Appeal process · Out-of-network

No Surprises Act: open negotiation and federal IDR

For surprise out-of-network and emergency services, the No Surprises Act doesn't run through the normal appeal ladder at all — it routes payment disputes into open negotiation and, failing that, federal arbitration.

The No Surprises Act (NSA), implemented under 45 CFR Part 149, governs many out-of-network emergency services and certain non-emergency services at in-network facilities. Instead of balance billing the patient, the provider and plan resolve the payment amount through a 30-business-day open negotiation, and if that fails, through federal Independent Dispute Resolution (IDR) — a 'baseball-style' arbitration where each side submits an offer and the arbitrator picks one.

When the NSA pathway applies

  • Emergency services delivered out-of-network.
  • Certain non-emergency services by out-of-network providers at in-network facilities.
  • Air-ambulance services from out-of-network providers.
  • It is a payment dispute between provider and plan — not a medical-necessity appeal, and not a bill to the patient beyond in-network cost-sharing.

Open negotiation, then IDR

  1. 1

    Open negotiation

    Either party initiates a 30-business-day open negotiation over the out-of-network rate after the initial payment or denial.

  2. 2

    Initiate IDR

    If negotiation fails, a party initiates federal IDR within the required window and a certified IDR entity is selected.

  3. 3

    Each side submits an offer

    Both parties submit a proposed payment amount with supporting information.

  4. 4

    Binding selection

    The IDR entity selects one of the two offers; the determination is binding for that dispute.

Frequently asked

Is NSA IDR the same as appealing a denial?
No. IDR resolves the out-of-network payment amount between provider and plan; it is not a medical-necessity appeal and does not involve balance-billing the patient beyond in-network cost-sharing.
What law governs the NSA?
The federal No Surprises Act, implemented in regulation at 45 CFR Part 149. State surprise-billing laws may apply to fully insured plans in some situations.

Primary sources: 45 CFR Part 149 (No Surprises Act). General information, not legal or medical advice — confirm against the governing rule for the plan type.

Related guides

CO-45 · Allowed amount (out-of-network)ERISA plans & appeal rightsExternal review (IRO)

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