NSA · Federal IDR

How federal NSA IDR works. And what Kronos Revenue does at every step.

Understanding the process at a regulatory level is the only way to evaluate whether any IDR vendor is handling your claims correctly. This page explains it as written in the statute and implementing regulations, then explains what Kronos Revenue does at each phase.
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  • Surgeon founded
  • HIPAA compliant · BAA on request
  • One claim per CPT at federal IDR

Download the NSA IDR filing checklist before you initiate a dispute.

Download the NSA IDR checklist

The federal IDR regulatory framework.

Governing law: No Surprises Act, Public Law 116-260, Division BB, Title I · Implementing regulations: 45 CFR Part 149

Phase 1 — Initial payment or denial

The insurer must issue an initial payment or denial within 30 calendar days of a claim for an out of network service covered under the NSA. This initial payment is almost always based on the insurer qualifying payment amount (QPA), which CMS data shows running more than 30% below historical in network rates for surgical services.

Phase 2 — Open negotiation

Either party sends a written Open Negotiation Notice. The 30 business day negotiation period begins. Most do not reach agreement. The notice must be sent within 30 business days of the initial payment or denial. Missing that window closes the IDR pathway for that claim.

Phase 3 — IDR initiation

If negotiation fails, either party has 4 business days after the negotiation period closes to send a Notice of IDR Initiation and file with a certified IDR entity (IDRE). The IDRE is selected by agreement within 3 business days, or assigned by CMS.

Phase 4 — Payment determination

The IDRE reviews both parties payment offers and supporting documentation. Final offer arbitration: the IDRE picks one offer. No splits. The losing party pays the IDRE administrative fee (currently $50 per dispute — confirm before filing). The IDRE has 30 business days to issue a determination.

What Kronos Revenue does at each phase.

Phase 1 — EOB intake and eligibility review

You forward the EOB. We review within one business day. We confirm: NSA eligibility, plan type coverage, active cooling off period, open negotiation window status. 44% of 2024 IDR disputes were challenged as ineligible by payers (CMS data, Zelis analysis, March 2026). We catch eligibility errors before submitting, not after.

Phase 2 — Open negotiation

We send the Open Negotiation Notice on your behalf, document delivery with timestamps, and manage all insurer communications during the negotiation window.

Phase 3 — IDR submission

CPT coded payment offer: one claim per CPT code. Never batched. Clinical necessity narrative built from your operative note. Market rate comparisons from Sydra library of 213+ ingested determinations. Provider credentials: CV, training, procedure volume, board certifications.

Phase 4 — Determination and follow up

We submit to the IDRE portal, track the determination timeline, receive the outcome. Favorable: follow up on payment. Adverse: review reasoning, advise on re filing eligibility. Quarterly recovery review covering all active and closed cases.

Why documentation quality determines the outcome.

The IDRE sees two competing offers. Yours and the insurer. They pick one. Your offer wins when it establishes your fee is consistent with what providers actually win on this specific CPT, and demonstrates the clinical circumstances justify your fee.

Kronos Revenue prepares both on every submission.

Onboarding: four weeks to full handover.

Week 1

BAA and engagement letter signed. Practice profile built.

Week 2

First five claims processed in parallel with your current process. You see our submissions before we file them.

Week 3

Full handover. Kronos Revenue is now the IDR layer for your practice.

Week 4

First monthly report delivered.

Medical review

Questions about our NSA IDR process

How long does onboarding take?
Four weeks from BAA signature to full handover, with a proof of concept in Week 2.
What is the ongoing communication cadence?
Live support 9–5 M–F, 24 hour email response, and a monthly report with quarterly review calls.
Who is on my file?
A dedicated RCM specialist trained by Dr. Abrahams, with escalation to Heisha Rivera (Director of Revenue Cycle) and Dr. Abrahams for high value cases.
What do I need to provide to get started?
Forward EOBs or grant secure EMR access, share your specialty mix and provider count, and sign the BAA and engagement letter.

References

  1. CMS Federal IDR Q1/Q2 2025 Public Use File (January 21, 2026)
  2. Georgetown University CHIR · Health Affairs webinar, March 2026
  3. Brookings Institution NSA Arbitration Databook · April 2026
  4. ACR — Providers prevail in vast majority of IDR claims · January 29, 2026
  5. Zelis — NSA IDR eligibility challenges · March 2026
  6. No Surprises Act: Public Law 116-260, Division BB, Title I
  7. Federal IDR regulations: 45 CFR Part 149
  8. CMS No Surprises Act overview
  9. Federal IDRE portal

Explore more on Kronos Revenue

Get a free NSA IDR review

Get a free NSA IDR review(914) 705 6830
  • Surgeon founded
  • HIPAA compliant · BAA on request
  • One claim per CPT at federal IDR