A Major Win for Physicians
What the New NSA IDR Operations Rule Means for You
By Jennifer Brown, Attorney and Vice President of Payer and Government Relations, Emergency Care Partners
June 11, 2026
For years, independent physicians, emergency medicine groups, and other out-of-network providers have navigated a federal arbitration process marked by procedural complexity, substantial administrative costs, and an informational asymmetry that plagued the process. Effective June 4, 2026, that landscape changed – with a rule designed to make the process clearer, more efficient, and more equitable for all stakeholders.
The Tri-Departments’ newly published No Surprises Act (NSA) IDR Operations Rule represents one of the most consequential procedural advances for providers. It addresses operational deficiencies that provider organizations have raised with the Departments for over five years – and this Rule delivers on nearly all of them.
Here’s what you need to know.
What is the No Surprises Act and Why Does it Matter?
The No Surprises Act (NSA), enacted in 2022, was designed to protect patients from unexpected medical bills when they receive care from out-of-network providers in circumstances beyond their control: emergency departments, surgical settings where an in-network surgeon engages an out-of-network anesthesiologist, and facilities where radiologists and pathologists operate independently of the institution.
The law prohibits balance billing in these circumstances, meaning out-of-network providers may not bill patients beyond their in-network cost-sharing amounts. This is sound policy for patients, and one ECP agrees with. In addition to this protection, the NSA created an independent dispute resolution process whereby providers and insurers can dispute the payment received.
What is Independent Dispute Resolution?
When a provider and an insurer disagree on what an out-of-network claim should be paid, either party can initiate a dispute through the Independent Dispute Resolution Process created by the NSA. Both sides submit their proposed payment amounts and supporting rationale to a certified, independent arbitrator. The arbitrator reviews the submissions and selects one party’s figure as the final payment.
Because the arbitrator selects one side’s figure in its entirety, both parties have a strong incentive to submit well-supported, reasonable offers. The process was intended to be accessible, efficient, and impartial.
In practice, however, the system generated significant friction. Administrative fees were high enough to deter smaller providers from filing lower-dollar disputes. Determining whether a specific claim was eligible for the federal process — as opposed to a state-level process — was often unclear, with no standardized mechanism for insurers to communicate that information. The mandatory “cooling off” period between disputes created ongoing confusion and stalled claims for months. And throughout, providers frequently lacked basic identifying information about the plan they were actually disputing.
Providers and their advocates spent years submitting formal comments, testifying before federal agencies, and engaging directly with the Departments of Health and Human Services, Labor, and Treasury — the “Tri-Departments” that jointly administer the NSA. The IDR Operations Rule is the Tri-Departments’ considered response to that sustained advocacy.
The Biggest Changes, and Why They Matter
1. The Administrative Fee Drops from $115 to $15, Effective Almost Immediately
This is the most immediate and financially impactful provision in the rule.
Under the prior framework, both parties to a dispute each paid a non-refundable administrative fee of $115 per dispute, regardless of outcome. For large provider organizations managing substantial dispute volumes, this represented a manageable operational cost. For smaller practices, rural providers, and independent groups operating on tighter margins, however, the fee was often determinative — the economics of pursuing lower-dollar claims simply did not support it.
The new rule reduces that fee to $15 per dispute, an 87% reduction, derived using the same calculation methodology but reflecting the government’s revised cost estimate for administering the program.
The practical consequence is meaningful: claims that were previously uneconomical to pursue may now be viable. Providers who have foregone recoveries due to unfavorable cost-benefit calculations now have a path to participation. Importantly, this change takes effect today, June 11, 2026.
This is a direct benefit to every provider who files disputes, but it carries particular significance for smaller and rural providers who were, in effect, priced out of a process that was intended to serve them.
2. Plans Must Now Tell Providers Which Process to Use: RARC and CARC Codes
One of the most persistent and fundamental problems within the IDR system has been a deceptively simple one: providers frequently could not determine whether a given claim belonged in the federal IDR process or in a state-level proceeding.
This distinction is consequential. The federal process applies to ERISA-governed plans — generally self-funded employer plans subject to federal law. However, 21 states have enacted their own balance billing statutes and arbitration frameworks, and fully insured plans in those states fall under state jurisdiction. Densely populated states including California, Florida, Texas, New York, and Illinois each maintain separate processes.
The problem this created was structural: insurers possessed all relevant jurisdictional information, while providers were left to infer eligibility from incomplete data. Revenue cycle teams developed tools and workflows to estimate eligibility, but these remained approximations, and incorrect routing produced rejected disputes, wasted resources, and administrative burden.
The new rule addresses this at the source. Plans will be required to include a RARC (Remittance Advice Remark Code) or CARC (Claim Adjustment Reason Code) with every initial payment or denial, specifically indicating federal IDR eligibility. From the initial remittance, and before a provider has begun evaluating whether to dispute a claim, they will have a clear, standardized indication of the applicable process.
Guidance on the specific codes will be issued within six months of the rule’s publication date, with plans required to implement the requirement within four months thereafter, bringing full implementation to approximately April 2027. The operational impact on eligibility accuracy will be significant.
3. The Cooling Off Period is Reduced from 90 Days to 30 Business Days
The IDR process incorporates a “cooling off period,” a mandatory interval following a dispute determination before a provider may initiate a subsequent dispute against the same party on a similar claim. The original 90-day period was designed to create space for good-faith negotiation prior to re-entering arbitration.
In practice, it generated widespread confusion. Because providers routinely dispute claims against the same large insurers that administer plans across a broad employer base, claims frequently became subject to overlapping or perpetual cooling periods. Inconsistent interpretation by IDR entities of when and against whom the cooling period applied compounded the problem.
The new rule reduces the cooling-off period for batch disputes from 90 calendar days to 30 business days — a targeted correction to one of the most common sources of delay and uncertainty, enabling providers to manage their dispute pipelines more actively and with greater predictability.
4. Batch Dispute Cap Set at 50 Claims, Up from the Proposed 25
Providers may consolidate similar claims against the same insurer into “batch disputes,” submitting them as a single filing. The 2023 proposed rule would have limited batches to 25 line items. The final rule establishes a cap of 50 qualified IDR items and services per batch.
The Tri-Departments noted that, based on internal data, 99 percent of batch disputes already fall within this threshold. The cap is therefore unlikely to alter current filing practices for the overwhelming majority of providers, while providing the system with a reasonable administrative boundary.
5. The IDR Registry: Definitive Identification of the Disputing Party
A point of confusion that often surprises those outside the revenue cycle world: when a provider submits a dispute against a major insurer like Aetna, UnitedHealthcare, and others, the actual counterparty is frequently not the insurer itself. Rather, it is a self-insured employer that has engaged the insurer as a third-party administrator (TPA) to process claims on its behalf.
This distinction is operationally critical. Cooling periods, payment obligations, and jurisdictional determinations attach to the underlying plan, not the TPA. Without reliable identification of the plan itself, providers could not accurately determine against whom cooling was running, who bore the payment obligation, or which regulatory framework governed the dispute.
Following years of advocacy from the provider community on this nuanced issue, the Tri-Departments responded by establishing a federal IDR registry. All health plans must register and obtain a unique registration number, which must accompany every initial payment or denial. The registry will capture key plan-level details, including plan type (e.g., whether the registrant is a self-insured group health plan subject to ERISA), the legal business name of the plan, and for self-insured group health plans, the legal business name of the plan sponsor. Registration is required at the individual plan level for self-insured coverage and at the issuer level for fully insured coverage. From the first remittance, providers will have reliable, plan-level identification — reducing misidentified parties, improving the accuracy of cooling determinations, and limiting delayed or rejected disputes on procedural grounds.
6. A Federal IDR Portal: A Unified Operational Framework
The rule mandates the creation of a federal IDR portal through which many IDR-related communications will be conducted. This eliminates one of clinicians’ most persistent operational frustrations: the obligation to use insurers’ proprietary portals for IDR submissions and responses.
The rule is unambiguous: plans may not require providers to use proprietary portals for any activity related to the federal IDR process. All submissions, including open negotiation notices, dispute initiations, and responses, will flow through the federal portal, creating a single, auditable record of the entire dispute lifecycle. The portal is expected to be operational in the second half of 2026.
7. Open Negotiation Notices Must Receive a Response
Before a claim may enter the IDR process, the initiating party must first transmit an open negotiation notice — a formal communication indicating intent to proceed to arbitration absent agreement on a payment rate. This period was designed to encourage settlement prior to arbitration.
For years, the mechanism functioned primarily as procedural formality. Providers transmitted open negotiation notices; insurers routinely did not respond. The period introduced delay without producing substantive dialogue.
The new rule requires that plans respond to open negotiation notices. A substantive counteroffer is not mandated, but a response is. Combined with the new federal portal’s documentation requirements, this creates a verifiable record of engagement and reinforces the transparency and accountability that runs throughout this rule.
8. Certified IDRE Selection: Allowance of Additional Time for Selection
Under the prior framework, the last IDRE selected in the selection process typically became the IDRE for the dispute — a dynamic that invited gamesmanship, as a party who delayed their selection until the final moment could effectively dictate the outcome of the selection process.
The new Rule addresses this directly. The party last in receipt of an IDRE selection notice now receives an additional two business days to either agree to or object to the other party’s proposed certified IDRE. If that party agrees, or does not respond within the extended window, the Departments designate the proposed IDRE. If that party objects, the Departments select a certified IDRE at random from among those not already proposed by either party. This additional time will create a more balanced approach to IDRE selection.
A Rule Grounded on Physician Advocacy
Virtually every provision in this rule has a direct antecedent in formal comments, correspondence, and testimony from provider organizations. The RARC/CARC eligibility code requirement? Providers first raised that need in 2021. The administrative fee reduction? Repeatedly documented in comment submissions. The cooling period ambiguity? The subject of extensive provider advocacy over multiple rulemaking cycles.
The Tri-Departments engaged seriously with that record, and the result is a rule that constitutes a meaningful, practical improvement for providers at every scale of operation.
For sophisticated provider organizations such as Emergency Care Partners (ECP), the fee reduction and enhanced eligibility clarity will generate immediate financial benefit and measurable reductions in administrative overhead. For smaller practices and rural providers who were previously deterred by cost or procedural complexity, this rule removes barriers to a system that was always intended to be accessible to them.
What Comes Next
The rule’s general effective date is August 3, 2026.
Key milestones:
– Effective Today, June 11th, 2026: Administrative fee reduced to $15 per dispute
– By December 2026: Tri-Departments to issue guidance on RARC/CARC codes
– Second half of 2026: Federal IDR portal expected to launch
– By April 2027: Plans required to include RARC/CARC codes with all initial payments and denials
Providers should engage their revenue cycle teams, billing partners, and legal counsel to assess how these changes affect existing dispute workflows, particularly with respect to fee thresholds for claim pursuit and eligibility tracking once the RARC/CARC codes are implemented.
This rule does not resolve every challenge within the IDR framework; robust enforcement remains an ongoing concern. But for the first time in years, the operational architecture of the federal IDR process is moving in favor of transparency and efficiency for all stakeholders, the direct result of sustained, organized advocacy from the provider community.
Jennifer Brown
Jennifer Brown is an Attorney and Vice President of Payer and Government Relations at ECP. She works closely with EDPMA and other provider advocacy organizations on federal and state healthcare policy. For questions about the NSA IDR Operations Rule and what it means for your organization, contact our team at ECP.
About Emergency Care Partners
Emergency Care Partners (ECP) is the largest single-specialty emergency medicine group in the United States, providing emergency medicine and emergency department management services to hospitals across the country. With operations spanning 10 states, ECP sees over 1.7 million patient visits annually across 66+ sites of service, supported by a clinical workforce of 1,400+ physicians and mid-level providers and 12 private physician practices.
ECP delivers comprehensive back-office support across revenue cycle management, financial and operational reporting, provider recruiting, training, compliance, contracting, scheduling, payroll, and marketing.
ECP is committed to developing and maintaining expertise across all dimensions of emergency medicine — including the laws and regulations that materially impact its operations, such as the No Surprises Act — in furtherance of delivering the highest quality care to its patients. ECP engages directly with federal and state policymakers on issues central to emergency medicine and serves as a knowledgeable and consistent advocate for providers navigating an increasingly complex reimbursement environment.
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