Answers / Who qualifies

Can infusion and injection claims use federal IDR?

Emergency department and freestanding ER care

Under the Act, emergency services include the screening exam and whatever care is needed to stabilize a patient, delivered at a hospital emergency department or at an independent freestanding emergency department, a separately licensed emergency facility that is not part of a hospital. That protection holds when neither the facility nor the physician is in network. IV hydration, injected medication, and IV push drugs given during an ER visit are part of that care, and that setting is nearly all of the record: 102,033 of the 106,545 disputes with an administration code in 2025 had a line billed at the emergency room place of service, and 119,559 of the 127,513 disputes carried an emergency department visit code.

Hospital outpatient departments

A hospital outpatient department is a covered facility for care that is not an emergency. When the hospital is in the plan's network and the provider who bills is not, balance billing protection can apply, and either side can request IDR once open negotiation ends. Ancillary services such as emergency medicine, anesthesiology, pathology, and radiology can never be waived. Other out-of-network services at a participating facility can be waived only if the provider gives written notice and the patient consents ahead of time. A planned visit to an out-of-network hospital is outside the Act. In the 2025 files, 1,479 disputes with an administration code had a line at the on-campus hospital outpatient place of service, 438 at an assisted living facility, and 69 at an inpatient unit.

Offices, infusion suites, and home infusion

For care that is not an emergency, the Act covers a patient only at one of four kinds of facility: a hospital, a hospital outpatient department, a critical access hospital, or an ambulatory surgical center. An infusion given in a physician's office, a freestanding infusion suite, or the patient's home happens at none of them. Urgent care centers are generally not emergency facilities under the Act either, because only a facility that the state licenses to provide emergency services, separately from a hospital, counts. Claims from those settings may fall under a state law or under the contract between the provider and the plan, which are separate processes.

Checks to run before filing

Four facts sort most infusion and injection claims: the place of service on the claim, the plan type and whether a state process applies, whether the hospital is in the plan's network, and the day the plan first paid or denied the claim. Claims paid by Medicare, Medicare Advantage, Medicaid, or TRICARE are outside federal IDR, and a fully insured plan in a state that runs its own surprise billing arbitration follows that state's process. The open negotiation period runs 30 business days from the first payment or denial, and the IDR request is due within 4 business days after it closes. Lido IDR works through those checks and tracks both dates, then files for a flat fee per arbitration, pricing each offer from the decisions at idrexplorer.com.