External review. A process for appealing an adverse insurer determination — that is, a coverage decision — that involves consideration of whether an insurer is complying with the No Surprises Act.
Federal enforcement. The federal government has responsibility for enforcing the relevant provisions.
Hybrid. State process for determining payments to out-of-network providers where a state requires a standard payment from insurer to providers as compensation for the out-of-network service, and also has a dispute resolution process if the resulting payment is rejected or otherwise fails.
Hybrid, Limited IDR. State process for determining payments to out-of-network providers where a state requires a standard payment from insurer to providers as compensation for the out-of-network service, and also has a dispute resolution process in limited circ*mstances (for example, only for emergency services), if the resulting payment is rejected or otherwise fails.
Independent dispute resolution (IDR). Process for determining payments to out-of-network providers when providers challenge the amount paid by the insurer and when negotiations fail.
Patient–provider dispute resolution. A process for resolving disputes between patients and providers with regard to good-faith cost estimates.
Payment Rule. State process for determining payments to out-of-network providers where a state requires a standard payment from insurer to provider as compensation for the out-of-network service.
Provider. A facility covered under the No Surprises Act (hospital, critical access hospital, hospital outpatient department, or ambulatory surgery center), an individual physician or nonphysician provider, or an air-ambulance provider.
Shared (collaborative enforcement). Enforcement is shared, and a collaborative enforcement agreement between the state and the federal government will be used to allocate responsibilities for at least some designated provisions. For example, for enforcement against providers, the state might investigate and issue voluntary enforcement letters and the federal government would impose civil monetary penalties as needed.
Shared enforcement. Some provisions are enforced by the state and some by the federal government.
Specified state law. A state law that is recognized as having a specific mechanism to determine how much insurers should pay out-of-network providers.
State enforcement. The state has responsibility for enforcing the provisions that apply to state-regulated insurers and/or providers.
