The No Surprises Act Independent Dispute Resolution (IDR) Process
Summary
The No Surprises Act
Independent Dispute Resolution (IDR) Process
The No Surprises Act (NSA, P.L. 116-260 Div. BB, Title I) established certain federal consumer protections related to surprise billing—that is, circumstances in which individuals receive large, unexpected medical bills when they are unknowingly, and potentially unavoidably, treated by out-of-network (OON) providers. In those situations, the law generally (1) limits the amount consumers pay to what they would have paid had the care been provided by an in-network provider and (2) establishes a federal IDR process (before a private arbitrator (IDR entity)) that may be used to determine how much insurers must pay OON providers for the care. This Infographic summarizes the federal IDR process, incorporating a June 2026 final rule(91 Fed. Reg. 33900) aimed at improving the IDR process functionality.
What are the surprise billing circumstances to which NSA's protections apply?
OON emergency services
OON nonemergency services Provided at an in-network facility
OON air ambulance services
What happens after an OON provider furnishes care in these circumstances?
OON provider bills patient's insurer Day 1*
Insurer pays or denies claim Day 30*
If provider is unsatisfied with payment amount or denial
Open negotiation Between provider and insurer Day 71*
No agreement Proceed to IDR process Day 110*
IDR Process
IDR initiated
When either party (typically the OON provider) submits notice to the other party and the IDR portal maintained by the Centers for Medicare & Medicaid Services (CMS) Day 116*
Non-initiating party responds Day 121*
Preliminary joint selection or random assignment of IDR entity Day 124*
IDR entity determines dispute eligibility Day 137*
Final IDR entity selection and parties pay administrative fee to CMS Day 130*
IDR entity attests to no conflict of interest Day 129*
If eligible, each party submitsa payment offer Each party also pays the IDR entity fee Day 144
IDR entity selectsbetween offers Selection must be based on(1) QPA** and (2) other specified factors, and is generally not judicially reviewable Day 172*
Payment or reimbursement Relevant party must pay or reimburse amounts per determination Day 202*
Refund of IDR entity fee IDR entity refunds IDR entity fee to the prevailing party Day 214*
From 2023 through 2025
4.7 M+ disputes were initiated. 99.9% of disputes were initiated by OON providers and facilities. 85.7% of disputes resulted in the OON provider or facility as the prevailing party.
*Number of days are estimated using CMS guidance on IDR Timeline for Claims. The estimate also assumes an initial bill occurs on a Monday, does not account for holidays, and assumes, where applicable, the maximum duration for each step.
**QPA, or qualifying payment amount, is generally an insurer's 2019 median in-network rate for the item or service, indexed for inflation. 42 U.S.C. §300gg-111(a)(3)(E).
Information as of August 27, 2026. Prepared by Ryan Rosso, Specialist in Health Care Financing; Wen Shen, Legislative Attorney; and Mari Lee, Visual Information Specialist.