The No Surprises Act IDR guide for providers

01What the law covers

Since January 1, 2022, the No Surprises Act has protected patients in group and individual health plans from surprise out-of-network bills in three situations, and given providers and plans a way to settle what the plan owes:

• Emergency services at a hospital emergency department or freestanding emergency facility, in or out of network.
• Non-emergency care by an out-of-network provider at an in-network facility, such as anesthesia, radiology or pathology at an in-network hospital or ambulatory surgical center.
• Air ambulance services from out-of-network providers, when the plan covers air ambulance.

The patient pays in-network cost sharing and cannot be balance billed. What remains is between the provider and the plan: the out-of-network rate.

02How the payment amount gets set

In order of precedence:

1. An all-payer model agreement, where one exists (Maryland is the example).
2. A specified state law that sets a method for the rate, for plans the state regulates. Texas, New Jersey, New York, Florida, Georgia, Washington and others have one. See the state IDR guide.
3. Otherwise, an amount the provider and plan agree on, or one set through federal IDR.

Self-funded employer plans are regulated federally, so their claims usually go federal even in states with their own law.

03Open negotiation

Before IDR, either party must start a 30-business-day open negotiation by sending a notice within 30 business days of the plan’s initial payment or notice of denial.⁹ Under the 2026 operations rule, the notice goes through the federal IDR portal with the remittance or denial attached, and the other party must respond by business day 15.⁴

04Federal IDR, step by step

If open negotiation ends without agreement, either party may initiate IDR during the 4 business days that follow.

• The parties have 3 business days to agree on a certified IDR entity; the other side may object. If they cannot agree, the Departments assign one.
• Each party submits an offer, supporting information and its fees within 10 business days of the entity’s selection.
• The entity picks one of the two offers within 30 business days of its selection and explains why.
• The plan pays any amount owed within 30 calendar days of the determination.

05What the IDR entity weighs

The entity must consider the qualifying payment amount and what the parties submit about additional circumstances, including:

• The provider’s training, experience, and quality and outcome measures.
• The market share held by the provider or the plan in the area.
• The acuity of the patient and the complexity of the service.
• For facilities, teaching status, case mix and scope of services.
• Good-faith efforts to enter a network agreement, and contracted rates in the previous four plan years.

Air ambulance disputes add their own factors, such as vehicle type, clinical capability and the population density of the pick-up location. Courts struck down earlier rules that told entities to give the QPA extra weight, so a well-supported brief matters.

Who decides matters too. Provider win rates ranged from 19% to 99% across IDR entities and years.⁷

06Fees

07Batching

Several items can go into one dispute. Under the 2026 rule a batch holds up to 50 line items, grouped by one patient encounter, by the same or a comparable service code, or for anesthesiology, radiology, pathology and laboratory services by CPT section.³ More on batching.

08After the determination

Payment is due within 30 calendar days. A 90-calendar-day cooling-off period follows, during which the initiating party may not bring a new dispute against the same party for the same or similar item; items furnished in that period can be filed in the 30 business days after it ends.⁹

When a plan does not pay, the provider can complain to CMS or the state regulator. Providers prevailed in 85% of disputes in Q1 2024¹, so getting paid is where much of the money is lost.

09State processes

Where a specified state law applies, its forum and clock replace the federal ones. Each state differs: Texas uses arbitration for professionals and mediation for facilities; New Jersey uses final-offer arbitration with a $1,000 threshold; Washington delayed moving to the federal process until at least 2028. Read the state guide.

10The 2026 operations rule

Finalized in May 2026 and published June 4, 2026, the rule moved open negotiation into the federal portal, set a 15-business-day response, capped batches at 50 items with three grouping options, required entities to decide eligibility within 5 business days of selection, cut the admin fee to $15 and created a registry of plans subject to the federal process.³

11A checklist for providers

1. 01Know every initial payment and denial date. That is when the first clock starts.
2. 02Check plan type and state before filing. Ineligible filings cost fees and time.
3. 03Audit the QPA before you make an offer. Against the service, the units and the market.
4. 04Batch to the cap where items qualify. Keep unusual claims out of batches.
5. 05Track the 30-day payment clock on every award. Escalate on day 31.

This guide summarizes federal rules and published data. It is not legal advice. Confirm current rules with counsel before acting.