While some stakeholders anticipated the implementation of the Federal IDR Operations Rule in 2025, the focus has now moved to 2026 as the pivotal year for these changes.
A significant milestone was recently reached: the proposed operations rule is now officially under review at the Office of Management and Budget (OMB), signaling that the Departments are moving closer to finalization.
According to CMS’s Proposed Rule Fact Sheet, these proposed changes are specifically designed to improve communication between parties and increase the overall efficiency of the Federal IDR process.
The 2026 Regulatory Roadmap
There are nine core pillars that remain central to the regulatory “to-do” list:
- The Federal IDR Registry: To eliminate the difficulty of identifying the correct plan, the rule mandates a registration system. Each plan will be assigned a unique IDR registration number to be included in initial payment or denial notices, providing the precision needed for accurate dispute initiation.
- Standardized Open Negotiation: The rule aims to move the open negotiation process out of messy email chains and into the Federal IDR Portal. This creates a verifiable digital paper trail and ensures both parties are engaging in good faith.
- CARC and RARC Standardization: To minimize eligibility disputes, the rule will likely mandate specific Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) to clearly explain claim downcoding or denials from the outset.
- Expanded Batching Criteria: One of the most anticipated changes highlighted in the CMS Fact Sheet is the expansion of batching rules. The rule proposes allowing items and services to be batched if they relate to the treatment of a similar condition, a single patient encounter, or are billed under the same service code.
- Direct Administrative Fee Collection: The Departments propose collecting the non-refundable administrative fee directly from the parties (rather than through IDR entities). This change includes a strict two-business-day window for payment after an entity is selected.
- Expedited Eligibility Timelines: To address the historical backlog, the rule proposes requiring certified IDR entities to determine eligibility within five business days of being selected, significantly accelerating the front end of the process.
- Cooling Off Period: To address confusion surrounding the cooling-off period, the rule anticipates shifting the current 90 day (about 3 months) cooling off period to a lesser, unspecified number (From 1 day to 89 days)
- Low Dollar Claims: To address small dollar claims, the Department is considering a Low Dollar Threshold pathway for lower case in controversy amounts that will reduce administrative fee in order for small business parties to participate in IDR
Are you prepared for the 2026 IDR regulatory shift? Questions about implementing IDR processes or scaling your medical review operations? Our team can provide guidance tailored to your program requirements.
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