No Surprises Act (NSA)
The No Surprises Act (effective 2022) bans most out-of-network surprise bills for emergency care, air ambulance, and out-of-network providers at in-network facilities. It also created a Federal Independent Dispute Resolution (IDR) process between providers and payers.
What No Surprises Act (NSA) does
The NSA, enacted as part of the Consolidated Appropriations Act 2021, did three things. (1) It banned balance billing for emergency services, post-stabilization services, air ambulance, and out-of-network providers (anesthesiology, pathology, radiology, etc.) at in-network facilities — patients pay only in-network cost-sharing. (2) It established the Federal Independent Dispute Resolution (IDR) process: when payer and out-of-network provider can't agree on the payment amount, an IDR entity picks one of the two parties' final offers ('baseball arbitration'). (3) It required all health plans to give patients written notice of their NSA rights and a Good Faith Estimate for self-pay/uninsured services.
When to invoke it
Cite the NSA when an out-of-network provider bills the patient for the balance after the plan paid in-network rate at an in-network facility, or when the bill arises from an emergency. The strongest provisions: §2799A-1 (balance-billing ban for OON at in-network facilities), §2799A-2 (emergency services), §2799A-7 (IDR). Patient remedies include HHS complaint (via the No Surprises Help Desk: 1-800-985-3059) and state insurance commissioner complaint.
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Open negotiation window | 30 business days from initial payment |
| Time to initiate IDR | 4 business days after open negotiation ends |
| IDR entity decision | 30 business days from selection |
| Good faith estimate to uninsured | Before scheduled service (3 business days notice if scheduled 10+ days out) |
Plans this applies to
- All non-grandfathered group health plans
- Individual health insurance
- Self-funded ERISA plans
- Federal employee plans
Frequently asked questions
What does No Surprises Act (NSA) require?
The NSA, enacted as part of the Consolidated Appropriations Act 2021, did three things. (1) It banned balance billing for emergency services, post-stabilization services, air ambulance, and out-of-network providers (anesthesiology, pathology, radiology, etc.) at in-network facilities — patients pay only in-network cost-sharing. (2) It established the Federal Independent Dispute Resolution (IDR) process: when payer and out-of-network provider can't agree on the payment amount, an IDR entity picks one of the two parties' final offers ('baseball arbitration'). (3) It required all health plans to give patients written notice of their NSA rights and a Good Faith Estimate for self-pay/uninsured services.
When do I cite No Surprises Act (NSA) in an appeal?
Cite the NSA when an out-of-network provider bills the patient for the balance after the plan paid in-network rate at an in-network facility, or when the bill arises from an emergency. The strongest provisions: §2799A-1 (balance-billing ban for OON at in-network facilities), §2799A-2 (emergency services), §2799A-7 (IDR). Patient remedies include HHS complaint (via the No Surprises Help Desk: 1-800-985-3059) and state insurance commissioner complaint.
What are the key deadlines under No Surprises Act (NSA)?
Open negotiation window: 30 business days from initial payment. Time to initiate IDR: 4 business days after open negotiation ends. IDR entity decision: 30 business days from selection. Good faith estimate to uninsured: Before scheduled service (3 business days notice if scheduled 10+ days out)
Which plans does No Surprises Act (NSA) apply to?
All non-grandfathered group health plans; Individual health insurance; Self-funded ERISA plans; Federal employee plans.
Related
- CARC 45Common denial code where No Surprises Act (NSA) applies.
- CARC 204Common denial code where No Surprises Act (NSA) applies.
- 42 CFR 422 Subpart MThe Medicare Advantage appeal track. MA enrollees have FIVE levels of appeal (vs the 2 levels typica
- 42 CFR 438 Subpart FThe federal floor for Medicaid managed care appeals. Beneficiaries get internal plan appeal + State
- ACA §1557 (Nondiscrimination)ACA §1557 prohibits discrimination in health programs and activities on the basis of race, color, na
- ACA §2711 (No Lifetime/Annual Limits)ACA §2711 prohibits lifetime AND annual dollar limits on Essential Health Benefits. Plans that try t
Sources
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