No Surprises Act Billing, IDR and Open Negotiation

What Is the No Surprises Act, and What Does It Mean for a Provider?

The No Surprises Act (NSA) is a federal law that bans most surprise out-of-network bills and gives providers a federal dispute process for the payment. Patients pay no more than in-network cost sharing, and the provider and the health plan settle the rest between themselves, first by open negotiation and then, if needed, by federal IDR (independent dispute resolution).

CMS describes balance billing as billing a patient for the part of a bill the plan does not cover, and surprise billing as an out-of-network provider or facility unexpectedly billing for that balance. The Act protects people covered by employer group health plans, individual and group insurance, and Federal Employees Health Benefits carriers. Medicare, Medicare Advantage, Medicaid, CHIP, TRICARE, Indian Health Service and VA care are outside it.

For a hospital, freestanding ER or physician group, the protection for the patient is a limit on what you can collect from them. The protection for you is the right to dispute a low payer payment. Both come with deadlines counted in business days, and a missed day can end a claim's dispute rights. That is why billing offices treat NSA claims as their own workflow.

Which Services Does the No Surprises Act Cover?

CMS lists three categories: most emergency services, non-emergency services from out-of-network providers during visits to certain in-network facilities, and covered services from out-of-network air ambulance providers. Under 45 CFR 149.410, a nonparticipating emergency facility or provider must not bill the patient more than the in-network cost-sharing amount for emergency services.

The non-emergency category applies at four facility types: a hospital, a hospital outpatient department, a critical access hospital and an ambulatory surgical center. A doctor's office or community clinic is outside it. A patient can waive the protection for some non-emergency services through a signed notice and consent, but never for emergency medicine, anesthesiology, pathology, radiology, neonatology and the other ancillary services listed on the notice and consent page.

Coverage edge cases, such as urgent care licensing, are answered on the No Surprises Act FAQ.

How Does an Out-of-Network Payment Dispute Work?

A dispute runs in two stages: open negotiation, then federal IDR. Under 45 CFR 149.510, either party can start open negotiation within 30 business days of the initial payment or denial, the negotiation lasts 30 business days, and either party can start IDR within 4 business days after it ends.

The certified IDR entity picks one of the two offers. It must consider the qualifying payment amount (QPA) first and then the other circumstances the rule lists. The QPA is the benchmark figure the plan calculates and discloses, and how it calculates and discloses it is on the qualifying payment amount page.

Count the days before you send anything. The NSA deadline calculator works out each business-day deadline from the date of the payment or denial.

Some claims never reach federal IDR because a state process sets the payment. The state surprise billing laws page shows how to read the CMS state chart before you file.

What Changed in 2026 and What Is Still Pending?

Three 2026 developments change how disputes are filed and priced. They are the federal IDR operations rule, the Fifth Circuit's en banc decision on the QPA and the batching changes that start on November 1, 2026.

The rule is Federal Register document 2026-11140 (91 FR 33900), published June 4, 2026. It renumbered parts of 45 CFR 149.510 and cut the administrative fee from $115 to $15 per party for disputes initiated on or after June 11, 2026. Many parts wait for the Departments to announce portal functionality, and 149.510(h)(10) says the earlier requirements continue until each applicability date. The IDR operations rule page lists each date.

On August 11, 2026, the full Fifth Circuit held in Texas Medical Association v. HHS, No. 23-40605, that parts of the 2021 QPA rule were unlawful. The court said non-negotiated ghost rates and the blanket exclusion of bonus and incentive payments were invalid. The eCFR text as of October 20, 2026 had not been updated, so check CMS before relying on a QPA rule.

Batching changes apply from November 1, 2026. A batched dispute can hold up to 50 qualified IDR items and services, and the new cooling-off rule applies to disputes with open negotiation starting on or after that date. The batching claims page explains which claims can go together.

What Should a Billing Office Check Before Starting a Dispute?

Check four things before any notice goes out: the plan type, the state, the service and the dates. A mistake in any of them can send a dispute to the wrong process or past a deadline.

1. Plan type: confirm the patient's coverage is one the Act reaches, and that it is not Medicare, Medicaid, CHIP or TRICARE, which federal IDR does not cover.
2. State: look up the state where the service was furnished in the CMS chart to see whether a state process sets the payment.
3. Service: confirm it is an emergency service, a non-emergency service at one of the four facility types, or an air ambulance transport, and that no valid consent was obtained.
4. Dates: write down the date the initial payment or denial was received, then count 30 business days for the notice and 4 business days for IDR.

The payer's disclosure with the initial payment or denial is the best starting document, since it must contain the QPA and a statement of your open negotiation and IDR rights. Keep the remittance with the file; the IDR notice needs a copy of it.

What About Self-Pay and Uninsured Patients?

Self-pay patients have their own protection: the Good Faith Estimate. A provider must give an uninsured or self-pay patient a written estimate of expected charges, due 1 or 3 business days after scheduling, or 3 business days after a request, under 45 CFR 149.610. The Good Faith Estimates page covers content, co-providers and record keeping.

If the final bill is at least $400 above the estimate, the patient can start patient-provider dispute resolution within 120 calendar days of the initial bill, and the provider must stop collections while it is pending. That process is on the patient-provider dispute resolution page. It is separate from the payer disputes above.

Where Do I Read About Each Part of the Act?

Each topic has its own page, written from the provider and facility side. Start with the one that matches the claim in front of you.

• Open negotiation: the 30-business-day windows and the notice.
• The federal IDR process: initiation, entity selection, offers, fees and payment.
• The qualifying payment amount: calculation, disclosure and the court decisions.
• Batching claims: what can be filed together.
• The 2026 IDR operations rule: what applies now and what waits for the portal.
• State surprise billing laws: when a state process applies.
• Notice and consent, air ambulance, Good Faith Estimates and patient-provider dispute resolution.

How Does Nucleus Align Run a No Surprises Act Case?

A designated NSA team owns every case, from the first remittance to the last payment. It screens the claim, builds the file, counts each deadline and follows the money. Our totals to date:

1. Screening: we verify benefits for every patient the client sends each day. Self-funded (ERISA) plans go to federal IDR, and fully insured plans regulated by a state go to that state's process. Medicare and Medicaid claims, including Medicare Advantage and Medicaid managed care, sit outside the dispute process.
2. Eligibility: we read the remark codes on the remittance. Payers must use the specified remark codes for services on or after January 1, 2027, so until then we confirm eligibility from the plan, the service and the remittance together.
3. Service and plan: the client confirms the visit was in an emergency department or a freestanding emergency department, and we confirm the patient's plan and what it covers.
4. Documents: we need the UB-04 and CMS-1500 claims, the medical records, the 835 ERA files or EOBs, and any payer contracts.
5. Case file: every case starts from a dedicated email address. Printed documents and proof of submission go in a separate folder for each case, so dates and notice delivery can always be shown.
6. Deadlines: we track the 30-business-day open negotiation period and the 4-business-day window to start IDR. The 2026 rule adds a response by the 15th business day, but that part is not in force yet.
7. Fees: the client pays the administrative fee and the IDR entity fee. A party that misses a fee deadline has its offer treated as not received, so we track every fee deadline and tell the client in writing when each is due.
8. Portal: our team prepares every notice and dispute package. An authorized user located in the US submits in the federal portal, as the portal's rules require, usually a person on the client's team set up during onboarding.
9. After the decision: the payer must pay within 30 calendar days. If it does not, or pays the wrong amount, we follow up and file a complaint with the No Surprises Help Desk. Our practice is to escalate when 45 days pass without payment.

Older claims are worked as far back as payer filing limits allow. Federal IDR windows are fixed, so a claim past them cannot enter federal IDR, and we review the other options on a call. Reports are monthly and customized to what the client needs, with day-to-day updates by email, and an NSA client dashboard is being built. Win rates by payer are shown on a call, as totals only. We do not share references or sample dispute packages, because they contain other clients' and patients' information.

NSA and IDR work is a monthly retainer based on the client's volume of eligible IDR patients, quoted on a call; see pricing. Onboarding takes up to one week, and we agree the exact plan on the call. The out-of-network billing and IDR service page describes the workflow, and to have us look at a set of underpaid claims, book a call.