In January 2025, the Centers for Medicare & Medicaid Services (CMS) released Part 69 of its ongoing FAQ series, addressing the implementation of the No Surprises Act (NSA).
While the document largely reiterates prior guidance on Qualified Payment Amount (QPA) calculations and disclosure obligations, the key development in this update is the introduction of a new extension pathway for providers, facilities, and air ambulance services who miss Independent Dispute Resolution (IDR) deadlines due to delayed or missing disclosures from health plans or issuers.
This blog highlights the key actionable updates from CMS’s guidance, with input from FHAS experts Lauren Masulis and Luigi Romano, and offers practical recommendations to help stakeholders navigate these changes.
What’s Changed: Historically, providers who failed to receive timely QPA disclosures were forced to absorb the financial loss when they missed the open negotiation deadline. This new policy allows these providers to request an extension, providing a valuable opportunity to pursue disputes even when the necessary disclosures were delayed or never received.
Under this extension policy, providers now have the option to submit a formal request to CMS for deadline relief. The request must be submitted via email and include an explanation of why the QPA disclosures were delayed or missing, along with supporting documentation.
As Lauren Masulis notes, “It's important for providers to get their outstanding claims in promptly. Even if all are not accepted, submitting them in a timely way helps make sure they’re in the mix when recovery opportunities come up.”
How to Request an Extension: To request an extension, providers need to email CMS at FederalIDRQuestions@cms.hhs.gov. In the email, they should include the following details:
Keep in Mind: While this extension policy represents a significant shift, it’s important to note that CMS has not guaranteed approval of these requests. Each request will be reviewed on a case-by-case basis, and CMS response times may vary. Providers should be prepared for the possibility that their request may be denied, but at least they now have a chance to pursue their claims.
Following the Fifth Circuit’s decision in TMA III, plans and issuers must calculate QPAs using a good-faith, reasonable interpretation of the applicable statutes and regulations, as outlined in the 2024 QPA methodology. This significant change impacts both how QPAs are calculated and how these amounts are disclosed to providers, facilities, and air ambulance services.
In light of the TMA III decision, CMS has extended enforcement discretion through August 1, 2025, for both providers and plans that rely on the 2021 or 2023 QPA methodologies. This means that for items and services provided before this date, health plans and issuers can continue to use the 2021 or 2023 QPA methodologies, provided that they do so in good faith and comply with the necessary disclosure requirements. The Fifth Circuit's decision may still be reheard, which could alter future guidance, so it’s important for stakeholders to stay up to date.
One of the primary sources of confusion for providers has been the start of the 30-business-day window for opening negotiations in IDR. In the past, when disclosures were delayed or sent separately from payment or denial notices, the timeline for sending a negotiation notice often began prematurely, leaving providers in a bind.
CMS’s clarification on this issue is a welcome relief. The agency has confirmed that the 30-business-day window for opening negotiations in IDR will not begin until the provider receives both the initial payment (or denial) and the required QPA disclosures. If there is a delay in receiving one or the other, the clock is effectively paused until both documents are in hand.
This clarification is crucial because it offers providers more certainty around their rights in the IDR process and supports them in pursuing timely negotiation, even when paperwork arrives late or is out of sync.
Plans and issuers must ensure that QPAs are disclosed to nonparticipating providers, facilities, and air ambulance services with initial payments or notices of denial. Under the clarified rules, the disclosure must include:
These disclosures should be provided promptly, and failure to comply with these requirements could delay the initiation of the negotiation process. As Masulis notes, “It’s crucial for providers to track the delivery methods of all documents and be ready to act if there are discrepancies or delays in receiving these disclosures.”
In light of the recent updates, here are some key recommendations for health plans, issuers, and providers to follow as they navigate the IDR process:
CMS’s introduction of an extension policy for missed IDR deadlines due to delayed disclosures is a significant development that offers providers a lifeline in disputes. While CMS has made it clear that approval of extension requests is not guaranteed, the ability to request a deadline extension is a crucial new opportunity for providers who have been hampered by timing issues beyond their control.
FHAS will continue to monitor developments in the CMS FAQ guidance and provide ongoing insights to help our clients stay informed and compliant as they navigate the evolving IDR process under the No Surprises Act.