When state law governs the plan, the dispute goes through the state.
Fully insured plans, no-fault auto carriers and workers' compensation insurers each have state-level processes for payment disputes. We identify the right forum, meet its deadlines and build the case.
Federal or state: which applies
The plan type decides the path, not the provider's preference.
Filing in the wrong forum gets a dispute dismissed. This is the first thing we check on every claim.
State process
Fully insured plans regulated by the state
- The state has a surprise-billing law covering that service
- The insurance card often shows the state regulator or "fully insured"
- Some self-funded plans opt in where state law allows it
Federal process
Self-funded employer plans and gaps in state law
- ERISA self-funded plans that have not opted in
- Services or plans not covered by the state law
- See Federal NSA IDR
State frameworks we navigate
Different states, different forums, different clocks.
New York
Independent dispute resolution under New York's surprise-billing and emergency services law (Financial Services Law, Article 6), using IDR entities designated by the Department of Financial Services. Covers emergency services and surprise bills under state-regulated plans, and certain bills to uninsured patients.
New Jersey
Binding arbitration under the Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act (2018), overseen by the Department of Banking and Insurance. Applies to state-regulated plans and to self-funded plans that opt in.
Texas
Arbitration through the Texas Department of Insurance for out-of-network emergency care and certain services at in-network facilities under state-regulated plans, following the 2019 surprise-billing law.
California
Independent dispute resolution for non-emergency services by non-contracted providers at contracted facilities, under the state's 2016 surprise-billing law, through the applicable state regulator.
Other states
A growing number of states have their own surprise-billing payment standards or dispute processes. We check the rules for the state where care was provided and the plan type before choosing a path.
State laws, regulations and forum procedures change. Descriptions here are general summaries for orientation only. We confirm the current rules for each claim before filing.
PIP & no-fault arbitration
Auto-injury claims denied or cut? There is a state forum for that.
No-fault states give medical providers a route to challenge PIP denials and reductions. In New York, no-fault disputes are commonly handled through arbitration administered by the American Arbitration Association. In New Jersey, PIP disputes go through the state's designated dispute resolution organization.
- Denials based on independent medical exams (IME) or peer reviews
- Fee-schedule reductions and coding disputes
- Late-payment and interest issues
- Benefit exhaustion and coverage questions
- Coordination with your attorney where representation is required
Workers' compensation disputes
Workplace-injury bills follow the state's fee schedule and its dispute rules.
Each state's workers' compensation board or division has its own process for medical bill disputes, authorization disputes and fee-schedule disagreements.
- Bill objections and fee-schedule disputes
- Authorization and medical necessity disputes
- Required forms, reports and attachments
- Carrier follow-up through the state process
How we run a case
Six steps, from intake to payment.
The same discipline we apply to federal IDR, adapted to the state forum's rules.
Intake and triage
We gather the claim, remittance, plan details and dates, and confirm which process (federal, state, no-fault or workers' compensation) applies.
Eligibility and deadline check
Each state sets its own filing windows and eligibility rules. We confirm the claim qualifies and calculate every deadline.
Pre-filing resolution
Where it makes sense, we try reconsideration, appeal or negotiation first. A paid claim is better than a won case.
Filing and submissions
We prepare the application, supporting documentation and position statement in the format the state forum requires.
Hearing or decision support
We respond to requests from the arbitrator or entity and coordinate with your counsel where a hearing or legal representation is needed.
Award follow-through
We track payment of any award, post it, and close the loop in your A/R reporting.
Request a review
Tell us which claims are stuck.
Out-of-network underpayments, PIP denials or workers' compensation disputes. We will tell you which forum applies and whether it is worth pursuing.
Ascendix is a billing and revenue cycle company, not a law firm, and does not provide legal advice or legal representation. Where a forum requires an attorney, we coordinate with your counsel. No outcome is guaranteed.