No Surprises Act dispute management that checks every line, builds the rate evidence and positions the offer before the deadline
Every dispute checked for eligibility and answered with rate evidence on time.
See one case, screen by screen ↓It is how a health plan or TPA works the federal independent dispute resolution cases that out-of-network providers bring under the No Surprises Act: reading each notice, checking eligibility, assembling rate evidence, submitting an offer before the deadline and paying after a decision. This solution adds six agents that do the reading, matching, checking, evidence and drafting; a person decides the offer.
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Out-of-network groups, air ambulances and facilities now take payment disagreements to federal independent dispute resolution in very large numbers, and every dispute runs on business-day clocks. Ten business days after the IDR entity is selected, the plan’s offer and its supporting information are due. Miss it, and the arbiter picks the provider’s number.
Inside those ten days the analyst has to find the original claim behind every line, check whether each line belongs in federal IDR at all — state law, Medicare members, late initiation, bad batching, cooling-off — pull the QPA calculation and any prior contract, and write the explanation. Then comes the real decision: what number to offer, when the arbiter must choose one of the two offers whole. Offering the QPA by reflex loses most of the time, and the losing party pays the entity’s fee.
Estimated split for a typical batched dispute, in hours, by hand and with the solution.
Six agents check every line, build the rate evidence and place each offer against past decisions; the analyst signs.
Kestrel Emergency Physicians, an Atlanta emergency medicine group that left Bramblecrest Health’s network at the end of 2024, has batched 18 lines of CPT 99285 into federal IDR. Here is what happens next, screen by screen, in the working solution.
Marisol opens the queue: 412 open disputes and open negotiation notices, 61 offers due, a ten-business-day strip of deadlines with Mon 12 Oct marked as a holiday. Tamsin Air Medical is co-signed and goes in today. Next is Kestrel, DISP-4418207 — 18 lines, 3 flagged out, $23,592.30 at stake over what was paid.
“A missed offer is a default loss at the provider’s number.”
The case opens with the agents’ run across the top: notice read, 18 claims matched, 15 of 18 lines eligible, 5 exhibits built, 64 past decisions gathered, reply drafted — 7 min 40 s in all. Three clocks sit above it: eligibility notice due Wed 14 Oct, offer due Fri 23 Oct, decision due Mon 23 Nov.
The last step is a person: “You position and sign — Marisol Ortega.”
Seven checks on every line, from the claim, the plan’s funding and the notice dates. Fifteen lines are on the self-funded ERISA plan of Corvane Logistics and pass. Lines 7 and 12 are on Bramblecrest Georgia Individual Silver, a fully insured product. Line 16 was started too late.
Line 7, claim BH26-3343182, fails one check: no specified state law or All-Payer Model may apply. Georgia’s Surprise Billing Consumer Protection Act governs this fully insured product. For line 16, open negotiation ended Wed 9 Sep, so IDR had to start by Tue 15 Sep; Kestrel started it on Tue 6 Oct.
The agents drafted the notice to Lakeshore Review Group asking that lines 7, 12 and 16 be found not eligible, and stating that the offer on the other 15 lines follows by 23 October. Lena reviewed it at 09:31. Marisol sends it — a day before it is due.
“Eligibility notices are co-signed by the legal reviewer.” The agents draft them; only a person sends.
The QPA calculation ($356.40 in 2019, indexed to $412.18), Kestrel’s own former contract — 99285 at $588.00 in 2024, trended to $624.41 — the median in-network rate of 11 comparable groups ($596.20), the open negotiation record and a summary of the 15 visits. Each maps to a factor the arbiter must weigh, and each is attached.
Past decisions are used to position the offer and are never attached to the reply.
Marisol sets the offer at the QPA, $412.18. The number line shows every past determination for 99285 in the Atlanta region. Where the plan offered near the QPA, the arbiter chose the plan in 5 of 24 cases. Expected cost for the 15 lines: $27,051.
The reply warns: “Offering the QPA alone. In 24 past disputes with a plan offer near the QPA, the arbiter chose the plan 5 times.”
She switches the chart to Kestrel only: 9 past decisions with Kestrel. The plan was chosen in 6. Kestrel’s wins came when the plan offered close to the QPA, and once at $538.61; every time Bramblecrest offered above $560, the plan was chosen.
Back at the recommended $640.00 — 1.55 × QPA, 2.5% above Kestrel’s trended contract rate — 15 of 17 similar past offers were chosen and the expected cost of the batch falls to $12,020. Marisol opens the reply: the offer laid out as the federal IDR portal asks for it, $9,600.00 for 15 lines, and a written explanation drafted from the five exhibits, every statement cited.
With more than $20,000 at stake, the reply needs Lena’s co-signature. Marisol signs at $640.00 at 09:38, Lena co-signs at 09:52, and Marisol submits to the federal IDR portal at 09:55. Checks before submission: the offer is at or above the QPA, at or above Kestrel’s trended contract rate, every statement cites an attached exhibit, the eligibility notice is sent.
“Signed by Marisol Ortega, co-signed by Lena Achterberg. The agents do not submit; you do.”
The same batch, seen by the four people who carry it — what their week looked like, and what it looks like now.
Six agents check every line, build the rate evidence and place each offer against past decisions; the analyst signs.
Reads federal IDR initiation notices, open negotiation notices and portal messages, and extracts the dispute number, parties, lines, dates and the provider’s offer.
Finds each line’s original claim, remit, QPA disclosure and the plan’s funding type, matching on claim number, member, date of service and code.
Runs seven eligibility checks on every line — coverage under the Act, state law, the service, open negotiation, initiation within 4 business days, batching and cooling-off — and counts every business-day clock, federal holidays excluded.
Assembles the exhibits: the QPA calculation, prior contracts in the last four years trended, comparable in-network rates, the open negotiation record and a summary of the visits.
Gathers past determinations for the same code and QPA region from the plan’s own record and the federal public use files, fits the chance of each offer being chosen and the expected cost, and recommends the offer with the lowest expected cost.
Writes the written explanation for the offer as the analyst positions it, each statement cited to an exhibit, and re-drafts when the offer moves.
Decides; legal co-signs large replies. The agents propose; a named person decides.
The analyst can ask about the offer, the eligibility, the deadlines or a provider’s record — and the answer moves the screen to match.
Why $640 and not the QPA?
Because offering the QPA mostly loses here. In 24 past decisions for 99285 in the Atlanta region where the plan offered near $412, the arbiter chose the plan 5 times. Where the plan offered $600–$680, it chose the plan in 15 of 17. $640 is the lowest point on the expected-cost curve: $12,020 for the 15 lines, against $27,051 at the QPA. It also sits just above Kestrel’s own former contract rate, trended to $624.41.
Which lines should we object to?
Three of the 18. Lines 7 and 12 are on Bramblecrest Georgia Individual Silver, a fully insured product, where Georgia’s surprise billing law applies instead of federal IDR. Line 16 was started 15 business days late: its open negotiation ended 9 Sep, so IDR had to start by 15 Sep. The notice to Lakeshore Review Group is drafted and Lena has reviewed it; it is due tomorrow, Wed 14 Oct.
What happens if we miss Friday the 23rd?
The arbiter picks Kestrel’s number. If a party submits no offer within 10 business days of the entity’s selection, the entity selects the other party’s offer. Here that is $29,775.00 for 15 lines, $23,592.30 more than was paid, plus the entity’s fee. The team has 61 offers due in the next ten business days; this one has 8 left.
How has Kestrel done against us in arbitration?
Nine decisions on 99285 since April; the arbiter chose Bramblecrest in 6. Kestrel won three: two when the plan offered close to the QPA ($422.83 and $405.58) and one at $538.61. Every time Bramblecrest offered above $560, the plan was chosen — most recently DISP-4234653 on 13 Aug at $688.21.
13 screens from the working solution, on its sample data. Pick one to see it large.
Every change is versioned and on the audit trail.
| Setting | Default | Choose from |
|---|---|---|
| Business-day calendar | Federal holidays 2026, ET | Federal holidays 2026, ET · CT |
| Warn when an offer has | 3 business days left | Any number of business days; escalates to the team lead at 1 |
| Payment after a decision | 30 calendar days | Reminder to claims at day 20 |
| Co-signature by the legal reviewer when the provider’s offer exceeds what was paid by more than | $20,000 | $10,000 · $20,000 · $35,000 |
| Offer floor | The QPA | Agents never draft an offer below it |
| Warn below the provider’s own former contract rate | On | Prior contracts in the last four years, trended |
| Positioning chart window | Last 6 months | 6 · 12 · 18 months; widened to similar codes below 20 decisions |
| Open negotiation settlement authority | 175% of QPA | 150 · 175 · 200% of QPA; above it, the VP of payment integrity signs |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample dispute data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (CMS, Federal IDR process reports, update to 31 Jul 2026: 394,140 disputes initiated in July 2026; 98,398 of 671,465 disputes closed in Jun–Jul 2026 found ineligible). Federal IDR timelines: 45 CFR 149.510. People, plans, employers, provider groups, facilities and IDR entities named on this page are fictional — characters and sample data in the working solution.
It is how a health plan or TPA works the federal independent dispute resolution cases that out-of-network providers bring under the No Surprises Act: reading each notice, checking eligibility, assembling rate evidence, submitting an offer before the deadline and paying after a decision. This solution adds six agents that do the reading, matching, checking, evidence and drafting; a person decides the offer.
The eligibility checker runs seven checks on every line: covered by the Act, no specified state law or All-Payer Model, out-of-network emergency service, open negotiation completed, IDR started within 4 business days after it ended, batched correctly, and not in a 90-day cooling-off period. It drafts the eligibility notice for the lines that fail, with the reason for each.
It does not decide; it recommends. The outcome analyst places the case on a number line beside the QPA, the provider’s offer and every past determination for the same code and region, and shows the expected cost at each offer. The analyst drags the offer, sees how similar past offers fared, and sets the number.
Under 45 CFR 149.510, a party that submits no offer within 10 business days of the IDR entity’s selection loses by default to the other party’s offer. The solution counts every clock in business days with federal holidays excluded, orders the queue by the next deadline and warns when an offer has 3 business days left, escalating at 1.
Only as comparable in-network rates, named by letter — another provider’s contract is never cited by name. The provider’s own former contract, if there is one in the last four years, is used and trended, because prior contracted rates are a factor the arbiter must weigh.
Yes. Every open negotiation notice sits on its 30-business-day clock with a suggested counter-offer band drawn from past decisions for the same code and region, and the provider reimbursement manager’s settlement authority marked. Above that authority, the VP of payment integrity signs.
Yes. The agents never submit to the IDR portal, never send an eligibility notice, never set the offer and never offer below the QPA. A named analyst signs and submits every offer, and the legal reviewer co-signs replies with more than $20,000 at stake and every eligibility notice.
The Agentic Solution Engine builds and deploys it from your requirements — your claims and remit feeds, contract library, reply templates and a sample of past disputes — and it goes live once every quality gate has passed. We will walk you through it on your own disputes first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run No Surprises Act Dispute Management on a sample of your own federal IDR cases.