New Rule Amends No Surprises Act Dispute Process for Out-of-Network Health Care Payments

Effective January 1, 2022, the federal No Surprises Act established independent dispute resolution ("IDR") to resolve disputes between health care providers and commercial insurers over out-of-network payments. Through IDR, either party may initiate an arbitration process in which a certified IDR entity selects one of the two parties' payment offers as the final rate.

In recent years, insurers have brought a wave of federal-court litigation attempting to contest IDR awards. The new final rule (the Federal Independent Dispute Resolution Operations Final Rule, CMS-9897-F) eases the procedural and administrative friction providers have encountered in IDR, without diminishing the Act's core patient protections.

Key changes include:

• The rule reduces the per-party administrative fee from $115 to $15 per dispute (effective for disputes initiated on or after June 11, 2026).
• The rule finalizes a requirement that payors use specific claim adjustment reason codes and remittance advice remark codes when providing claim decisions to an out-of-network provider or facility. By standardizing this communication at initial payment or denial, the rule aims to improve a longstanding information asymmetry between insurers and providers, giving providers uniform information regarding IDR eligibility.
• The rule formalizes certain processes already in place via sub-regulatory guidance to address the eligibility of disputes: The initiating party must submit a Notice of IDR Initiation with an attestation of eligibility and supporting documentation, to which the non-initiating party must respond within three business days. The certified IDR entity must then determine eligibility within five business days of its selection.
• The rule establishes a new IDR Gateway platform, launching later this year, which will allow parties to initiate disputes, track status, and manage activity in a single portal.
• The rule doubles the maximum number of qualified IDR items or services that may be included in a single batched dispute from 25 to 50 line items, allowing parties to consolidate more related claims into one proceeding and reduce the overall number of individual disputes filed.

H.R.4710, the No Surprises Act Enforcement Act, remains pending in Congress and could introduce additional changes to the IDR framework if enacted. Participants in the process should continue to monitor these developments to ensure compliance with the most up-to-date procedures.