDR entity selection, both parties submit their final payment offers and all supporting "credible information." The provider's submission package is the most consequential document in the process.
Statutory factors the IDR entity must consider (42 U.S.C. § 300gg-111(c)(3)(A)-(G)): The QPA; provider's training, experience, and quality/outcome measurements; patient acuity and complexity; teaching status and case mix of facility; market share in geographic region; good faith efforts (or lack thereof) to join the network; and prior contracted rates over the previous 4 years. The IDR entity cannot consider billed charges, UCR, Medicare/Medicaid rates.
Authority: 42 U.S.C. § 300gg-111(c)(3); 45 C.F.R. § 149.510(c)(4)
The IDR entity must issue a written determination within 30 business days selecting one party's offer. The determination must explain which offer was selected and why, including how the statutory factors were weighed. Providers win 85% of determinations as of 2024 data. Median winning provider offer: 4× the QPA.
The losing party pays the IDR entity's fee (approximately $200–$700 per dispute). Both parties split the administrative fee (~$115 each per dispute as of 2025). For batched disputes, a single administrative fee covers all grouped claims — dramatically reducing per-claim cost.
Authority: 42 U.S.C. § 300gg-111(c)(5); CMS IDR Public Use Files Q3-Q4 2024; Georgetown CHIR analysis March 2026
The two processes have significant structural differences. Understanding which applies to your claims is the first step to a successful dispute strategy.
| Feature | NY State IDR (FSL Art. 6) | Federal NSA IDR (42 U.S.C. § 300gg-111) |
|---|---|---|
| Filing Window | 3 years from original payment | 4 business days after 30-day negotiation period |
| Applies To | Fully insured NY health plans regulated by DFS | Self-funded ERISA plans; plans issued outside NY; air ambulance |
| UCR Benchmark | 80th percentile FAIR Health UCR — a core factor | QPA (2019 median in-network rate + CPI) — starting benchmark |
| QPA Presumption | No presumption — all factors equal weight | No presumption (struck down by TMA I litigation, 2022) |
| Arbitration Style | Baseball-style — one offer selected | Baseball-style — one offer selected |
| Regulatory Body | NY Department of Financial Services (DFS) | CMS / HHS / DOL / Treasury (federal) |
| Filing Portal | dfs.ny.gov IDR portal | cms.gov/nosurprises federal portal |
| Self-Funded Plans | Not covered (pre-2022 plans only by exception) | Covered for plans issued/renewed on or after Jan 1, 2022 |
| Medicare/Medicaid | Not covered | Not covered |
| Emergency Services | Covered (hospitals in NY) | Covered nationwide (including outside NY) |
| Air Ambulance | Not covered | Covered |
| Governing Citation | FSL §§ 600-616; 23 NYCRR 400 | 42 U.S.C. §§ 300gg-111 to 300gg-139; 45 C.F.R. Part 149 |
For fully insured NY health plans (the majority of individual and small group plans purchased in New York), NY state IDR applies — and NY's multi-year claim recovery window makes this the more forgiving framework. For self-funded ERISA plans (common with large employers who self-insure), the federal NSA process applies, and the 4-day filing window is critical. Many practices have a mix of both — and a claim audit is the only way to know exactly what you have. Our free evaluation includes this analysis.
Strategic implication: Because billed charges cannot be used as a benchmark, providers must anchor their offer to allowable factors — particularly FAIR Health UCR, prior contracted rates, and market data. Offers calibrated to these benchmarks win; offers at billed charges lose credibility.