Common and Avoidable Ineligibility Errors: In IDR Filings, Details Matter

Every dispute presented for Independent Dispute Resolution (IDR) must pass an eligibility review before proceeding into the full process set forth under the federal No Surprises Act. While the number of rejected disputes has been falling, a surprising number of filings are still found ineligible.  

In her role supervising FHAS’s Account Services, which manages IDR communications with clients, Lauren Masulis oversees thousands of filings every month and sees common issues that lead to ineligibility. She offers critical advice to stakeholders.  

“Details matter,” Masulis says. “Even the slightest typo or information placed in the wrong field, let alone missing information, can stop the whole case from reaching arbitration. FHAS recommends double checking information before initiating the dispute.”  FHAS notes the pending IDRE operations rule will help parties as it requires more information sharing among the parties, which will greatly benefit eligibility determinations.  

In addition, FHAS urges stakeholders to test automation platforms with synthetic data before implementation and use. Automating the administrative parts of the IDR process is becoming more prevalent, and FHAS notes that while human errors generally are isolated events, programming errors can impact a vast number of disputes.  

Updated initiation forms have helped improve eligibility rates, but as of the most recent data provided by the Centers for Medicare & Medicaid Services, more than 15% of disputes were found ineligible.  

FHAS commonly sees the following errors that lead to ineligibility.  

1. The service is not covered by the federal IDR.  
   The IDR process considers only a very specific scope of services and issues. Matters falling outside of that scope will not be considered. Some common examples include:  
   • When a patient knowingly chooses out-of-network care for an elective service.  
   • When state laws apply instead, which occurs if an all-payor agreement or a specified state law (SSL) is in place.  
   • The submission of a service that was denied due to an adverse benefit determination. The submission of a denial based on medical necessity would be an example of this common error. An adverse benefit determination must be disputed through a plan’s or issuer’s claims and appeals process, not through the Federal IDR Process.   
      
2. Missing or incorrect Open Negotiation period information. 
   Accurate information is critical on the open negotiation form. Forms that have missing or incorrect information, including typos, incorrect email addresses or dates, can cause the open negotiation to be considered incomplete, or to not have occurred.  
    
3. Filing outside required timelines. 
   As with the Open Negotiation documentation, dates matter. Initiating a claim outside of required timelines leads to ineligibility. It also is important for both parties to understand any extensions due to extenuating circumstances that have been granted for the dispute. 
    
4. Incorrect batching of claims.  
   Batching continues to be an area that leads to resubmissions and eventually to ineligibility determinations. Expanded batching criteria is expected when the proposed Federal IDR Operations Rule is finalized. For now, while multiple qualified IDR items or services may be considered as part of a batched IDR determination, they must meet required criteria, including:  
   • The items and services are furnished by the same provider or facility; AND 
   • Payment for the items and services are made by the same group health plan or health insurance issuer; AND 
   • Items and services were furnished during the 30-day period following the date on which the first item or service included in the batched determination was furnished, AND 
   • Such items and services are related to the treatment of a similar condition. 
      
5. Incorrect insurance plan or coverage type.  
   A lack of provider visibility into the insurance plan or type of coverage can make it challenging to get this information correct. However, it is the provider’s responsibility to make sure the information is included and accurate. 

Accuracy and timeliness are significant in the IDR process and can mean the difference between ineligibility and prompt resolution.  Learn more tips and information to improve your IDR filings by visiting the FHAS IDR Knowledge Base.   

Common Error	What It Means / Why It Causes Ineligibility
Service not covered by federal IDR scope	The dispute involves services or issues that fall outside what the IDR process is designed to review (e.g., voluntary out-of-network elective care, situations governed by state law, or claim denials due to medical necessity that must go through appeals instead).
Missing or incorrect Open Negotiation information	Incomplete or inaccurate forms (typos, wrong dates, incorrect email addresses) can invalidate or negate the open negotiation period.
Filing outside required timelines	Disputes must be initiated within specific timeframes. Missing deadlines or misunderstanding extensions results in automatic ineligibility.
Incorrect batching of claims	Multiple claims must meet strict criteria to be batched (same provider/facility, same plan/issuer, within 30 days of first service, and related to a similar condition). Failure to meet all criteria makes the batch ineligible.
Incorrect insurance plan or coverage type	Providers must submit accurate insurance and coverage information. Errors or missing details can invalidate eligibility.