Final rule lowers No Surprises Act IDR fees, adds requirements

Regulations issued Thursday to update the No Surprises Act’s independent dispute resolution (IDR) process represent an effort to improve access while also streamlining the volume of cases.

CMS and the Departments of Labor and Treasury published a final rule that significantly lowers IDR fees but includes more requirements of the insurers and providers that seek to use the process. The rule affects how parties document out-of-network payment disputes, engage in open negotiation and submit claims for review by certified IDR entities.

IDR is the mechanism established under the No Surprises Act to resolve certain out-of-network payment disputes between providers and insurers. Such disputes can arise when the Act protects patients from being balance-billed for out-of-network care during emergency department visits or for certain nonemergency services furnished at in-network facilities.

The final rule “largely focuses on improving some of the logistics and administrative steps for payment dispute resolution,” Carol Skenes, chief of staff with Turquoise Health, said in emailed comments.

The rule states that bottlenecks in the IDR portal have eased significantly since the proposed version of the rule was issued in 2023. But although arbitrators have become more efficient at closing disputes, a backlog of 430,000 cases remained as of June 2025, according to a report in Health Affairs.

Lower administrative fees could improve IDR access

One change that could increase traffic in the IDR portal is a reduction in the administrative fee for IDR participants from $115 to $15 per case. The new fee also represents a big drop-off from the proposed version of the rule, which recommended a $150 charge, or $75 for low-dollar disputes.

It’s anticipated that the lower fee will expand access to the IDR process, especially for smaller providers. Although slashing the fee could further increase the number of IDR cases, the federal departments say other finalized provisions should counter that trend.

Payers face new claim communication requirements

The rule is intended to improve communication between providers and payers before disputes reach IDR. Health plans will be required to include standardized claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) when responding to out-of-network claims, helping to indicate whether a claim is IDR-eligible.

Other information newly required during the initial response to a claim includes the legal name of the insurer, plan sponsor information (for self-funded plans), an IDR registration number, and instructions for how providers can initiate the negotiations that precede IDR.

“These changes, as finalized, will facilitate better communication between parties prior to and during open negotiation, and ultimately reduce the number of ineligible payment disputes submitted to the federal IDR process,” CMS wrote in a fact sheet on the new rule.

Open negotiation becomes a more structured step

To encourage substantive negotiations before IDR, the final rule standardizes key steps in the 30-day open-negotiation period and requires additional details from the parties.

“The departments have received numerous reports that the parties are not meaningfully engaging in open negotiation before proceeding with IDR, including reports of open negotiation notices submitted containing vast numbers of items and services, not all of which would ultimately be eligible for the federal IDR process,” CMS wrote.

Via the final rule, the negotiation period cannot begin until the notice, along with the initial payment remittance or denial, is formally submitted through the IDR portal, and notices must contain more detailed claim information than before. In addition, the responding party must reply within 15 business days.

Batching rules and eligibility reviews will shape dispute volume

Batching of multiples claims into one IDR filing will be allowed for services provided to a single patient on the same date or on consecutive dates that are billed together. Claims sharing the same or comparable billing codes also are eligible for batching, as are certain specialties (e.g., anesthesia, radiology, pathology, lab) that fall within the same CPT category.

While those requirements could limit batching, the final rule allows for as many as 50 line items per dispute. That’s up from 25 items in the proposed rule, as CMS acknowledged concerns that the proposed number was too restrictive.

IDR eligibility scrutiny is set to increase

Certified IDR entities (i.e., arbitrators) must determine whether a dispute is eligible for IDR within five business days after assignment. Providers and insurers face the same deadline when responding to requests for missing information.

If such information is not provided on time, the arbitrator may proceed with the case or close the dispute. Arbitrators also are prevented from considering the payment offer of any party that does not pay the administrative fee on time, and the party still would be liable for the fee.

Whereas the proposed rule contained a provision allowing the federal departments to step in and perform eligibility determinations in instances of systemic delay or operational backlogs, the final rule does not include that option. Arbitrators can request deadline extensions during systemic disruptions.

Payer identification should become easier

A new IDR registry requires payers to register and obtain a unique IDR registration number. This directory is meant to help providers identify the correct payer and for arbitrators to more easily determine IDR eligibility.

“Providers have reported that when they initiate open negotiation, it is often difficult to identify the payer and find the correct contact information, particularly when trying to distinguish between different group health plans offered by the same plan sponsor,” CMS wrote.

More work to be done

A worthy next step would be to improve the mechanics of the qualifying payment amount (QPA) calculation, Skenes said. The QPA equals the median contracted rate paid by an insurer for a given service in a given region. It’s a benchmark used to determine patient cost-sharing when No Surprises Act billing protections apply, and it plays a central role in IDR determinations.

“In addition to any process improvements this final rule yields, a clear, transparent QPA calculation could also help future disputes avoid landing in the IDR queue,” Skenes said. “The downstream effects of a trustworthy QPA include more productive engagement in the open negotiation window and the IDR process. All of those improvements together ultimately can help pave the way for a more manageable path to accurate payment of out-of-network claims.”

Transparency regarding QPA calculations could be addressed after the resolution of litigation involving that issue. A 2023 case brought by a provider advocacy group is pending at the U.S. Court of Appeals for the Fifth Circuit.

Timeline for implementation

Several provisions in the final rule will take effect upon or shortly after publication in the Federal Register, including the reduced administrative fee and expanded CARC/RARC communication requirements. Many other changes will become applicable 90 days after the rule’s effective date.