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Qualifying Payment Amount (QPA)

The QPA is the benchmark rate behind the No Surprises Act. It sets what patients pay for protected out-of-network care and guides payment disputes.

Qualifying payment amount (QPA): a benchmark rate set by the No Surprises Act. It is generally the median in-network rate a health plan had on January 31, 2019 for the same or a similar service in the same area, increased each year for inflation.

How the QPA Is Calculated

The plan takes its contracted rates for the same or a similar service, from providers in the same or a similar specialty, in the same area and insurance market.
It uses the rates in effect on January 31, 2019, and leaves out bonuses, risk-sharing and other incentive payments.
It finds the median of those rates. The plan needs at least three contracted rates; if it has fewer, it uses other data.
It raises that median each year by the change in the consumer price index (CPI-U).

What the QPA Is Used For

Use	How it works
Patient cost sharing	For protected care, your coinsurance or deductible is figured on the lesser of the billed charge or the QPA, unless a state law or all-payer model sets the amount.
Payment disclosure	The plan must send the QPA with its first payment or denial for a protected out-of-network claim.
Payment disputes	If the provider and plan cannot agree, a certified independent dispute resolution (IDR) entity considers the QPA among other factors.

Example

An out-of-network anesthesiologist bills $2,000 for care at an in-network hospital. The plan's QPA is $600, and you have already met your deductible, with 20% coinsurance. You owe 20% of $600, which is $120. The anesthesiologist cannot bill you for the rest.

For Billing Teams

Check the QPA on the remittance for every protected out-of-network claim.
Do not balance bill the patient above the in-network cost share.
If the payment looks too low, you can negotiate with the plan and then use the federal IDR process.
The federal IDR administrative fee is $15 per party for disputes started on or after June 11, 2026, down from $115.

Patients can check a surprise bill with our No Surprises Act calculator. See also what the allowed amount is and the full medical billing glossary.

Sources: 45 CFR 149.140 (QPA methodology); 45 CFR 149.30 (recognized amount); CMS, QPA Calculation Methodology fact sheet; Departments of HHS, Labor and Treasury, Federal IDR Operations final rule (May 2026).

Frequently Asked Questions

What is a qualifying payment amount?

The QPA is a benchmark rate under the No Surprises Act. It is generally the median rate a health plan had in its contracts on January 31, 2019 for the same or a similar service in the same area, raised each year for inflation.

Is the QPA what I have to pay?

No. For care the No Surprises Act protects, your coinsurance or deductible is usually figured on the lesser of the billed charge or the QPA, unless a state law sets the amount. You pay only that in-network share, not the QPA itself.

Where do I find the QPA for a claim?

The plan must give the QPA with its first payment or denial for a protected out-of-network claim. Providers see it on the remittance. Patients can ask the plan or look on the EOB.

What is the QPA used for in IDR?

When a provider and plan cannot agree on payment, a certified IDR entity picks one of their offers. The QPA is one of the factors it must consider, along with other information both sides send.

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Reviewed by Hassan Raza Awan, Founder — 4+ years of hands-on U.S. medical billing experience. General billing information — verify against current CMS guidance and your payer contracts.

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