How to File Out-Of-Network Insurance Underpayment Claims for Surgeons in 2026

To file out-of-network insurance underpayment claims for surgeons:


  1. Determine whether your claim is eligible for additional reimbursement.
  2. Gather all documents.
  3. Complete the required open negotiation period.
  4. File your dispute through the Federal IDR.
  5. File your dispute through state arbitration.


It's Friday night. You just finished a 4-hour emergency surgery for an out-of-network patient. Weeks later, the Explanation of Benefits (EOB) arrives. You billed $25,000, but the insurance company paid only $3,500. That's a $21,500 underpayment. This happens to surgeons every week. Out-of-network claims are routinely underpaid based on the Qualifying Payment Amount (QPA), the payment benchmark insurers use for contracted rates.


The Federal Independent Dispute Resolution (IDR) process lets you challenge the underpayment and recover more reimbursement. But only if you file correctly. Only if you meet the deadlines. Callagy Recovery handles the entire filing process for you. You can focus on patient care while we manage the Federal IDR or state arbitration process to recover the money you deserve.

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How Does Callagy Recovery Handle Insurance Underpayment Claims for Out-Of-Network Surgeons?

  1. Review your underpaid EOBs. Send us your underpaid EOBs, and we will determine whether each claim qualifies for Federal IDR or state arbitration. If a claim isn’t eligible, we explain why. 
  2. Collect the required documents. We tell you exactly what we need, including the operative note, original claim submission, and any insurance correspondence. Then, we organize everything for your filing.
  3. Complete the required open negotiation. We notify the insurer that you believe the claim was underpaid, submit evidence supporting a higher reimbursement, and manage the required 30-business-day negotiation period. If no agreement is reached, we move your claim to Federal IDR. 
  4. Prepare your filing. We determine a fair reimbursement amount by reviewing benchmark payment data, your claim details, and supporting medical records. Then, we build your case with evidence, complete the required paperwork, and make sure everything is ready for Federal IDR or state arbitration.
  5. Submit your claim. We file your claim through the correct Federal IDR or state arbitration system, upload all required documents, and make sure everything is submitted before the required deadlines. Once your filing is accepted, we send you the confirmation details.
  6. Connect with your billing workflow. After the one-time setup, eligible claims and supporting documents are automatically uploaded to our HIPAA-compliant portal, so we can continue filing underpaid out-of-network claims with very little work from your staff.


With Callagy Recovery, you don’t need to analyze anything or understand the rules. Just send us what we need once. We'll handle your current claim and future eligible out-of-network underpayment claims.

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What Are the Steps for Filing an Out-of-Network Insurance Underpayment Claim?

Step 1: Determine If Out-of-Network Underpaid Claims Are Eligible for Additional Reimbursement

  • The patient’s health plan. Commercial health plans and many self-funded ERISA plans are generally eligible for additional reimbursement through the Federal Independent Dispute Resolution (IDR). Government health programs, like Medicare, Medicaid, TRICARE, VA benefits, and workers’ compensation, use their own payment dispute processes. 
  • Where and how the surgery was performed. Emergency services and non-emergency services provided by an out-of-network surgeon at an in-network facility may qualify for Federal IDR. Claims involving out-of-network facilities may have different eligibility requirements under the No Surprises Act.
  • Your state’s out-of-network payment dispute rules. States such as New York, New Jersey, Florida, and others have their own arbitration system for certain underpaid claims. If your state's process applies, you usually use it instead of Federal IDR to pursue additional reimbursement.
  • The date the insurer initially paid or denied the claim. Before filing for additional reimbursement, you must complete the required 30-business-day open negotiation period with the insurer. Missing this deadline prevents you from disputing the underpayment.

Step 2: Gather All the Documents to Dispute Out-of-Network Underpaid Claims

  • The original CMS-1500 or UB-04 claim form submitted to the insurer. This supports the accuracy of the claim submitted to the insurer.
  • The original Explanation of Benefits (EOB) or payment/denial notice from the insurer. This confirms the insurer's payment or denial and supports your payment dispute.
  • The itemized medical bill. This allows the arbitrator to compare your billed charges with the insurer's payment and evaluate your requested reimbursement amount.
  • The operative report or medical records. These support the medical necessity of the surgical service and verify that the procedures billed match the care provided.
  • Supporting reimbursement documentation. This includes additional evidence, such as payment benchmarks, reimbursement analyses, prior payments for similar services, fee schedules, applicable contracts (if relevant), and other documentation allowed under Federal IDR or your state's arbitration process. Use these documents to support your requested reimbursement amount.

Step 3. Complete the Required Open Negotiation for an Underpaid Out-of-Network Claim

  1. Start open negotiation within 30 business days of receiving the initial payment or denial. If you miss this deadline, you lose the right to file for Federal IDR. 
  2. Fill out the official Open Negotiation Notice in the Federal IDR Portal. You must add the CPT codes, service dates, place of service, payment or denial details, QPA, and your requested reimbursement amount. 
  3. Send a copy of the notice to the insurer. Use the contact information listed on the EOB or remittance advice.
  4. Keep your confirmation email, receipt, timestamp, or other proof showing when you submitted the notice. 
  5. Watch for the insurer's response. They must provide an Open Negotiation Response Notice by the 15th business day.
  6. Discuss the underpaid claim with the insurer. Support your requested amount using the procedure’s complexity, the patient’s condition, and your expertise. 
  7. Save copies of every email, phone call, offer, and counteroffer during the negotiation.
  8. If you both agree on an amount, sign a Settlement Agreement with the payment amount and payment deadline. 
  9. If you don't reach an agreement, wait until the 30-business-day negotiation period ends before filing for Federal IDR.

Step 4: File Out-Of-Network Underpaid Claim Dispute Through Federal IDR

  1. File for Federal Independent Dispute Resolution (IDR) within 4 business days after the 30-business-day open negotiation period ends. If you miss the deadline, Federal IDR is no longer available. 
  2. Fill out the Notice of IDR Initiation form in the Federal IDR Portal. You need contact details, claim information, CPT codes, dates of service, place of service, the initial payment amount, the QPA, and your preferred Certified IDR Entity. 
  3. Download the completed form and send a copy to the insurer on the same day. 
  4. Pay the $15 Federal Administrative Fee and the $200-$840 Certified IDR Entity fee. 
  5. Agree on a Certified IDR Entity with the insurer within 3 business days. If you can’t agree, CMS will choose one. 
  6. Submit your final payment amount and supporting documents by the deadline set by the Certified IDR Entity.

Step 5: File Out-Of-Network Underpaid Claim Dispute Through State Arbitration

  1. Check your state's out-of-network payment dispute rules if state law applies. If yes, use your state's arbitration process. If not, file through Federal IDR.
  2. Follow your state’s filing deadline after the required open negotiation period ends. 
  3. Submit your dispute through your state’s arbitration portal or insurance agency. 
  4. Fill out your state’s arbitration or dispute resolution application. Include the claim details, patient information, CPT codes, EOB, proof of negotiation, and your requested payment amount. 
  5. Send a copy of your arbitration request to the insurer if your state requires it. 
  6. Pay any filing or arbitration fees required by your state.

What Happens After You File for Federal IDR?

After you file for Federal IDR, the insurer also submits its final payment offer and supporting documents. The Certified IDR Entity then reviews both sides and chooses either your proposed payment amount or the insurer’s offer. The arbitrator cannot choose a different amount. This encourages both sides to submit a fair payment offer.


If the arbitrator chooses your offer, the insurer must pay the additional reimbursement within 30 calendar days. If the insurer’s offer is selected, the initial payment stands and the dispute ends.

How Long Does the Federal IDR Filing Process Take?

The Federal IDR filing process takes 31 to 34 business days from the initial payment or denial to submitting the out-of-network underpaid claim dispute. But the entire process, including arbitration and additional reimbursement payment, may take around 3 to 8+ months.

Can Out-Of-Network Surgeons File Multiple Underpaid Claims At Once?

Yes, out-of-network surgeons can file multiple underpaid claims at once. You can batch up to 50 line items in one Federal IDR dispute. Batching reduces filing fees, administrative work, and the time required to file each claim. However, you must only batch claims that:

  • Use the same surgeon, physician group, and facility. 
  • Use the same insurance company and health plan. 
  • Use the same CPT code or come from the same patient encounter. 
  • Were performed within the same 30-business-day service window.

Is Filing for Federal IDR Worth the Time and Cost?

Yes, filing for Federal IDR is worth the time and cost for eligible underpaid claims. According to CMS, out-of-network surgeons win about 88% of Federal IDR disputes if filed correctly. Plus, most surgeons recover much more than the insurer’s initial payment. Here is how much you can recover for each specialty:

Specialty
Federal IDR Recovery Amount

Neurosurgery

$83,120

Orthopedic Surgery

$41,580

Neurology

$36,298

Plastic Surgery

$31,828

Pain Management

$25,568

Other Specialties

$23,827

Hand Surgery

$13,121

General Surgery

$8,278

Anesthesiology

$6,410

Who Can File Out-Of-Network Insurance Underpayment Claims?

  • Out-of-network surgeons and physicians.
  • Hospital-based specialists (such as anesthesiologists, CRNAs, pathologists, and radiologists).
  • Ambulatory surgical centers (ASCs).
  • Hospitals and surgical hospitals.
  • Air ambulance providers. 
  • RCM companies.
  • Medical billing companies and billing managers. 
  • Healthcare law firms and healthcare recovery companies. 

What Are the Challenges of Filing Out-Of-Network Insurance Underpayment Claims?

  • Determining claim eligibility. Some underpaid claims fall into gray areas. You need a strong understanding of the No Surprises Act to know whether it qualifies for Federal IDR. According to the Center on Health Insurance Reforms, nearly 40% of Federal IDR disputes were challenged as ineligible, and about 15% to 20% were dismissed in 2025.
  • Keeping track of deadlines. Tracking 1 claim is manageable. But if you're managing 10+ underpaid claims, you can easily miss deadlines and lose the chance to recover additional reimbursement.
  • Finding the right documents. Claim records are often stored across multiple systems. It can take 30 minutes to an hour to collect everything. For 20 claims, that's 10-20 hours of administrative work.
  • Finding the time to file. Surgeons, RCM companies, and billing managers already have busy schedules. Filing an underpaid claim dispute takes time away from patient care and routine billing.
  • Avoiding filing errors. Even a small mistake, such as missing information or incorrect claim details, can cause your filing to be rejected. You then have to start over and resubmit everything. 
  • Navigating the Federal IDR Portal. The portal can be difficult to use, especially for first-timers or those managing multiple claims. 
  • Explaining why the claim was underpaid. When filing for Federal IDR, you must clearly explain why you believe the insurer underpaid the claim. Many practices provide a vague explanation or fail to support their requested amount, which weakens their case.
  • Dealing with insurance companies. Insurers use different tactics to underpay claims and avoid paying additional reimbursement. You must know the reasons your medical revenue claims are underpaid to be able to fight insurers effectively.

Should You File Out-Of-Network Underpaid Claims Yourself?

No, you shouldn't file out-of-network underpaid claims yourself. For out-of-network surgeons, RCM companies, and billing managers, outsourcing the filing process is more efficient. It saves valuable time, lets you stay focused on patient care and routine billing, and gives you a better chance of recovering the additional reimbursement owed.

Why Choose Callagy Recovery to File Your Out-Of-Network Underpaid Claims?

  • We pay all filing and arbitration fees upfront. If we successfully recover additional reimbursement for your claim, you only pay 20% of the recovered amount.
  • We have a 94% win rate. We file around 4,000 underpaid claims each month, and we recover money for almost all of them. 
  • We have a proven track record. Callagy Recovery has recovered over $1 billion in additional reimbursement and has represented leading surgeons like Dr. Jennifer Phillip-Jones and Dr. Michael Tangiers.
  • Callagy Recovery works with Callagy Law. We have a legal team that knows exactly how to fight insurer tactics and recover underpaid claims for out-of-network surgeons. 
  • We have 27+ years of experience. We've spent decades recovering underpaid insurance claims, so we know how to navigate complex reimbursement disputes.
  • We recover 5x to 15x the initial payment. If an insurer only paid $3,000, we can recover an additional $12,000 to $42,000, depending on the claim.
  • We reduce your administrative workload. After your initial setup, our team handles future eligible claims, from filing and documentation to deadlines and follow-up.
  • You always know the status of your claims. Our HIPAA-compliant portal gives you visibility into your active disputes and updates throughout the process.
  • We stay on top of every deadline and document. Callagy Recovery makes sure every eligible underpaid claim is submitted accurately and on time.
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Start Filing Your Underpaid Out-of-Network Claims Before Time Runs Out!

If you have underpaid EOBs sitting on your desk right now, it’s important to act quickly. The dispute process has strict deadlines, and missing a required timeline prevents your claim from moving forward through Federal IDR or state arbitration.


You can handle the process internally. But you need to manage eligibility requirements, documentation, negotiations, filing requirements, and deadlines. For many practices, this becomes time-consuming and difficult to manage alongside patient care or billing responsibilities.


A revenue recovery partner like Callagy Recovery can handle the process from reviewing your claim to filing and arbitration. Our team understands the requirements for underpaid out-of-network claims. We identify eligible claims that may qualify for additional reimbursement.


If your practice has underpaid claims, don’t wait until a deadline passes. Contact Callagy Recovery today for a free review of your claims and learn how much additional reimbursement you can recover.

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