How it works
How a dispute moves, step by step.
A federal dispute has eight steps, and federal rules set a deadline for each one. Here is every step in order: what we do, what your practice does, and the clock that governs it.
Intake
Once the agreements are signed, your remittances reach us through your clearinghouse and we match each payment to its claim.
What we do
- Set up secure delivery of your 835 remittance files.
- Match each payment to its claim and flag every out-of-network line.
- Start the clock on each claim from the day its payment or denial arrived.
What your practice does
- Sign the business associate agreement (BAA), the services agreement and the representative authorization.
- Point your clearinghouse remittance delivery to us.
The clock
The plan must send an initial payment or a denial within 30 calendar days of receiving a clean claim, meaning one with everything the plan needs to decide it. For air ambulance, the 30 days run from when the bill is sent.
Eligibility screen
Every claim is checked before a dollar of fees is spent. A claim that does not belong in the federal process is ruled out, and you see the reason.
What we do
- Check the plan type and coverage, whether the No Surprises Act protects the service, and whether a state surprise-billing law governs the claim.
- Check cooling-off periods and filing windows.
- Record the reason for every claim we rule out.
What your practice does
- Answer our questions on any claim we cannot settle from the records.
The clock
Screening has to finish inside the window to start open negotiation: 30 business days, starting the day the initial payment or denial is received.
Open negotiation
We send the plan a notice to negotiate. A dispute can end here if the plan makes a fair offer.
What we do
- Send the open negotiation notice within 30 business days of the initial payment or denial.
- Negotiate with the plan for up to 30 business days.
- Bring you any settlement offer, with our recommendation.
What your practice does
- Approve or decline any settlement offer.
The clock
Open negotiation lasts 30 business days, counted from the day the notice is first sent, and ends early if both sides agree.
Under the 2026 federal rule, once open negotiation moves into the federal IDR Gateway, the period will start on the day the notice is submitted there, and the plan must respond by the 15th business day.
Initiation
If negotiation does not settle, we start federal independent dispute resolution (IDR) as your authorized representative.
What we do
- File the notice of IDR initiation.
- Group claims into batches where the rules allow. For open negotiation starting on or after November 1, 2026, a batch holds at most 50 line items.
- Have a named person on our team attest to each filing.
What your practice does
- Nothing. We file under your authorization.
The clock
Initiation is due within 4 business days after open negotiation ends.
IDR entity selection
A certified IDR entity, an independent arbitrator certified by the federal government, is chosen to decide the dispute.
What we do
- Propose an entity and respond to the plan’s choice.
- Pay the federal administrative fee and the entity’s fee. We advance both.
What your practice does
- Nothing.
The clock
The plan has 3 business days after receiving the notice of initiation to accept the proposed entity or object and propose another. If the two sides do not agree, the federal Departments (Health and Human Services, Labor and the Treasury) select one, no later than 6 business days after initiation.
Offers
Each side submits one payment offer with its supporting information. Ours is built from payment data and reviewed by a named person before it goes in.
What we do
- Build the offer from payment data for the service and the market.
- Write the supporting brief.
- Have a named person on our team review every offer and brief before it is submitted.
- Confirm both fees have posted first. An offer is not considered received until both fees are paid.
What your practice does
- Share facts about the care that support the offer, such as case complexity or the clinician’s training, when we ask.
The clock
Offers are due within 10 business days after CMS sends the Notice of Offer, which follows final selection of the entity. Both fees must be paid by then.
Determination
The entity picks one of the two offers. It does not split the difference.
What we do
- Record the decision the day it arrives.
- Hold any new claims that fall inside a cooling-off period and file them when the window opens.
What your practice does
- Nothing until payment.
The clock
The entity decides within 30 business days after its selection is finalized.
Afterward, the side that started the dispute waits out a cooling-off period before filing the same services against the same plan: 90 calendar days, or 30 business days for batched disputes whose open negotiation started on or after November 1, 2026.
Claims that arise during cooling-off are not lost. They are filed in the window that follows: 30 business days after a 90-day period, or only 4 business days after a batched period.
Payment and reconciliation
An award is not a result until the money arrives. We track every payment to the cent.
What we do
- Track the plan’s payment and chase late or short payments.
- Reconcile each payment against its remittance.
- Recover the entity fee refund when we win.
- Tell you the same day if a determination means you owe the plan a refund.
What your practice does
- Receive payment from the plan.
- Pay our share of what the plan paid above its initial payment, on a monthly invoice.
The clock
The plan must pay any amount owed within 30 calendar days of the determination.
The entity refunds the winning side’s fee within 30 business days.
If the determination is lower than what the plan already paid (its initial payment plus the patient’s cost sharing), your practice owes the plan the difference within 30 calendar days.
Business days and calendar days
Most IDR clocks count business days: weekends and federal holidays do not count. A few count calendar days, where every day counts. Treating one as the other is the most common way to miss a deadline, so every deadline we track records which kind it is and the rule it comes from.
Where CMS or the IDR entity sends a notice that starts a clock, we count from that notice, not from our own submission date.
Federal rules change. We re-check every clock against CMS guidance and update this page when they do.
Federal rules last checked against CMS guidance on .