Am I eligible for IDR or PPDR?

Statute-pinned · primary sources only

Decision tree at a glance

Which dispute path applies?

Are you on Medicare / Medicaid / TRICARE / VA?

NSA does not apply

Beneficiary protection rules apply — contact the program directly.

Are you uninsured or self-pay?

PPDR branch

If actual bill exceeds GFE by ≥ $400, file PPDR within 120 days.

45 CFR §149.620

Was this a ground-ambulance bill?

NSA does NOT cover

State law controls. ~10-15 states have own balance-billing protection.

Was it emergency, air-ambulance, or OON ancillary at INN facility?

Federal NSA applies

Patient files NSA complaint with CMS Help Desk (1-800-985-3059). Provider/plan run Federal IDR.

45 CFR §149.510

Scheduled OON + you signed a 72hr+ notice-and-consent waiver?

NSA waived (limited)

Negotiate directly. Ancillary services (anesthesia, radiology, pathology) cannot be waived even if signed.

PHSA §2799B-2

The two pathways

Under NSA, there are two procedurally-distinct dispute pathways:

Federal IDR (45 CFR Part 149 Subpart E) — provider vs plan baseball-style arbitration. The provider initiates; the patient does not. The patient's role is to file an NSA complaint with the CMS Help Desk at 1-800-985-3059 if balance-billed in violation.
PPDR (45 CFR Part 149 Subpart F) — Patient-Provider Dispute Resolution foruninsured / self-pay patients only. Eligibility requires the actual bill to exceed the good-faith estimate by $400+. Filing window is 120 calendar days from bill receipt.

Decision tree (by axis)

Payer type: Medicare, Medicaid, TRICARE, VA → NSA does not apply (separate beneficiary protections). Commercial fully-insured + self-funded ERISA + Medicare Advantage → NSA may apply.
Service type: Emergency, OON ancillary at INN facility, air ambulance → NSA covers. Ground ambulance → NSA does NOT cover; state law controls.
Notice-and-consent waiver: If you signed a compliant waiver 72+ hours before a scheduled OON non-emergency at an INN facility — NSA is waived. Ancillary services cannot be waived.
ERISA preemption: Self-funded ERISA plans escape state-DOI jurisdiction. State IDR pathways apply only to fully-insured state-regulated plans.

Payer × service-type matrix

Where each plan + service routes

Payer ↓ / service →	ER	OON anc.	Air amb.	Ground amb.	Scheduled OON
Commercial fully-insured	Federal IDR + NSA complaint + State DOI overlay 45 CFR §149.510	Federal IDR + NSA complaint + State DOI overlay 45 CFR §149.510	Federal IDR + NSA complaint PHSA §2799A-5	State law (if any) + Negotiate otherwise State DOI	NSA waived if 72h consent + Ancillary still protected PHSA §2799B-2
Self-funded ERISA	Federal IDR + NSA complaint + DOL/EBSA enforcement 45 CFR §149.510	Federal IDR + NSA complaint + DOL/EBSA enforcement 45 CFR §149.510	Federal IDR + NSA complaint + DOL/EBSA enforcement PHSA §2799A-5	ERISA preempts state law + Negotiate directly 29 U.S.C. §1144	NSA waived if 72h consent + Ancillary still protected PHSA §2799B-2
Medicare Advantage	Federal IDR + NSA complaint 45 CFR §149.510	Federal IDR + NSA complaint 45 CFR §149.510	Federal IDR + NSA complaint PHSA §2799A-5	State law (if any) State DOI	NSA waived if 72h consent PHSA §2799B-2
Original Medicare	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE
Uninsured / self-pay	PPDR (if GFE delta ≥ $400) + Negotiate otherwise 45 CFR §149.620	PPDR (if GFE delta ≥ $400) 45 CFR §149.620	PPDR (if GFE delta ≥ $400) 45 CFR §149.620	Negotiate / charity care —	PPDR (if GFE delta ≥ $400) 45 CFR §149.620

Run the decoder

The interactive 8-axis decision tree:

NSA dispute-path decoder

8-axis decision tree. Answer the questions; the engine routes you to the correct dispute path and procedural clock. Your inputs never leave your browser.

Service typeWho is your payer?State of service

Facility statusProvider status

Bill dateEOB receipt date

Quick answers

Frequently asked

Can I file Federal IDR as a patient?

No. Federal IDR (45 CFR §149.510) is a provider/plan process. Patients file NSA complaints with the CMS No Surprises Help Desk at 1-800-985-3059 instead.

What is the 30-day open-negotiation period?

Under 45 CFR §149.510, provider and plan have 30 business days to negotiate the payment for a covered NSA service after the initial payment or notice of denial. If they don't agree, the provider has 4 business days to initiate Federal IDR.

What is the 4-day IDR initiation window?

After the 30-business-day open-negotiation period expires, the provider has 4 business days to initiate Federal IDR through the CMS portal at nsa-idr.cms.gov. Missing this window forfeits the provider's IDR right for that claim.

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Informational, not medical, legal, or insurance advice. Consult a healthcare-billing attorney or patient-advocate before acting on a No Surprises Act dispute. The free CMS NSA complaint pathway is 1-800-985-3059.