What Ophthalmology teams should benchmark
Ophthalmology IDR outcomes are shaped by code mix. The same payer can look fair in one lane and misaligned in another. Start with the codes that dominate your disputed claims, then compare state and payer behavior.
The purpose of this page is to help a specialty leader or RCM team decide where the federal IDR data supports a closer claim-level review.
Top states for Ophthalmology disputes
| State | Disputes | Provider win rate | Median award |
|---|---|---|---|
| Texas | 275 | 78.2% | 4.5x |
| New Jersey | 143 | 90.2% | 26.2x |
| New York | 95 | 67.5% | 8.2x |
| California | 68 | 87% | 62.9x |
| Arizona | 24 | 85% | 14.1x |
| Arkansas | 19 | 100% | 3.5x |
| Florida | 16 | 84.6% | 3.2x |
| Indiana | 14 | 100% | 7.3x |
| Virginia | 12 | 100% | 6.8x |
| Kansas | 11 | 100% | 2.9x |
Top payers in Ophthalmology
| Payer | Disputes | Provider win rate | Median award |
|---|---|---|---|
| BCBSTX | 156 | 83.7% | 4.1x |
| Cigna / MultiPlan | 139 | 82.3% | 13.6x |
| Aetna | 112 | 80% | 9.4x |
| UnitedHealthcare | 94 | 79.7% | 9.1x |
| Anthem Blue Cross | 66 | 81.8% | 22.4x |
| UMR (clearhs.com) | 37 | 85.7% | 8.2x |
| Cigna | 25 | 85.7% | 48.5x |
| BLUE SHIELD OF CA | 19 | 75% | 61.5x |
| BCBSAZ | 18 | 80% | 14.1x |
| Horizon | 13 | 100% | 13.4x |
Filing checklist before you take Ophthalmology 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 Ophthalmology median provider-won award is 8.1x QPA across 791 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.
Open the Ophthalmology dashboard
Filter Ophthalmology disputes by state, payer, and year to compare the public benchmark with your own out-of-network payment experience.
FAQ
How many Ophthalmology federal IDR disputes are in the dataset?
This benchmark shows 791 Ophthalmology disputes.
What is the Ophthalmology provider win rate?
The non-default provider win rate is 82.4%.
What should Ophthalmology groups compare first?
Start with service-code mix, then narrow by payer and state. That sequence usually gives a more useful answer than a national specialty average.
What changes in 2026 and 2027 affect Ophthalmology IDR filings?
The administrative fee dropped to $15 per party for disputes initiated on or after June 11, 2026, batching expands to 50 line items for open negotiation periods starting on or after November 1, 2026, and standardized CARC/RARC remittance codes arrive January 1, 2027.
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.