On May 28, 2026, the Centers for Medicare & Medicaid Services (CMS), in coordination with the Departments of Labor, Treasury, and Health and Human Services (HHS), released a final rule implementing additional operational policies under the No Surprises Act (NSA), focused on the federal independent dispute resolution (IDR) process.

This rule builds on prior rulemaking and responds to significant challenges in the IDR system, particularly the unexpectedly high volume of disputes and widespread inefficiencies in processing and communication. Since the launch of the IDR portal in April 2022, more than 5.1 million disputes have been submitted, far exceeding initial projections and placing sustained strain on the system.

This final rule does not directly increase reimbursement but significantly alters the operational framework governing out-of-network payment disputes under the No Surprises Act. For sleep medicine practices, the immediate impact will be increased administrative complexity, along with new expectations related to documentation, coding accuracy, and engagement in the negotiation process. These changes will directly affect revenue cycle strategies and administrative workflows. At the same time, improved transparency and standardization may create opportunities to resolve disputes earlier and more efficiently, reducing reliance on the IDR process in some cases.

IDR utilization and system burden

A central theme of the final rule is addressing persistent inefficiencies in the IDR process, driven by high dispute volume, frequent eligibility challenges, and limited engagement during the required negotiation period. CMS notes that a significant portion of disputes submitted to the IDR process have ultimately been deemed ineligible or improperly initiated, contributing to delays and administrative burden. For sleep medicine practices, this reinforces that the IDR process will remain a critical, but increasingly scrutinized, mechanism for resolving payment disputes with payers.

Payment communication and transparency

The final rule includes significant updates to payment communication requirements, mandating that plans and issuers provide enhanced information alongside initial payments or denials. It also requires the use of standardized claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) in both electronic and paper remittance advice. These changes are intended to improve transparency and ensure that providers have sufficient information to understand how payment amounts were determined before initiating a dispute. For sleep medicine providers, these updates may meaningfully improve visibility into payer decision-making.

Open negotiation process

The rule strengthens requirements for the 30-business-day open negotiation period, which must occur before initiating IDR. This includes standardizing the content and timing of negotiation notices and clarifying when the negotiation period begins. CMS has identified a lack of meaningful engagement during this period as a key driver of high IDR volume and inefficiency. In practical terms, sleep medicine practices will need to treat the open negotiation phase as a substantive and time-sensitive step in the dispute process rather than a procedural formality.

Eligibility and intake requirements

CMS finalized new measures to improve the accuracy of dispute submissions and reduce the volume of ineligible cases entering the IDR process. These measures include enhanced eligibility review procedures, additional documentation requirements at the time of dispute initiation, and clearer rules governing timing and qualification criteria. This has direct implications for sleep medicine practices, particularly those submitting multiple related claims.

Bundled payment arrangements and batching

The final rule provides a clarified definition of “bundled payment arrangements” and distinguishes these from batched disputes, addressing a major source of confusion in the IDR process. Bundled payment arrangements generally refer to situations in which multiple services are billed or reimbursed under a single service code, whereas batching involves grouping multiple similar claims for dispute purposes. This distinction is particularly relevant for sleep medicine, where diagnostic services may involve multiple components.

Administrative fees and process timing

The rule refines administrative fee policies and establishes clearer timelines for key steps in the IDR process, including initiation, submission of payment offers, and final determinations. CMS also addresses concerns related to low-dollar disputes, recognizing that administrative costs may outweigh the financial benefit of pursuing IDR in certain cases. For sleep medicine practices, this introduces a more strategic decision-making process around dispute submission.

Plan and issuer registration requirements

The rule requires plans and issuers to register in the federal IDR portal, which is intended to improve identification of parties and streamline the dispute process. By ensuring that payer information is standardized and accessible, CMS aims to reduce administrative friction and facilitate more efficient dispute initiation and resolution.

For sleep medicine providers, this may help address a common operational challenge: difficulty identifying the correct payer entity or determining whether a claim falls under federal IDR, state law, or another payment framework. Over time, improved payer transparency and registration may reduce delays associated with misdirected disputes or incomplete information.

Ongoing legal and policy uncertainty

CMS acknowledges that the IDR framework continues to be shaped by ongoing litigation, including court decisions affecting the methodology for calculating the qualifying payment amount (QPA) and the criteria used in IDR determinations. These legal developments have already led to changes in guidance and temporary disruptions in the IDR process.

For sleep medicine practices, this means that the payment landscape for out-of-network services remains fluid and subject to change. Providers should anticipate additional updates through future rulemaking or regulatory guidance and should remain engaged with AASM advocacy efforts on these issues. Continued uncertainty around QPA calculations, in particular, may influence reimbursement for sleep diagnostic services and reinforce the importance of maintaining strong documentation and negotiation practices.

Recent advocacy efforts are summarized in the following articles:

The IDR process will remain a critical tool for challenging underpayments, particularly for services such as polysomnography and unattended sleep testing. However, success under this framework will depend on a more strategic, detail-oriented approach to revenue cycle management.

The final rule fact sheet can be accessed here.

Members may send questions about this final rule to coding@aasm.org.