Federal and state IDR coverage.

Alaska repealed its 80th-percentile payment rule effective January 1, 2024. That rule no longer supplies the state payment amount for later services. The state's May 2024 guide directs self-funded claims and claims outside applicable state law to federal IDR. Review earlier service dates separately. Insured-plan provider complaints remain available through the Division of Insurance; that complaint channel is not a separate state IDR arbitration program.

CMS identifies federal IDR for qualifying insured claims in American Samoa, including covered emergency, facility-based nonemergency and air-ambulance services. Its letter identifies no applicable local payment law or All-Payer Model Agreement. Confirm the plan, covered service and filing deadlines.

CMS identifies state payment rules for defined nonemergency professional services at contracting facilities. Federal IDR applies outside that scope; emergency and air-ambulance services need separate review.

The cited CMS letter identifies state payment rules for insured provider and emergency-facility services, with federal IDR for air ambulance. Check the service and plan against current state requirements.

CMS identifies emergency and certain in-network-facility or referred laboratory services under state law. Other qualifying services, including air ambulance, need federal-route review.

The cited CMS letter identifies state payment law for covered emergency services under defined insured coverage. Federal IDR may govern qualifying services outside that scope and air ambulance.

State reimbursement rules and the claim-dispute program have plan, service, and claim-value conditions. Check HMO thresholds and whether state law determines the rate before selecting federal IDR.

PRP's Florida service scope

Georgia rules cover qualifying emergency and inadvertent nonemergency provider/facility claims. Later CMS guidance treats air ambulance as a federal route; do not apply the older letter's blanket state-air-ambulance statement.

Private self-funded plans: verify Georgia election; federal route for qualifying claims when not opted in.

CMS identifies federal IDR for qualifying insured claims in Guam, including covered emergency, facility-based nonemergency and air-ambulance services. Its letter identifies no applicable local payment law or All-Payer Model Agreement. Confirm the plan, covered service and filing deadlines.

CMS identifies defined pathology, anesthesia, neonatology, radiology, and emergency-department services under PPO coverage at participating facilities. Other qualifying plan/service combinations require federal review.

Federal IDR is the CMS route for NSA-qualified services. Later Louisiana law adds distinct ground-ambulance payment protections; ground ambulance is outside federal NSA IDR.

Distinguish state payment rules for qualifying surprise and emergency claims from the narrower state emergency-IDR process. Current law excludes air ambulance except a narrow prior-authorization provision; check that exception before federal routing.

Private self-funded plans: verify Maine opt-in for the service date and covered scope.

Separate hospital rate setting under the All-Payer Model from professional services. CMS also identifies defined HMO and EPO/PPO payment rules; federal IDR applies where those rules do not determine the rate.

Private self-funded plans: federal route for qualifying claims, with a separate check for applicable hospital rate setting.

The revised 2023 letter identifies defined emergency and facility-based professional services, including certain state/local governmental plans. Provider type, disclosure, patient choice, and service scope matter; air ambulance routes federally.

Private self-funded plans: federal route for qualifying claims. Michigan/state-local governmental plans need separate review.

CMS identifies state law for unanticipated out-of-network professional care at an in-network facility. Qualifying services outside that scope and air ambulance require federal review.

The cited CMS letter identifies state law for defined emergency services under health benefit plans. Other qualifying services and air ambulance require federal review.

State emergency-payment provisions depend on the plan, provider, and prior network relationship. Nevada guidance distinguishes applicable state rate rules from federal IDR; verify the relevant statutory provision.

Private self-funded plans: verify Nevada election and whether the rate provision applies.

Newer state IDR law and 2026 rules provide a case-by-case state/federal choice for covered disputes. Confirm scope, plan participation, and initiation timing; do not pursue both processes for the same dispute.

Check state opt-in/participation and the state-versus-federal election for this dispute.

Check inadvertent, emergency, or urgent service scope and the plan. New Jersey publishes self-funded plan opt-in/opt-out information; air ambulance and other qualifying exceptions require federal review.

Private self-funded plans: check the published plan list and service-date opt-in/opt-out status.

PRP's New Jersey service scope

CMS identifies state rules for emergency and defined nonemergency services at participating facilities. Coverage type, consent, and provider availability affect scope; other qualifying services need federal review.

The 2024 CMS letter distinguishes emergency services and statutory surprise bills from other qualified services, including certain advance coverage determinations. Air ambulance uses federal IDR; confirm the plan and statutory definition.

PRP's New York service scope

CMS identifies federal IDR for qualifying insured claims in Northern Mariana Islands, including covered emergency, facility-based nonemergency and air-ambulance services. Its letter identifies no applicable local payment law or All-Payer Model Agreement. Confirm the plan, covered service and filing deadlines.

CMS identifies state payment law for emergency and defined nonemergency services at in-network facilities. The cited letter assigns air-ambulance services to federal IDR.

CMS identifies federal IDR for qualifying insured claims in Puerto Rico, including covered emergency, facility-based nonemergency and air-ambulance services. Its letter identifies no applicable local payment law or All-Payer Model Agreement. Confirm the plan, covered service and filing deadlines.

TDI distinguishes facility mediation from provider arbitration for covered services. Its current guidance includes ERISA plans that opt in. Federal rules apply to other qualifying plans and air ambulance; check newer plan categories.

Private self-funded plans: verify Texas opt-in; other specified state/governmental plan categories also need review.

PRP's Texas service scope

CMS identifies federal IDR for qualifying insured claims in U.S. Virgin Islands, including covered emergency, facility-based nonemergency and air-ambulance services. Its letter identifies no applicable local payment law or All-Payer Model Agreement. Confirm the plan, covered service and filing deadlines.

Check state scope for emergency and defined surgical/ancillary services at in-network facilities. Verify any self-funded plan election for the relevant plan year; qualifying exceptions and air ambulance require federal review.

Private self-funded plans: confirm the state list and plan-year effective dates.

Check emergency and defined facility-based services under state law, plus any self-funded plan election. Added ground-ambulance protection has separate scope and opt-in details; it is outside federal NSA IDR.

Private self-funded plans: confirm election and scope, including any separate ground-ambulance attestation.