No Surprises Act Final Rule Will Require IDR Registration
Summary: On May 28, 2026, the U.S. Departments of Labor, Health and Human Services, and the Treasury (the Departments) released a much-anticipated final rule (Final Rule) to improve operations of the federal independent dispute resolution (IDR) process under the No Surprises Act (NSA).
Among other things, the final rule establishes a federal IDR registry requirement for self-funded group health plans and health insurance issuers participating in the federal IDR process.
Read on for more information.
No Surprises Act (NSA) and IDR Background
The No Surprises Act (NSA)[1], signed into law at the end of 2020 and implemented in 2022, established federal protections against surprise medical billing (also referred to as “balance billing”) for individuals enrolled in group health plans[2] and health insurance coverage. Surprise medical bills generally comprised the difference between a billed change and the amount your health plan or insurance coverage paid. This resulted in unforeseen financial burdens on patients who received medical care from an out-of-network provider or facility, often without the patient’s knowledge or notice by the facility/provider that the visit would result in additional charges.
The NSA’s protections apply to three categories of medical services outlined below:
- emergency services, including both facility and professional charges, received in a hospital’s emergency department or an independent freestanding emergency center,
- nonemergency services provided by an out-of-network provider during a visit at an in-network health facility,
- for example: an out-of-network surgeon performing surgery at an in-network hospital,
- out-of-network provider of air ambulance services.
The NSA also established the federal independent dispute resolution (IDR) process to resolve payment disputes between health plans/health insurance issuers and out-of-network providers when a specified state law or an applicable all-payer model agreement does not provide a method for determining the payment amount.
The federal IDR process has received more than 5 million payment disputes since it was launched in April 2022, exceeding the Departments’ expectations and resulting in significant delays and costs.[3] Additionally, implementation of the NSA has been substantially impacted by ongoing litigation.[4]
In response to the ongoing NSA litigation and operational challenges within the federal IDR system, the Departments issued this Final Rule revising portions of the IDR process and related administrative requirements.
Many NSA requirements directly affect providers and health insurance issuers. However, employer-sponsored group health plans remain responsible for ensuring compliance with the NSA through their insurance carriers, third-party administrators (TPAs), and other plan service vendors.
Final Rule Overview
The Final Rule focuses on improving how the IDR process works by creating consistency and uniformity for parties navigating claims through the IDR process. Specifically, the Final Rule’s changes are intended to reduce processing delays, improve communication between plans and providers, reduce submission of ineligible disputes, and standardize federal IDR operations.
The Final Rule does not make any changes to the NSA’s protections against surprise medical bills or the methodology for calculating out-of-network payment amounts.
Although the Final Rule is generally effective on August 3, 2026. several operational requirements will be implemented through future guidance from the Departments and phased implementation timelines.[5]
Most of the Final Rule’s operational and administrative changes intended to improve and enhance the IDR process will directly impact carriers, TPAs and other plan services vendors as responsible entities for claims administration and federal IDR process participation. Still, employers sponsoring self-funded group health plans should be aware of a key provision of the Final Rule affecting them involving the federal IDR registration process outlined below.
Final Rule’s IDR Registration Process
The Final Rule’s IDR registration process will require all health plans and issuers, including self-funded group health plans, to submit to the registry data elements (detailed below) and obtain a registration number. The federal IDR registry will be a searchable database that will help identify the proper payers involved in an initiated NSA payment dispute.
Registry Timeframes: Plans will be required to register within 90 business days of the creation of the registry, or within 90 business days of establishing a new group health plan, if later.
Plans will also be required to update any applicable information in the registry within 30 calendar days of a change to plan information, and confirm the accuracy of the data annually in the fourth quarter of each calendar year. Failure to confirm annual registration accuracy will be treated as a failure to register, requiring re-registration in the following calendar year.
Registry Data Elements: The IDR registration process will require the following data elements from a self-funded group health plan:
- Legal business name of the group health plan and/or group health plan sponsor,
- Whether the plan is a governmental or church plan, or subject to ERISA (the Employee Retirement Income Security Act of 1974),
- For self-funded governmental and church plans, whether they are subject to an All-Payer Model Agreement or have opted into specified state laws,
- For governmental plans only, the state(s) in which the plan is offered,
- Contact information for the plan, which can be a plan’s TPA, including a contact who can initiate open negotiation of payments and a contact who can initiate the IDR process on behalf of the plan,
- Plans using multiple contacts, such as different TPAs by location, must provide a consolidated open negotiation contact to triage external requests,
- The plan’s 5-digit HIOS identifier or the plan/plan sponsor’s EIN and plan number,
- Additional information necessary to identifying the plan and specified federal or state requirements for determining applicable federal and state out-of-network rates, and
- Additional information necessary for administrative fee collection.
Registry Delegation: Health insurance issuers will be able to register once on behalf of all fully-insured plans they cover, but employer plan sponsors will be required to register separately for each self-funded group health plan subject to the IDR process.
Notably, the Final Rule confirms that a self-funded group health plan sponsor may delegate IDR registry requirements to their TPA or other plan service vendor. However, if their TPA/vendor fails to register, the plan sponsor will be in violation of the registration requirements and will be unable to participate in the IDR process.
IMPORTANT NOTE: The Departments will announce when the IDR registry becomes available to registrants and the deadline for registration, which should occur 90 days from that date.
Employer Plan Sponsor Action Items
Now that the Departments released this Final Rule, employers sponsoring group health plans should continue broadly reviewing NSA compliance practices and procedures with their carriers, TPAs, and other plan service vendors typically responsible for claims administration and federal IDR process participation.
When the IDR registry becomes available:
- Fully insured employer group health plan sponsors should coordinate with their insurance carrier since the Final Rule confirms the obligation to register rests with the carrier.
- Self-funded employer plan sponsors should consider taking the following steps:
- Monitor for the Departments announcement of IDR registry availability to trigger the 90-business day registration deadline,
- Prepare IDR registration information including gathering required data elements detailed above,
- Confirm their TPAs will register and manage ongoing compliance on their behalf, including:
- Registering the employer’s group health plan within 90 business days of the IDR registry becoming available,
- Updating the registration within 30 calendar days upon any change to the plan information contained within the registry, and
- Confirming the accuracy of plan information contained within the registry in the fourth quarter of each calendar year.
Your Gehring Group team will provide relevant updates when available, including when the IDR registry becomes available. In the meantime, please contact your Gehring Group team with any questions or concerns.
[1] The NSA was part of the Consolidated Appropriations Act, 2021.
[2] Group health plans comprised only of “excepted benefits,” such as stand-alone dental and vision plans, excepted benefit HRAs, and most health FSAs, are not subject to the NSA or the IDR process.
[3] https://www.cms.gov/newsroom/press-releases/federal-rule-takes-aim-health-care-bureaucracy-reducing-dispute-fees-boosting-transparency
[4] See Tex. Med. Ass’n v. U.S. Dep’t of Health & Hum. Servs., Case No. 6:23–cv–00059–JDK, (E.D. Tex. August 3, 2023)
[5] Anticipated to be available 24 months after the August 3, 2026 effective date of the Final Rule.