Healthcare technology company Zelis rolled out an AI-native solution to help health plans manage Independent Dispute Resolution complexity under the No Surprises Act.
Independent Dispute Resolution (IDR) is the process for adjudicating out-of-network claims created by 2020’s No Surprises Act (NSA).
Zelis' solution uses AI to automate payers’ workflows, from claim repricing, open negotiation, dispute prevention, case management and IDR resolution. The company unveiled the new solution as dispute volume, compliance requirements and process deadlines pressure payer operations, executives said.
In late May, the Centers for Medicare and Medicaid Services finalized changes to the No Surprises Act dispute resolution process. The rule, finalized jointly by the Departments of Health and Human Services, Labor and Treasury as well as the Office of Personnel Management, would reduce the administrative fees on disputes from $115 to $15, which the feds argue will make it easier to participate while "maintaining a self-sustaining program."
The final rule introduces new communication, open negotiation, eligibility, batching and process requirements designed to reduce ineligible disputes and improve efficiency across the federal dispute resolution process.
The rule requires payers to use standardized claims codes in communications about out-of-network care, making it easier for providers to identify whether a particular claim is eligible for IDR.
Zelis says its new solution supports evolving requirements, including changing deadlines, reporting obligations and process complexity under the NSA.
The solution automates workflows and reduces operational blind spots across the IDR process, helping streamline out-of-network claims processing. The solution enables payers to move from manual, fragmented dispute management to a more strategic, data-driven operating model, according to the company.
By using automated intake, documentation, alerts and escalation workflows, the solution ensures cases progress on time, reducing the risk of missed deadlines, unnecessary fees and avoidable financial leakage, company executives say. The solution features real-time dashboards, Qualified Payment Amount (QPA) comparison analytics, full communication audit trails and evidence-based pricing recommendations.
And it features predictive intelligence for customized case submissions, challenges non-qualifying disputes and surfaces Independent Dispute Resolution Entity (IDRE) behavior and provider patterns to optimize settlement strategies and drive stronger performance, the company said.
"Rule changes by CMS and HHS have improved the efficiency and long-term sustainability of the NSA, but payers are overwhelmed by complexity and costs associated with the IDR process," said Jim Bridges, president, price optimization at Zelis, in a statement. “Zelis NSA Claim Advantage gives payers a smarter way to manage the IDR lifecycle. It combines AI-native automation, data-driven intelligence and human review across every step in the journey to identify risks earlier, reduce avoidable disputes and replace the guesswork with predictable outcomes.”
Far more claims were pushed to the IDR phase than the feds had initially anticipated in setting up the No Surprises Act process. When it first opened in 2022, the federal IDR portal received an influx of disputes nearly 14 times greater than what was initially projected—and the annual volume is now more than 100 times the initial projection, according to a 2025 HHS fact sheet (PDF).
Since April 2022, when the processes were established, there have been more than 5 million disputes sent to IDR, according to CMS.
Payers have roundly criticized this trend, citing data that show a small number of providers account for a large swath of disputes that reach IDR. And when cases are sent to arbitration, providers are overwhelmingly likely to win, and win big.
IDR has largely favored providers over payers in the wake of court decisions that revised the guidance the CMS provides to third-party arbitrators. In the second quarter of 2025, for instance, the rates put forth by providers during an IDR dispute were selected in about 87% of closed disputes.
Zelis says its new solution builds on its experience with claims processing, including processing $2.39 billion in NSA claim savings in 2025 with only approximately 8% of claims escalated to IDR.
The company serves more than 750 payers, including the top five national health plans, regional health plans, TPAs as well as healthcare providers and consumers.