The Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury issued a final rule on the federal independent dispute resolution (IDR) process under the No Surprises Act (NSA). The final rule makes significant changes to improve how the IDR process functions by streamlining communication between the parties involved in the dispute, reducing the number of ineligible disputes submitted, and clarifying timelines and processes. A related fact sheet and news release are also available.
While employer sponsors of self-insured plans generally rely on their third-party administrators (TPAs) or other service providers to negotiate disputes through the IDR process on their behalf, they remain responsible for complying with the applicable rules.
Background
The NSA protects group health plan participants from balance bills when they: 1) seek emergency care, 2) are transported by an air ambulance, or 3) receive non-emergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.
Out-of-network providers and health plans can resolve payment disputes regarding out-of-network charges through the IDR process. Before starting, the parties must initiate an open negotiation period to determine a payment amount for the out-of-network services. If that open negotiation fails, either party may initiate the IDR process. The parties then may jointly select a certified IDR entity, which will issue a binding determination selecting one of the parties’ offers as the out-of-network payment amount. Both parties must pay an administrative fee, and the non-prevailing party is responsible for the certified IDR entity fee.
The Departments launched the IDR portal in 2022 to accept disputes regarding the appropriate out-of-network rate for claims subject to the NSA’s surprise billing protections. The portal is used by out-of-network providers, group health plans, health insurance issuers in the group and individual markets, and others to determine out-of-network rates after an unsuccessful negotiation.
The final rule lays the groundwork for transitioning to a centralized platform for managing disputes, known as the IDR Gateway.
Since its inception, the IDR process has experienced several operational and administrative difficulties and delays. Previous federal guidance addressing the IDR process, as well as provisions related to the methodology for calculating the qualifying payment amount (QPA), have been challenged in court. As of January 31, 2026, disputing parties have submitted over 5.1 million disputes for review.
The final rule lays the groundwork for transitioning to a centralized platform for managing disputes, known as the IDR Gateway. This transition will occur in the latter half of 2026.
Final rule key changes and requirements
The final rule significantly modifies the federal IDR process applicable to healthcare providers and payers, including employer-sponsored group health plans, as outlined below.
Communication
To improve communication between all parties involved in the IDR process and ensure they have the information necessary to resolve the dispute, including determining whether a claim is subject to the IDR process, the final rule standardizes the information that is communicated between healthcare providers and payers.
Payers must use specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) when they provide any paper or electronic remittance advice to an entity that does not have a contractual relationship with the payer. These codes will be used to indicate whether a claim for an item or service furnished by a provider is subject to the NSA and IDR process.
The final rule clarifies the information payers must give providers about the QPA, particularly when the “recognized amount” — the dollar amount that serves as a basis for calculating an individual’s cost sharing under the NSA for certain items and services — is not based on the QPA. When making a payment determination, certified IDR entities must begin with the presumption that the QPA is the appropriate out-of-network amount.
Open negotiation
The final rule makes several changes to the open negotiation requirements. One party must provide an open negotiation notice to the other party and the Departments through the IDR portal to initiate the open negotiation period. The 30-business-day open negotiation period begins on the date when the party submits the open negotiation notice and payment remittance or notice of denial of payment to the other party and the Departments through the IDR portal. The open negotiation notice must include certain information to help parties identify the item or service and whether the IDR process applies.
The final rule also establishes that the party receiving the open negotiation notice must respond with an open negotiation response notice to both the other party and the Departments by the 15th business day of the 30-business-day open negotiation period.
Claims batching
The final rule amends the requirements for when multiple related claims for resolution may be batched into a single proceeding. Qualified IDR items and services may be batched when:
- Items and services are furnished to a single patient on the same or consecutive dates of service and billed on the same claim form
- Items and services are furnished to one or more patients and billed under the same service code or a comparable code under a different procedural code system
- Anesthesiology, radiology, pathology, and laboratory items and services are furnished to one or more patients under service codes belonging to the same Category I CPT billing code section
Batched determinations are limited to 50 qualified IDR line items per dispute.
Fees
Under the final rule, the administrative fee drops from $115 to $15 per party per dispute, regardless of the amount in dispute or the dispute’s eligibility for the IDR process. The fee must be paid no later than the date a party submits its offer to the certified IDR entity, and the offer is not considered received until the fee is paid.
IDR Registry
The final rule requires self-insured group health plans and other payers subject to the federal IDR process to register with the Departments using the federal IDR Registry. This is intended to help providers correctly identify plans and health insurance issuers as well as their contact information and reduce the number of disputes initiated against the wrong party. It is also intended to reduce the number of ineligible disputes initiated within the IDR process. Each plan and issuer will be assigned an IDR registration number once all required information is submitted.
The information required when registering includes:
- The legal business names of the plan sponsor and the plan (along with the plan sponsor’s employer identification number and the plan’s ERISA plan number)
- The type of plan (e.g., self-insured ERISA plan or insured plan)
- Whether a self-insured group health plan has opted into a state law providing balance billing protections
- Contact information for the appropriate office or person to initiate open negotiation or the IDR process
- Any available Health Insurance Oversight System identifier
- Additional information needed to identify the plan or issuer and the applicable federal and state requirements for determining appropriate out-of-network payment rates for items or services to which the protections against balance billing apply
- Any additional fee collection information
Changes to a registrant’s information must be reported within 30 calendar days of the change. Registrants must also confirm the accuracy of their registration in the fourth quarter of each calendar year. The Departments will announce when the registry becomes available and the deadline for payers to register. Note that while the rule allows an employer plan sponsor to delegate the registration to a TPA or service provider, they are not relieved of their compliance responsibility. Also, if the registration requirements are performed by a TPA or service provider, the group health plan must require them to clearly delineate each group health plan for which it has authority to act.
Applicability dates
In general, the final rule takes effect on August 3, 2026, with varying applicability dates for certain provisions:
- The requirement that payers communicate information to providers using specific CARCs and RARCs, as well as the changes to the information that must be shared about the QPA, will be applicable on August 3, 2026. The Departments intend to post guidance on the DOL and Centers for Medicare & Medicaid Services websites by December 4, 2026, on when the use of specified CARCs or RARCs will be required, giving payers at least four months to comply
- The modifications to the definition of a batched dispute will be applicable for disputes with open negotiation periods beginning November 1, 2026
- The modifications to the IDR process, including open negotiation, IDR initiation, selection of the certified IDR entity, the federal IDR process eligibility review, treatment of batched and bundled qualified IDR item and services, the deadline for the submission of offers and payment determination and notification, and certain provisions related to withdrawals, will apply to disputes with open negotiation periods beginning 90 days after the Departments issue guidance announcing that the functionality supporting these provisions has become available. This is expected to be 24 months after the effective date of the final rule. These provisions will be implemented on a rolling basis
- The administrative fee amount of $15 per party per dispute will be applicable to disputes initiated on or after June 11, 2026 (the administrative fee for disputes initiated from January 22, 2024, to June 10, 2026, remains $115 per party, per dispute)
- The amended IDR procedures, in the event either party fails to timely pay the administrative or certified IDR entity fee, will be applicable on August 3, 2026 (the effective date of the final rule)
- The provisions establishing the federal IDR Registry and the associated requirements will become applicable 90 business days after the Departments issue guidance announcing that the functionality supporting the IDR Registry provisions is available
Going forward
Employer sponsors of self-insured group health plans should:
- Review the final IDR rule and begin to update their internal processes to ensure continued compliance; if relying on a TPA regarding the IDR process, employers should ensure the TPA is compliant by the applicable deadlines
- Review how their group health plans have been handling disputed claims that have been subject to the IDR process and consider what steps should be taken, beyond the final requirements, to improve outcomes related to IDR negotiations
- Review the new communication requirements and coordinate, as appropriate, with their TPAs to ensure any communications contain all required information, including the plan’s legal name and the name of the plan sponsor
- Register in a timely manner when the IDR registry opens; if relying on a TPA to register on their behalf, they should ensure that the TPA clearly specifies the name of their plan when registering