How the No Surprises Act applies
Pathology and lab claims need careful routing because not every lab claim is a No Surprises Act dispute. Protected emergency or facility-linked services may qualify, while other claims may belong in ordinary billing, payer appeal, or a state-law process.
Do not treat every out-of-network claim as an IDR claim. Start with patient protections and routing, then decide whether the public IDR benchmarks support escalation.
High-volume service codes
| Code | Service | Disputes | Provider win rate | Median award | Median award dollars |
|---|---|---|---|---|---|
| 85025 | Complete blood count (CBC) with automated differential | 93,474 | 82% | 4.8x | $268 |
| 80053 | Comprehensive metabolic panel (14 blood chemistry tests) | 74,243 | 81.9% | 6.3x | $621 |
| 81003 | Urinalysis, automated, without microscopy | 48,474 | 80% | 7.3x | $194 |
| 84484 | Troponin blood test (cardiac injury marker), quantitative | 30,936 | 81.7% | 4.6x | $344 |
| 87880 | Rapid strep A test | 28,967 | 79.8% | 4.4x | $217 |
| 81025 | Urine pregnancy test | 21,409 | 82.3% | 4.9x | $143 |
| 82150 | Amylase blood test (pancreas enzyme) | 18,936 | 78.7% | 7.5x | $318 |
| 87804 | Rapid influenza test | 18,489 | 85.1% | 3.6x | $249 |
Top payers
| Payer | Disputes | Provider win rate | Median award |
|---|---|---|---|
| BCBSTX | 62,662 | 82.3% | 5.5x |
| Cigna / MultiPlan | 17,404 | 74.5% | 3.7x |
| UnitedHealthcare | 15,219 | 79.4% | 4.2x |
| Aetna | 13,994 | 84.4% | 2.3x |
| UMR | 8,373 | 81.9% | 3.8x |
| Cigna | 7,975 | 80.9% | 4.8x |
| Anthem Blue Cross | 6,676 | 86.4% | 3.6x |
| Blue Cross and Blue Shield of Arizona | 5,722 | 79% | 13.2x |
Top states
| State | Disputes | Provider win rate | Median award |
|---|---|---|---|
| Texas | 97,851 | 79.7% | 5x |
| Arizona | 9,676 | 78.6% | 9.6x |
| California | 8,258 | 85.8% | 2.5x |
| Tennessee | 7,808 | 80.9% | 4.2x |
| Oklahoma | 6,097 | 90.2% | 9.4x |
| Arkansas | 6,017 | 83.7% | 15.8x |
| New Mexico | 3,570 | 90.6% | 5.6x |
| Mississippi | 3,522 | 84.1% | 4.7x |
Operational checklist
- Tie the lab service to the protected encounter or facility context.
- Confirm the payer and plan type before treating the claim as federal IDR eligible.
- Track high-volume lab codes separately because dollar values and QPA multiples vary.
- Use batch discipline; lab disputes can be numerous but easy to misroute.
Benchmark your Pathology & Lab claims
IDR Explorer compares your claim mix against CMS Federal IDR outcomes by payer, state, specialty, and service code.
FAQ
Does the No Surprises Act apply to pathology & lab?
Sometimes. Eligibility depends on the service setting, plan type, patient protections, state-law routing, and whether deadlines were preserved.
How many Pathology & Lab federal IDR disputes are in the dataset?
IDR Explorer shows 164,354 Pathology & Lab federal IDR disputes in the current benchmark set.
What should pathology & lab teams benchmark first?
Start with payer, state, and service-code mix, then compare QPA multiple, win rate, default rate, and timing against similar disputes.
Related guides
Sources and method
- CMS: Federal IDR reports and public use files
- CMS: About Independent Dispute Resolution
- CMS: Federal IDR timeline for claims
This guide uses CMS Federal IDR public use files through 2025Q4 and is for general information only. Confirm eligibility, deadlines, and state-law routing with current federal guidance, the relevant regulator, and counsel.