What the Emblem Health data says
The Emblem Health page is built for provider and RCM teams comparing out-of-network payment behavior under the No Surprises Act. A payer average can hide large swings by state and service code, so the tables focus on the combinations most likely to affect a claim file.
Use this page as a screen: if your disputed claims share the same payer, state, and code mix, the benchmark can tell you whether a deeper audit is worth time.
Top Emblem Health service codes
| Code | Service | Disputes | Provider win rate | Median award |
|---|---|---|---|---|
| 36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guida | 279 | 81.2% | 95.7x |
| 19318 | Breast reduction | 233 | 87.2% | 20.7x |
| 01930 | Anesthesia for therapeutic interventional radiological procedures involving the venous/lym | 231 | 89% | 14.2x |
| 01938 | Anesthesia for percutaneous image-guided spine injection/drainage, lumbar or sacral | 228 | 90.6% | 18.9x |
| 95938 | Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerv | 220 | 88.5% | 134.5x |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance | 183 | 90.5% | 27.8x |
| 20610 | Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee | 175 | 88.8% | 54.5x |
| 64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint ( | 167 | 86.1% | 72.1x |
| 64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint ( | 166 | 86.1% | 124.8x |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance | 159 | 91.3% | 106.1x |
Top states for Emblem Health disputes
| State | Disputes |
|---|---|
| New Jersey | 5,010 |
| New York | 3,405 |
| Connecticut | 265 |
| Florida | 72 |
| North Carolina | 22 |
| California | 15 |
| Missouri | 12 |
| Massachusetts | 8 |
| Pennsylvania | 8 |
| Texas | 8 |
Frequent filing representatives
| Representative domain | Disputes | Provider win rate |
|---|---|---|
| gottliebandgreenspan.com | 4,054 | 88.7% |
| mdcapitaladvisors.com | 1,686 | 87% |
| forthesurgeons.com | 479 | 83.4% |
| halkovichlaw.com | 393 | 92.8% |
| islandprofessionalbilling.com | 202 | 87.3% |
| onet-systems.com | 186 | 90% |
| primehealthcare.com | 153 | 96.4% |
| radixhealth.io | 152 | 93.5% |
| khcfirm.com | 148 | 92.8% |
| nsabilling.com | 136 | 86.7% |
Filing checklist before you take Emblem Health claims to IDR
- Confirm the claim is NSA-eligible: emergency care, or out-of-network care at an in-network facility, with no state arbitration law that displaces the federal process for that plan type.
- Start open negotiation within 30 business days of the initial payment or denial notice. The negotiation window then runs 30 business days.
- If negotiation fails, initiate federal IDR through the portal within 4 business days after the window closes.
- Batch same-payer items in the same service code category. Open negotiation periods starting on or after November 1, 2026 can batch up to 50 line items per dispute, up from 25.
- Budget for fees: the federal administrative fee is $15 per party for disputes initiated on or after June 11, 2026 (down from $115), and the non-prevailing party pays the certified IDR entity fee.
- Anchor your offer to the data: the Emblem Health median provider-won award is 28.6x QPA across 8,868 disputes.
The fee and batching changes come from the May 2026 federal IDR operations final rule. See the 2026 and 2027 No Surprises Act changes guide for the full timeline, or request a free NSA audit to see how your claims compare.
Benchmark your Emblem Health claims
IDR Explorer can compare a provider group against Emblem Health outcomes by state, specialty, and service code in the public IDR files. The fastest next step is a free NSA audit.
FAQ
How many Emblem Health federal IDR disputes are in the dataset?
This benchmark shows 8,868 Emblem Health disputes tied to emblemhealth.com.
What is the provider win rate against Emblem Health?
The non-default provider win rate is 87.7% in this payer slice.
Why does Emblem Health need state and code filtering?
Federal IDR outcomes vary by state, service line, and code mix. A payer-level average is a starting point, not the full answer.
Can I batch Emblem Health claims into one IDR dispute?
Yes, when items share the same payer and the same service code category. Open negotiation periods starting on or after November 1, 2026 can batch up to 50 line items per dispute, up from 25.
Related benchmarks
Sources and method
Providers won 85.8% of 3.39 million federal IDR disputes through 2025Q4, with a median provider-won award of 4.7x the qualifying payment amount, per CMS public use files.
- CMS: Federal IDR reports and public use files
- CMS: Federal IDR operations final rule fact sheet
- CMS: Federal IDR timeline for claims
Data source: CMS Federal IDR public use files, coverage through 2025Q4; data build 2026-09-24. Counts are CMS dispute counts unless a table says line items. Win rates on this page exclude payer no-show defaults unless labeled otherwise. Award multiples are medians versus the qualifying payment amount (QPA). Dollar figures, where shown, come from CMS QPA-and-offer fields or are anchored estimates, not payment records. This page is informational, not legal or reimbursement advice.