4 forms
In the Gateway from Nov 13, 2026
Initiation, initiation response, certified IDR entity selection and offer [1].
Home / White papers / Emergency department
White paper · No Surprises Act operations
NSA IDR Gateway 2027: an operating manual for emergency physician groups
Short answer: the Federal IDR Operations final rules took effect August 3, 2026 and switch on in stages: a $15 fee since June, a 50-line batch cap from November 1, Gateway filing from November 13, web forms closed after January 15, 2027, remark codes on every out-of-network remit from January 1. This manual turns those dates into roles, queues and clocks.
91 FR 33900 · effective Aug 3, 2026
Nov 13, 2026 · Gateway filing
N877 / N876 · from Jan 1, 2027
17 · certified IDR entities
Edition
White paper · 2027
Focus
Federal IDR
Audience
ER physician groups
Metric
1 in 6 ineligible
Effective date
Aug 3, 2026
Length
16 min read
$15
Administrative fee per party per dispute for disputes initiated on or after June 11, 2026, down from $115 [3]
50lines
Cap on a batched dispute whose open negotiation starts on or after November 1, 2026, with a 30-business-day cooling-off [1]
Jan 152027
Last day the Federal IDR web forms are available outside the IDR Gateway (resubmission form excepted) [1]
1in 6
Closed disputes found ineligible, 1,262,335 of 7,304,875; usually a missed window, wrong respondent or bad batch [2]
Seven fixed dates on the ER group calendar
Released May 28, 2026, published June 4 at 91 FR 33900, effective August 3 [4] [7]. CMS's August 7 timeline guide ties each provision to a date or to a future Gateway notice [3].
- 1Jun 11, 2026Administrative fee falls from $115 to $15 per party per dispute
- 2Aug 3, 2026Final rules effective; QPA disclosure, bundled payment definition and fee-failure procedures apply
- 3Sep 15, 2026IDR Gateway account creation opens
- 4Nov 1, 202650-line cap and 30-business-day cooling-off for batches with open negotiation from this date
- 5Nov 13, 2026Account holders submit initiation, response, entity selection and offer forms in the Gateway
- 6Jan 1, 2027Required NSA remark codes on remits for items furnished from this date
- 7Jan 15, 2027Web forms outside the Gateway close (resubmission form excepted)
Spring 2027 build order, each live 90 days after its Gateway notice
Everything else applies 90 calendar days after CMS announces the supporting Gateway function [3]. Do not run November on rules that are not yet live.
- 1
IDR Registry
- Payer registration, due within 90 business days of the announcement
- Registration number must appear with the initial payment or denial, with the plan's legal name and sponsor [4]
- 2
Suspension of resubmissions
- Incorrectly batched or bundled disputes; 120 days after the registry's registration period ends
- 3
Open negotiation
- Portal-submitted notice, clock starting on submission, response notice by business day 15
- 4
Initiation
- Amended Notice of IDR Initiation requirements
- 5
Certified IDR entity selection
- Amended selection process and the 5-business-day eligibility review
- 6
Withdrawal requests
- Submitted through the Gateway
- 7
Extensions
- Extenuating-circumstance requests through the Gateway
Takeaway
Two calendars run at once: the fixed dates, and a rolling set of 90-day clocks that start when CMS posts a Gateway notice. Subscribe to the CMS No Surprises notices page and assign one owner to read it.
Who signs up, and when
Announced March 16, 2026, confirmed July 15, account creation open September 15. Accounts are for those who process disputes, represent parties or submit IDR forms. Help desk: [email protected], 1-800-985-3059 [1].
| If your group | Who signs up | By when | Why |
|---|---|---|---|
| Files its own open negotiation and IDR notices | The group, with two named administrators and the staff who submit forms | Before November 13, 2026 to file in the Gateway; in any case before January 15, 2027 | Web forms outside the Gateway close after January 15, 2027 |
| Uses a billing company or law firm to file | The third-party administrator; confirm in writing that it has | Same dates | Parties using a TPA only need the TPA to sign up |
| Is switching vendors during the transition | Both the outgoing and incoming filer, with a handover list of open disputes | Before the first Gateway filing | Dashboards show Gateway disputes and mapped disputes started outside it |
| Has disputes in flight on old web forms | No new action beyond monitoring | Through determination | The resubmission form stays available outside the Gateway |
2 to 10
Gateway administrators
CMS recommends at least two per organization, no more than ten [1].
17
Certified IDR entities
After the September 11, 2026 certification of a seventeenth entity [1].
When the IDR Registry arrives, the registration number becomes the fastest way to identify the correct respondent on a self-funded claim [3].
50 lines and a 30-business-day cooling-off
What may be batched: items for one patient on the same or consecutive dates on the same claim form; items for one or more patients under the same service code or a comparable code; anesthesiology, radiology, pathology or laboratory items in the same Category I CPT section [4]. Timeliness validations were added to the form on September 24, 2026, and determination letters will state the cooling-off that applies [1].
| Rule | Open negotiation started before Nov 1, 2026 | Started on or after Nov 1, 2026 |
|---|---|---|
| Maximum line items per batched dispute | Prior limit under the earlier rules | 50 qualified IDR items or services |
| Cooling-off after a payment determination (batched) | 90 calendar days | 30 business days |
| Cooling-off (single and bundled disputes) | 90 calendar days | 90 calendar days |
| Same-patient batching | Same or consecutive dates, same claim form | Same or consecutive dates, same claim form |
| Same-code batching across patients | Permitted under existing definition | Same service code or comparable code in another code system |
| Dates of service within a batch | Within 30 business days of each other (web form rule since July 1, 2025) | Within 30 business days of each other |
| Form enforcement | Manual review | Notice of IDR Initiation form validates line counts and timeliness |
Worked example: one payer, one month, 150 disputed lines
At $15 per party the administrative fee is no longer the constraint; the entity fee and staff time per dispute are. Trade-off modeled in working NSA and IDR balances at small-dollar scale; November re-plan in The ED Operator.
Before November 1one batched dispute
150 lines1 dispute, 1 admin fee, 1 entity fee
From November 1three batched disputes
3 x 50 lines3 disputes, 3 admin fees, 3 entity fees
Old batchNew 50-line batches
Takeaway
Re-cut your batches by payer and service code now, and schedule open negotiation notices so a batch is complete before its clock starts. A notice sent on day one of the month cannot absorb claims paid on day twenty.
What applies now, what waits for the Gateway notice
The final rules move the notice into the portal, start the 30-business-day period on submission and require a response notice by the fifteenth business day [4]; those mechanics apply 90 days after the Gateway notice, third in the build order [3]. Until then the existing process runs: 30 business days, then initiation generally within 4 business days [5]. The plan's 30-calendar-day duty to pay or deny is unchanged under 45 CFR 149.110 [6].
| Step | Process in force today | Final rules (90 days after the Gateway notice) |
|---|---|---|
| Start of open negotiation | Provider sends the standard notice to the plan within 30 business days of the initial payment or denial | Notice submitted through the portal to the plan and the Departments; clock starts on submission |
| Plan response | No formal response notice required | Open negotiation response notice due by the 15th business day |
| Length | 30 business days | 30 business days |
| Initiation window | Generally 4 business days after the period ends | Initiation through the Gateway; amended initiation requirements |
| Eligibility review | Certified IDR entity reviews | Entity determines eligibility within 5 business days of final selection; parties answer information requests within 5 business days |
Day 1
Open negotiation notice sent and logged with the remit date, plan name and claim lines it covers.
Day 15
Response checkpoint: under the final rules the plan's response notice is due by the 15th business day.
Day 30
Period ends; initiation follows generally within 4 business days, in the Gateway from November 13, 2026.
Takeaway
Build the 15-business-day response checkpoint into your tracker today, even though it is not yet required. When the notice lands, your process will already be shaped for it.
Cheaper to file, costlier to miss a deadline
Administrative fee per party per dispute, by initiation date
Owed regardless of the amount in dispute or eligibility; entities collect it, and the Departments may pursue unpaid fees under federal debt collection law [4].
Jan 22, 2024 to Jun 10, 2026
$115100%
From Jun 11, 2026
$15-87%, five business days after publication [3]
Prior feeCurrent fee
Offer not received
An unpaid administrative or certified IDR entity fee at the offer deadline means the offer is not considered received; the fees remain owed. In effect since August 3, 2026 [4] [3]. For a group that files in volume, a missed fee is a lost dispute, not a late fee.
Public notice
Extenuating circumstances now include systematic delays such as unforeseen dispute volume or portal failures; the Departments post a notice when they extend deadlines [4].
N877 and N876, from January 1, 2027
Plans must use specified remark codes on every remit to a provider with no direct or indirect contract, for items furnished from January 1, 2027; the descriptions entered the X12 code set on November 1, 2026 [5]. Certified IDR entities, not plans, make the final eligibility call, so a provider who disagrees with a code can still initiate after open negotiation.
| RARC | Circumstance stated in the guidance | Federal IDR eligible? | Operating action |
|---|---|---|---|
| N877 | Initial payment under the NSA; recognized amount is the lesser of QPA or billed charge | Yes after open negotiation | Queue for open negotiation; start the 30-business-day clock |
| N876 | Notice of denial of payment under the NSA; same recognized-amount basis | Yes after open negotiation | Queue for open negotiation; confirm it is a payment denial, not a benefit denial |
| N871 | Initial payment calculated under a specified state law | No per the plan | Route to the state process; log the plan's position for the eligibility file |
| N872 | Final payment calculated under a specified state law | No per the plan | Close or route to state process |
| N944 | Denial of payment where cost sharing follows a specified state law or All-Payer Model | No per the plan | Route to the state process |
Full list with X12 timing: No Surprises Act remark codes for ER groups. Until the codes appear, eligibility is inferred from plan type, state and payment amount.
Why process discipline matters more than ever
Federal IDR disputes, cumulative April 15, 2022 to September 30, 2026
September 2026 alone: 390,602 initiations, up 9 percent from August. August and September closures (784,352) exceeded initiations (750,022), which CMS calls near-elimination of the backlog [2].
Initiated
7,798,616100%
Closed
7,304,87593.7% of initiated
Payment determination
5,805,32679.5% of closed
Found ineligible
1,262,33517.3% of closed, one in six
02M4M6M7.8M
VolumeDeterminationsIneligible
Watch
On August 11, 2026 the Fifth Circuit issued an en banc opinion affirming parts of a ruling that struck certain QPA regulations and guidance. CMS says the agencies are reviewing it, expect to issue guidance, and that the Federal IDR process remains operational [1]. Keep QPA disclosure requests in every file.
Roles, queues and clocks
- 1
Roles
Appoint the Gateway owner and administrators
- Two named administrators, plus a deputy who reads the CMS notices page weekly and records every 90-day clock
- 2
Posting
Tag every out-of-network ER claim at posting
- Plan type (self-funded, fully insured, FEHB), state, specified state law or federal pathway
- From January 2027, the RARC on the remit
- 3
Clock 1
Run the 30-calendar-day payment watch
- Flag any claim with no initial payment or denial 30 calendar days after the plan had what it needed; send the written demand the same day
- 4
Cut batches by payer and service code before the clock starts
- Same-code claims, same payer, 50 lines maximum, dates of service within 30 business days
- Open negotiation only when the batch is complete
- 5
Clock 2
Work the open negotiation window with checkpoints
- Day 1 notice logged; day 15 response checkpoint; day 25 settlement decision; day 30 close; initiation in the Gateway within the window
- 6
Money
Pay fees before the offer deadline
- Administrative and entity fees paid and receipted ahead of the offer
- 7
Evidence
Build the offer file once per payer and code
- QPA disclosure requests, the group's cost and case-mix evidence, prior determinations for that payer and code, reused across batches
- 8
Scorecard
Report monthly on five numbers
- Disputes initiated, found ineligible with reason, determinations won, median days from remit to determination, cash collected against the initial payment
Eight clocks an ER group must keep
| Clock | Length | Starts when | Source |
|---|---|---|---|
| Plan's initial payment or denial | 30 calendar days | Plan receives the information needed to decide the claim | 45 CFR 149.110(b)(3)(iv) [6] |
| Open negotiation | 30 business days | Notice sent today; portal submission once the final rules apply | Final rules fact sheet; RARC guidance |
| Open negotiation response | By the 15th business day | Open negotiation period begins (once applicable) | Final rules fact sheet |
| IDR initiation | Generally 4 business days | Open negotiation period ends | RARC guidance, footnote on eligibility |
| Eligibility determination | 5 business days | Final selection of the certified IDR entity (once applicable) | Final rules fact sheet |
| Cooling-off, batched | 30 business days | Payment determination on a batch with open negotiation from Nov 1, 2026 | CMS notice, October 2, 2026 |
| Cooling-off, single or bundled | 90 calendar days | Payment determination | CMS notice, October 2, 2026 |
| Payer registry registration | 90 business days | CMS announces the registry function | Implementation timeline guide [3] |
Takeaway
Most ineligible outcomes are calendar failures. Put every clock in one tracker with business-day arithmetic, and make the Gateway owner responsible for the dates, not the arguments.
Five moves before November 13
Confirm in writing who holds the Gateway accountYour group or your TPA; two named administrators either way.
Re-cut every open batch under the 50-line capBy payer and service code, dates of service within 30 business days.
Add the eight clocks to one trackerBusiness-day arithmetic; day 15 checkpoint already in.
Map N877, N876, N871, N872 and N944 to work queuesBefore the first January remit.
Test your inventory against the capOur emergency department billing services team runs tagging, the tracker and Gateway filing, so an N877 remit becomes a queued dispute the same day. Start with a free denial audit; see what ER groups should demand and the in-network companion, ED facility E/M leveling defense.
Frequently asked questions
When does the IDR Gateway replace the Federal IDR web forms?
CMS opened Gateway account creation on September 15, 2026. From November 13, 2026, Gateway account holders can submit the Notice of IDR Initiation, Notice of IDR Initiation Response, Notice of Certified IDR Entity Selection and Notice of Offer in the Gateway. The web forms will no longer be available outside the Gateway after January 15, 2027, except the Notice of IDR Initiation Resubmission form.
What are the new IDR batching limits and when do they apply?
Batched disputes are capped at 50 qualified IDR items or services. The cap and the rest of the batching provisions apply to disputes whose open negotiation period begins on or after November 1, 2026. Batched disputes started on or after that date also carry a 30-business-day cooling-off period after a payment determination; earlier batches and all single and bundled disputes keep 90 calendar days.
How much is the Federal IDR administrative fee now?
The administrative fee is $15 per party per dispute for disputes initiated on or after June 11, 2026, down from $115 for disputes initiated between January 22, 2024 and June 10, 2026. It is owed regardless of the amount in dispute or whether the dispute is found eligible, and if it or the certified IDR entity fee is unpaid at the offer deadline the party's offer is not considered received.
Does an ER group have to create its own Gateway account?
Only if it processes disputes, represents parties or submits IDR forms itself. CMS states that parties using a third-party administrator only need that administrator to sign up. CMS recommends two Gateway administrators per organization and no more than ten.
Which remark codes tell an ER group a claim can go to Federal IDR?
Under the July 17, 2026 guidance, N877 (an initial payment under the No Surprises Act) and N876 (a notice of denial of payment under the Act) mark items whose disputes are eligible for Federal IDR after open negotiation. N871, N872 and N944 mark amounts set under a specified state law or All-Payer Model that the plan treats as not eligible. Plans must use the codes for items and services furnished on or after January 1, 2027.
- CMS, No Surprises Act: Federal IDR notices (October 14, October 2, September 15, August 13, August 3, June 3 and May 29, 2026 entries)
- CMS, Federal Independent Dispute Resolution reports and public use files (cumulative and monthly dispute counts through September 30, 2026)
- CMS, Federal IDR Operations Final Rules Implementation Timeline Guide for Certified IDR Entities and Disputing Parties (August 7, 2026)
- CMS fact sheet: Federal Independent Dispute Resolution Operations Final Rule (May 28, 2026)
- Departments of the Treasury, Labor and HHS: Guidance on Required Remittance Advice Remark Codes Related to the No Surprises Act (July 17, 2026)
- 45 CFR 149.110, Preventing surprise medical bills for emergency services (eCFR)
- Federal Register, Federal Independent Dispute Resolution Operations final rules, 91 FR 33900 (June 4, 2026)
Checked October 25, 2026. Rules and payer policies change; confirm against the source before relying on them.
ServiceEmergency department billing services
NewsletterIDR batching change, November 1: the 50-line cap
InsightNo Surprises Act remark codes for ER groups
InsightFederal IDR dispute data, 2026
White paperWorking NSA and IDR balances at small-dollar scale
BlogWhat ER groups should demand from billing services
ServiceEmergency room billing services
How would your out-of-network inventory fare under the 50-line cap?
We tag your open out-of-network ER claims by pathway, re-cut the batches, and hand you the tracker with every clock on it, before the first Gateway filing.