Glossary

The No Surprises Act is a federal law, enacted as part of the Consolidated Appropriations Act, 2021, that protects patients in most self-funded and fully insured plans from surprise bills for emergency services, certain out-of-network care at in-network facilities, and air ambulance transport.

Generally, the plan's median contracted rate for the same or similar service in the same geographic area, as of a specified reference date. It sets the member's cost-sharing baseline and is a key reference point in IDR.

The federal arbitration process a payer or provider can invoke when open negotiation over an out-of-network claim fails. A certified IDR entity reviews each side's offer and picks one — it cannot split the difference.

An independent, government-certified arbitrator (or arbitration organization) that decides IDR cases. Selected jointly by the parties, or assigned if they can't agree.

The mandatory 30-business-day period after a claim payment or denial during which the provider and payer must attempt to agree on a payment amount before either can escalate to IDR.

Combining multiple, similar claims into a single IDR case to reduce administrative burden and fees. Batching rules are specific about what counts as similar enough to combine.

When an out-of-network provider bills a patient for the difference between what the provider charged and what the plan paid. The Act prohibits this for the claim categories it covers, shifting that gap into the payer-provider negotiation/IDR process instead.

A service or item a health plan does not cover as a benefit at all, regardless of network status. The No Surprises Act's protections apply to covered emergency, ancillary, and air ambulance services that happen to be out-of-network — they don't extend coverage to something a plan has excluded outright. Confirming whether a claim involves a network gap versus a plan exclusion is often the first question in scoping whether the Act applies.

A required estimate of expected charges that providers give to uninsured or self-pay patients (and, for insured patients, information the plan uses to generate an Advanced EOB) before a scheduled service.

A pre-service estimate of what a plan expects to pay and what the member is expected to owe, built from the provider's good faith estimate.

The federal law governing most employer-sponsored self-funded health plans, including the fiduciary duties that make plan sponsors responsible for how the plan — and its NSA compliance — is administered.

The contract structure under which a TPA administers a self-funded plan without assuming the underlying insurance risk, which sits with the employer (and its stop-loss coverage) instead.

A stop-loss underwriting practice of applying a higher attachment point (or excluding coverage) for a specific, identified individual with known high-cost risk, rather than spreading that risk across the whole group's rate.

The claim (or aggregate) dollar threshold above which stop-loss coverage begins to reimburse the self-funded plan.

A risk-financing structure in which multiple, typically unrelated employers pool and share medical stop-loss (or other) risk through a jointly owned insurance entity, rather than each buying coverage separately in the commercial market.