US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
The United States' federal surprise medical billing law: the No Surprises Act provisions of the Public Health Service Act and the HHS rule at 45 CFR Part 149, covering plan and issuer coverage and payment duties for out-of-network emergency, facility-based and air ambulance care, the qualifying payment amount, provider and facility balance billing prohibitions with the notice and consent exception, public disclosures, continuity of care, provider directory accuracy, gag clauses, prescription drug reporting, the IDR registry, the Federal independent dispute resolution process, and good faith estimates and dispute resolution for uninsured and self-pay patients.
US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 is a compliance framework from United States (federal) with 5 domains and 44 controls. The largest domains are Provider, facility and air ambulance duties: balance billing, notice and consent, disclosure (45 CFR 149.410 to 149.450; 42 U.S.C. 300gg-131 to 300gg-139) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (13 controls), Plan and issuer duties: patient protections, continuity, directories, gag clauses and reporting (45 CFR 149.310, 149.530, 149.710 to 149.740; 42 U.S.C. 300gg-113 to 300gg-120) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (11 controls), Plan and issuer duties: surprise billing coverage and the qualifying payment amount (45 CFR 149.100 to 149.150) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (8 controls). Every control below carries what it requires and what an assessor expects to see.
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Framework Domains (5)
Federal independent dispute resolution process (45 CFR 149.510 and 149.520) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
| Code | Title |
|---|---|
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.510(b)(1) | Start open negotiation within 30 business days of the initial payment or denial, using the prescribed notice, and respond by the 15th business day |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.510(b)(2),(c)(1)-(3) | Initiate the Federal IDR process within 4 business days after open negotiation ends, with the notice of IDR initiation, and select a certified IDR entity within 3 business days or accept the Departments' selection |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.510(c)(4) | Submit an offer with the required information within 10 business days of IDR entity selection and accept the entity's determination, which binds the parties for 90 days on the same items |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.510(d) | Pay the administrative fee and the certified IDR entity fee when due; the non-prevailing party bears the entity fee |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.510(e) | Certified IDR entities must meet the certification standards, screen for conflicts, keep IIHI confidential, report monthly and retain records |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.520 | For air ambulance disputes the certified IDR entity must weigh the air-ambulance-specific factors and report the air ambulance determinations monthly |
Plan and issuer duties: patient protections, continuity, directories, gag clauses and reporting (45 CFR 149.310, 149.530, 149.710 to 149.740; 42 U.S.C. 300gg-113 to 300gg-120) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
| Code | Title |
|---|---|
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.310(a)(1)-(2) | Let each enrollee designate any available participating primary care provider, and any participating pediatrician for a child |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.310(a)(3)-(4) | Allow direct access to participating obstetrical and gynecological care without referral, and give the notice of designation rights with every benefits description |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.530 | Register the plan or issuer in the Federal IDR registry, report changes within 30 days and confirm the registration annually |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.720-730 | File the annual prescription drug and health care spending (RxDC) report by 1 June for the prior reference year, aggregated by State and market segment |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.740 | Include in the RxDC report the plan-level identifiers, enrollment, top-50 drug lists, total spending by category, premiums, and rebates by therapeutic class and top-25 drugs |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-113 | Notify continuing care patients when a provider's network status ends and let them elect up to 90 days of transitional in-network coverage |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-114 | Maintain an internet price comparison tool and telephone price comparison guidance for cost-sharing estimates by provider |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-115(a)(1)-(2),(4)-(6) | Keep a public provider directory database, verify every entry at least every 90 days, remove unverifiable providers and update within 2 business days of provider notice |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-115(a)(3),(b) | Answer network-status enquiries within 1 business day in writing, keep the answer 2 years, and honour in-network cost sharing where the enrollee relied on wrong directory information |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-118 | Submit air ambulance claims data to the Departments for the two calendar years following the final rule, disaggregated as the statute lists |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-119 | Do not agree to gag clauses that restrict sharing provider-specific cost or quality information or access to de-identified claims data, and attest annually |
Plan and issuer duties: surprise billing coverage and the qualifying payment amount (45 CFR 149.100 to 149.150) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
| Code | Title |
|---|---|
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.100 | Use the prescribed claim adjustment reason codes and remittance advice remark codes to tell nonparticipating providers whether a claim is subject to the surprise billing rules |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.110(a)-(b)(2) | Cover emergency services without prior authorization and regardless of network status, and do not narrow the emergency definition by diagnosis code |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.110(b)(3) | For out-of-network emergency services, apply in-network cost sharing calculated on the recognized amount, pay within 30 days and count the cost sharing toward in-network limits |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.120 | Cover non-emergency services of nonparticipating providers at participating facilities at in-network cost sharing unless valid notice and consent were given, with the same 30-day payment and accumulator duties |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.130 | Cover nonparticipating air ambulance services at in-network cost sharing calculated on the lesser of the QPA and the billed amount, with direct payment within 30 days |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.140(a)-(b) | Calculate the median contracted rate for each item or service by service code, provider specialty, facility type, insurance market and geographic region |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.140(c) | Derive the qualifying payment amount from the median contracted rate, index it annually by the CPI-U, and use eligible databases or new-code rules where contracted rates are insufficient |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.140(d)-(f) | Disclose the QPA and its basis with each initial payment or denial, provide the further information a provider requests within 10 business days, and submit to audit |
Provider, facility and air ambulance duties: balance billing, notice and consent, disclosure (45 CFR 149.410 to 149.450; 42 U.S.C. 300gg-131 to 300gg-139) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
| Code | Title |
|---|---|
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.410(a),(c) | Do not balance bill patients for emergency services beyond in-network cost sharing, including for unforeseen urgent needs after stabilization |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.410(b) | Bill post-stabilization services out of network only when the attending physician confirms the patient can travel, valid notice and consent is obtained, the patient can receive it, and State law allows |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.410(d)-(e) | Retain emergency notice and consent documents for 7 years and tell the plan on each bill whether the post-stabilization conditions were met |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.420(a)-(b) | Do not balance bill for non-emergency services at a participating facility, and never for ancillary services or unforeseen urgent needs |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.420(c)(2)-(3),(e)-(g) | Obtain voluntary signed consent on the standard form, recording the notice and signature times, offer the documents in the 15 most common State languages, and give the patient a copy |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.420(c)-(d) | Give the standard written notice, separately from other documents, at least 72 hours before a scheduled service (or 3 hours on same-day scheduling), with the required content |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.420(h)-(i) | Retain non-emergency notice and consent documents for 7 years and notify the plan, with a copy of the consent, that the service was furnished at a participating facility |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.430(a)-(b) | Publish a plain-language disclosure of the balance billing protections, any State limits and the agency complaint contacts |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.430(c)-(f) | Post the disclosure on the website home page and on a prominent sign, and hand each covered patient a one-page notice no later than the request for payment or the claim |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.440 | Air ambulance providers must not bill patients beyond the in-network cost-sharing amount for covered out-of-network transports |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-138 | Accept the plan's payment and in-network cost sharing as payment in full for continuity-of-care patients and keep following the plan's policies |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-139(a) | Have business processes to send provider directory information to plans when joining or leaving a network, on material changes and on request |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::300gg-139(b) | Refund with interest any amount a patient paid above in-network cost sharing after relying on incorrect network information |
Uninsured and self-pay individuals: good faith estimates and patient-provider dispute resolution (45 CFR 149.610 and 149.620; 42 U.S.C. 300gg-136 and 300gg-137) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149
| Code | Title |
|---|---|
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.610(b)(1)(i)-(iv) | Ask every patient about coverage and whether a claim will be filed, treat any cost enquiry as a request, and advertise good faith estimates on the website, in the office and on site |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.610(b)(1)(v)-(vi),(ix) | Issue the good faith estimate within 1 business day of scheduling (3 business days when scheduled 10 or more days ahead or on request), after contacting co-providers within 1 business day |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.610(b)(1)(vii)-(viii),(x),(b)(2) | Reissue the estimate at least 1 business day before the service when the scope changes, bind replacement providers to the prior estimate, and limit recurring-service estimates to 12 months |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.610(c)-(d) | Include in the estimate the patient details, itemised services by provider with diagnosis and service codes and expected charges, provider identifiers, and the required disclaimers |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.610(e)-(f) | Provide the estimate in writing (paper or electronic as chosen) in plain language, keep it in the medical record, supply copies for 6 years, and correct errors promptly |
| us-no-surprises-act-42-usc-300gg-111-to-300gg-139-and-45-cfr-part-149::149.620(c)(5)-(6),(f) | While a patient-provider dispute is pending, stop collections and late fees, take no retributive action, supply the requested information within 10 business days and notify any settlement within 3 business days |
What is US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 and who does it apply to?
US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 is a compliance framework from United States (federal) with 5 domains and 44 controls. The United States' federal surprise medical billing law: the No Surprises Act provisions of the Public Health Service Act and the HHS rule at 45 CFR Part 149, covering plan and issuer coverage and payment duties for out-of-network emergency, facility-based and air ambulance care, the qualifying payment amount, provider and facility balance billing prohibitions with the notice and consent exception, public disclosures, continuity of care, provider directory accuracy, gag clauses, prescription drug reporting, the IDR registry, the Federal independent dispute resolution process, and good faith estimates and dispute resolution for uninsured and self-pay patients. It is used by organisations to establish and maintain compliance with industry standards and regulatory requirements.
What does US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 actually require?
US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 has 44 controls organised across 5 domains. The largest domains are Provider, facility and air ambulance duties: balance billing, notice and consent, disclosure (45 CFR 149.410 to 149.450; 42 U.S.C. 300gg-131 to 300gg-139) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (13 controls), Plan and issuer duties: patient protections, continuity, directories, gag clauses and reporting (45 CFR 149.310, 149.530, 149.710 to 149.740; 42 U.S.C. 300gg-113 to 300gg-120) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (11 controls), Plan and issuer duties: surprise billing coverage and the qualifying payment amount (45 CFR 149.100 to 149.150) – US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 (8 controls). Each control defines specific requirements that organisations must implement to achieve compliance.
If I already comply with another framework, how much of US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 do I already cover?
US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 does not currently have cross-framework mappings in our system. Check back as we continuously expand our mapping database.
How do I implement US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149?
Start your US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 compliance journey by running a self-assessment on our platform to identify your current compliance posture. Our AI advisory can answer specific questions about US No Surprises Act (42 USC 300gg-111 to 300gg-139) and 45 CFR Part 149 requirements, and cross-framework mapping helps you leverage existing controls from other frameworks you may already comply with. Create a free account to access all 44 controls and track your progress.
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