Departments Issue Final Rule on Surprise Billing Payment Disputes Between Providers and Insurers; Includes FAQs

Published August 26, 2022

The U.S. Departments of Labor, Health and Human Services, and the Treasury (the departments) issued final rules concerning standards related to the arbitration process implementing the No Surprises Act. These final rules will make certain medical claims payment processes more transparent for providers and clarify the process for providers and health insurance companies to resolve their disputes.

In July 2021, interim final rules were issued that included requirements for plans and issuers to furnish providers and facilities with certain information about their billed claims and the payment process. With these final rules, in the event a plan or issuer changes a provider or facility’s service code used for billing purposes to one of lesser value – which would reduce the payment to the provider or facility – the plan or issuer must now provide additional information when submitting an initial payment or a notice of denial of payment for items and services covered by the No Surprises Act.

The increased transparency required under these final rules is intended to help providers, facilities and air ambulance providers engage in more meaningful open negotiations with plans and insurers and will help inform the offers they submit to certified independent entities to resolve claim disputes.

The rules also finalize some aspects of the arbitration process afforded by the No Surprises Act. Parties or providers (including air ambulance providers), facilities, plans and issuers may use an arbitration process known as the Independent Dispute Resolution process, also known as the federal IDR process, to determine the total payment amount for out-of-network healthcare services for which the act prohibits surprise billing. The final rules include guidance for certified IDR entities on how to make payment determinations and instructs these entities that they must provide additional information and rationale in their written decisions. The rules state that the qualifying payment amount is based on the median contract rate, and certified IDR entities then must consider all additional permissible information submitted by each party to determine which offer best reflects the appropriate out-of-network rate.

These final rules address certain provisions of the July 2021 and October 2021 interim final rules that are relevant to the operation of the federal IDR process and revise certain provisions in light of two recent federal court decisions in challenges filed by the Texas Medical Association and LifeNet Inc.

The final rule is effective October 25, 2022.

ACA FAQs Part 55


The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury released Affordable Care Act (ACA) Frequently Asked Questions (FAQs) Part 55 with guidance on implementing the requirements of the No Surprises Act, including those related to surprise billing protections, open negotiation and the federal IDR process.

The FAQs are provided to answer questions from stakeholders on the following topics:
  • No-network and closed network plans
  • Air ambulance services
  • Emergency services furnished in a behavioral health crisis facility 
  • General disclosure for protections against balance billing. 
  • Standard notice and consent form and model disclosure notice regarding patient protections against balance billing 
  • Methodology for calculating qualifying payment amounts
  • Transparency in coverage (TiC Final Rules) machine-readable files:
    • Q22: May a group health plan that does not have its own website satisfy the requirements of the TiC Final Rules with respect to posting the machine-readable files on a public website, if the plan’s service provider posts the machine-readable files on its public website on behalf of the group health plan?
    • Q23: With regard to the internet-based self-service tool as required by the TiC Final Rules, will the list of codes for the 500 items and services required in the self-service tool for plan years (in the individual market, policy years) beginning on or after January 1, 2023 be updated when an item or service code is no longer valid?