This glossary focuses on provider-versus-plan payment disputes. It does not describe the separate patient-provider dispute-resolution process for uninsured or self-pay patients.

No Surprises Act (NSA)

Federal legislation that created protections against certain surprise medical bills and established a process for resolving some out-of-network payment disputes between providers or facilities and plans or issuers.

Independent dispute resolution (IDR)

The process through which a certified IDR entity considers the parties’ payment offers and selects one as the out-of-network payment amount for a qualified item or service.

Certified IDR entity

An organization certified by the Departments to make federal IDR payment determinations. PRP supports provider-side operations and is not a certified IDR entity.

Open negotiation

The required 30-business-day period in which the disputing parties may agree on an out-of-network payment amount before federal IDR is initiated.

Qualifying payment amount (QPA)

A No Surprises Act payment benchmark calculated under regulatory methodology and used in patient cost sharing and the federal IDR process. Provider teams should preserve the payer’s QPA disclosure and its claim context.

Initial payment or notice of denial of payment

The payer response that precedes a potential open-negotiation period. It is not necessarily the same as a final claim denial under every other appeal or benefit process.

Qualified IDR item or service

An item or service that falls within the governing federal requirements for the payment-dispute process. Whether an item or service is qualified depends on the law, plan, service, location, timing, and other claim-specific facts.

Batching

The submission of multiple qualified items or services together when current federal grouping requirements are satisfied. The 2026 operations final rules expand the potential line-item limit, subject to implementation and current guidance.

Out-of-network (OON)

A provider, facility, or service without the applicable network contract for the plan or coverage at issue. Out-of-network status by itself does not establish federal IDR eligibility.

Incremental recovery

PRP’s term for the amount ultimately paid minus the amount originally paid. It is a commercial reporting definition, not a CMS term.