The No Surprises Act
A federal law that protects patients from surprise out-of-network bills, and gives providers a way to dispute low payments from insurers.
What it covers
The law applies to three kinds of out-of-network care.
Emergency care
Emergency services, including some care after the patient is stabilized.
Care at in-network facilities
Non-emergency care from out-of-network providers at in-network hospitals and surgery centers.
Air ambulance
Out-of-network air ambulance transport.
Patients pay only their in-network share. Medicare, Medicaid, CHIP, and TRICARE are not part of this process.
How a payment dispute works
If an insurer pays too little, the law sets out a clear path.
- Start
Initial payment
The insurer sends a payment or a denial.
- 30 business days
Negotiation
Either side can open a negotiation to agree on a fair amount.
- Within 4 business days
IDR begins
If there's no agreement, either side can start Independent Dispute Resolution.
- Decision
One offer wins
An independent reviewer picks one side's offer. The plan pays within 30 days.
Federal or state?
Some states have their own surprise billing laws. When a state law applies to a claim, the state process is used instead of federal IDR. It mostly comes down to the patient’s plan.
Fully insured plans
Plans regulated by the state, in states that have their own law.
Self-funded employer plans
Employers that pay claims themselves, unless the plan opted into a state process where the state allows it.
State by state
We work claims in all 50 states. In 28 states and Washington, D.C., these disputes go through federal IDR. The other 22 states have their own surprise billing laws, so some claims go federal and some go state.
Here is a closer look at four of them.
New York runs its own IDR process through the Department of Financial Services. It covers out-of-network emergency care at hospitals, surprise bills at in-network hospitals and surgery centers, and certain referrals.
New York updated the process in 2026. The new rules apply to disputes filed on or after August 26, 2026.
NY Department of Financial ServicesNew Jersey’s 2018 law created an arbitration process for emergency, urgent, and unexpected out-of-network care. It covers state-regulated plans and self-funded plans that opt in.
Self-funded plans that don’t opt in go through federal IDR.
NJ Department of Banking and InsuranceConnecticut passed its surprise billing law in 2015. It applies to fully insured plans regulated by the Connecticut Insurance Department.
Self-funded employer plans fall under federal rules.
Connecticut Insurance DepartmentFlorida’s 2016 law bars balance billing for emergency care, and for certain non-emergency care at in-network hospitals, under PPO and EPO plans.
Disputes under that law go to court or to the state’s voluntary claim dispute resolution program.
Florida Legislature, HB 221 (2016)How we stay current
These rules change often. In 2026, both the federal IDR rules and New York’s IDR rules were revised.
- We follow CMS and state regulator updates
- We follow court rulings that affect IDR
- We work with experienced IDR consultants
- We check every claim for the right process before it’s filed
Not sure which process applies to your claims?
We’ll review them for free.
Request a free claims reviewSources
- CMS: Chart for determining the applicability of the federal IDR process
- CMS: About independent dispute resolution
- Congressional Research Service: No Surprises Act IDR data analysis, first half of 2023
- Federal Register: Federal IDR Operations final rule (June 2026)
- NY DFS: Insurance Circular Letter No. 5 (2026)
- NJ DOBI: Out-of-network consumer protections
- NJ DOBI: Bulletin 21-14
- Connecticut Insurance Department: No Surprises Act
- Florida Legislature: HB 221 (2016) final bill analysis