No Surprises Act with Zelis®
Simplifying compliance, reducing risk, supporting patients
Zelis® helps health plans, TPAs, healthcare providers and members confidently navigate the complexities of the No Suprises Act (NSA). Our highly configurable solutions combine regulatory expertise, AI-powered pricing technology, and proven support for surprise medical billing disputes, independent dispute resolution (IDR), and qualifying payment amount (QPA) determinations. As federal enforcement intensifies, Zelis delivers clarity, confidence and measurable savings – helping you protect patients, reduce risk and stay ahead of evolving regulations.
Zelis® comprehensive NSA compliance solution
Navigating the complexities of the No Surprises Act (NSA) requires more than just technology—it demands expertise, advocacy, and a partner who’s always ahead of the curve. With Zelis, you get a partner who simplifies NSA compliance, optimizes outcomes and supports your team every step of the way. Our combination of advanced technology, legislative expertise, and dedicated support means our clients are always prepared for what’s next.
AI-driven optimization: At the front-end of our NSA solution is ClaimPass®, Zelis’ proprietary AI-powered optimization engine. ClaimPass® dynamically evaluates every claim against client-specific parameters, state regulations, and NSA eligibility, ensuring that each claim is routed appropriately
Dispute support: Zelis dispute support team finds a 23% margin of error from providers on IDR submissions! From intake to resolution, we automate workflows to reduce manual errors and support compliance with NSA timelines. Our team manages negotiation and Independent Dispute Resolution (IDR) processes, ensuring adherence to all NSA requirements. The result is a seamless experience for clients, with timely filing, settlement, and dispute resolution handled by experts.
Expert guidance: Zelis’ in-house legal and legislative teams advocate for clients, monitor regulatory shifts, and partner closely with our dedicated operational team to support complex situations. We provide ongoing, comprehensive regulatory analyses and manage requirements and deadlines, so our clients stay ahead of changes.
What is the No Surprises Act?
Healthcare organizations face mounting pressure to comply with federal regulations, and few have created more urgency than the No Surprises Act (NSA). Enacted in December 2020 and effective since 2022, the NSA protects patients from surprise medical bills – unexpected charges that arise when patients unknowingly receive care from certain out-of-network services. The law restricts balance billing for emergency services, certain non-emergency services at in-network facilities, and air ambulance services, ensuring patients pay only their in-network cost share.
At Zelis, our solutions go beyond compliance. We simplify NSA and TiC requirements, reduce healthcare provider abrasion, enhance the member experience and unlock measurable savings.
Terms you should know
Balance billing: Billing patients for the difference between the healthcare provider’s charge and the health plan’s allowed amount for covered services. For example, if the provider’s charge is $400 and the health plan’s allowed amount is $300, the provider may bill the patient for the remaining $100.
Out-of-network billing: Charges for services rendered by healthcare providers who do not have a contract with the patient’s health plan.
Independent dispute resolution (IDR): A federal process for resolving payment disputes between payers and healthcare providers when negotiation fails; a certified arbitration entity selects one of the submitted offers.
Federal IDR portal: The online platform for submitting and managing IDR cases, overseen by CMS.
Surprise medical bills: Unexpected charges patients receive for certain types of out-of-network care their health plan didn’t cover.
Qualifying payment amount (QPA): The median in-network rate for a given service in a geographic area, used to determine patient cost share and as a benchmark in IDR disputes.
Open Negotiation: A mandatory 30-day period for payers and healthcare providers to resolve payment disputes before entering IDR.
Common challenges when responding to IDR submissions
The payers’ role in the Federal Independent Dispute Resolution (IDR) process is critical. At Zelis, we help payers stay ahead with complete, accurate, and compliant responses to provider disputes. To help disputes move forward without unnecessary delays or penalties, Zelis helps clients avoid these frequent missteps when responding to provider-initiated disputes:
Ineligible Disputes: Zelis evaluates each dispute to confirm it qualifies for the Federal IDR process, identifying cases that may not qualify or that may fall under state-specific laws or other exclusions. This helps clients avoid arbitration for ineligible disputes.
Misbundled Services: Zelis detects disputes that incorrectly batch multiple items or services, flagging them early in the process to prevent unnecessary challenges or delays.
Missing or Incorrect Info: Missing or incorrect data can stall the review process. Zelis validates critical information to ensure submissions are accurate, complete and compliant with IDR requirements, including: payer and provider contact information, health plan type and Qualifying Payment Amount (QPA) from the original payment or denial
Missing Open Negotiation Records: Zelis tracks and organizes open negotiation records, equipping clients with the necessary documentation to demonstrate that negotiation occurred and support their position during the IDR process.
Failing to Protect Sensitive Data: Zelis is committed to properly redacting all Protected Health Information (PHI) and Personally Identifiable Information (PII) before documentation is submitted, maintaining compliance with privacy regulations.
Missing Response Deadlines: Zelis monitors IDR deadlines and manages responses to certified IDR entity requests, helping clients avoid delays that could negatively impact dispute outcomes or result in penalties.
Who must comply and under what circumstances
The No Surprises Act applies to a broad range of stakeholders:
- Payers: Health plans and TPAs must ensure compliance with NSA and TiC rules, provide accurate cost estimates, and resolve disputes through negotiation or IDR.
- Providers: Hospitals, ambulatory surgery centers, anesthesiologists, radiologists, and other clinicians must follow balance billing restrictions, supply good faith estimates, and participate in dispute resolution.
- Patients: Individuals are protected from surprise medical bills and benefit from increased cost transparency and dispute resolution options.
Example Scenarios:
- A patient receives emergency care at an out-of-network hospital. Under NSA, the patient pays only their in-network cost share. The healthcare provider and payer must resolve payment through negotiation or IDR.
- An out-of-network anesthesiologist provides services during scheduled surgery at an in-network hospital. Because the patient couldn’t choose the anesthesiologist, NSA prohibits balance billing, and the patient is protected from additional charges.
- An out-of-network radiologist interprets imaging at an in-network urgent care facility. Since the service was delivered at an in-network location by an out-of-network provider without the patient’s ability to opt out, NSA applies.
- A patient is transported by an out-of-network air ambulance after a medical emergency.
How payment disputes are resolved (open negotiation to IDR)
When payers and healthcare providers disagree on payment for NSA-eligible medical claims, the process is as follows:
- Initial payment offer: Issued using Qualifying Payment Amount (QPA) as the claim benchmark for member cost share.
- Federal IDR Portal: All disputes are managed through the CMS portal, with strict timelines and documentation requirements.
- Open negotiation: A mandatory 30-day period for parties to resolve payment disputes directly.
- Independent Dispute Resolution (IDR): If negotiation fails, either party may initiate IDR via the federal portal. Both submit payment offers; a certified entity selects one using baseball-style, “all or nothing” methodology for outcome decision making.
- Certified IDR Entities: CMS certifies organizations to arbitrate disputes and determine prevailing offer.
Benefits of Working with Zelis®
Partnering with Zelis® delivers measurable advantages:
Reduced compliance risk: Stay ahead of regulatory changes and avoid costly penalties.
Cost savings: Provider-accepted, market-based pricing drives down costs for payers and providers.
Faster dispute resolution: Streamlined workflows and expert support accelerate payment negotiations and IDR outcomes.
Provider support: Dedicated provider dispute support fosters better payer-provider relationships and help plans avoid IDR and related fees.
Enhanced member experience: Out-of-network balance bill support helps members navigate medical bills.
From $150k to $430:
A health bill win that earned member trust
See how Zelis Health Bill Assistsm helped one member resolve an NSA claim
Ready to get help with No Surprises Act compliance?
There’s no shortage of ways we can help. Start a conversation with one of our Solution Advisors and build a thoughtful approach aligned to your business goals.
No Surprises Act FAQs from Payers
Zelis is a pricing, payments, and member support partner that supports health plans and third-party administrators. While we’re not the payer, we recommend pricing that’s based on individual plan preferences, regulatory guidelines, and fair market benchmarks—all with the goal of balancing fairness for providers and sustainability and compliance for plans. Our goal is to support timely, reasonable payment while reducing administrative friction for providers and payers alike.
For NSA-eligible claims, our pricing recommendations follow federal guidelines. This typically means referencing the Qualifying Payment Amount (QPA), which is a median in-network rate for similar services in that geographic market, to determine fair reimbursement. Some of our payer clients use their own QPA while others leverage Zelis’ QPA to price their claims as we are a qualified third-party eligible database.
We offer hands-on support from experienced experts who understand the NSA regulations and how to apply plan benefits. Our goal is to find common ground, minimize delays, and help payers and providers reach mutually agreeable pricing. If payers and providers cannot agree through negotiation, they may escalate to Independent Dispute Resolution (IDR), where a certified entity picks one of the submitted offers.
Leveraging market-based pricing, prioritizing open negotiation, robust documentation, and expert dispute support can help payers achieve fair outcomes.
Providers who receive a payment—or pricing information—from a plan Zelis supports may have questions if they’ve never worked with us directly. We’re here to answer their questions, clarify our role, and help make this process as fair and transparent as possible. We support a process that promotes affordability for members, fairness for providers, and sustainability for payers.
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Price Transparency
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Top Resources
Navigating the No Surprises Act in 2025: Regulatory Updates for Payers
Navigating the No Surprises Act in 2025: Trends and Insights for Payers
Navigating the No Surprises Act in 2025: Payer Challenges and Strategic Recommendations
