Healthcare technology company Zelis has deployed an AI-native solution that helps health plans manage the complexities of independent dispute resolution under the No-Surprises Act.
Independent Dispute Resolution (IDR) is a process for adjudicating out-of-network claims created by the No Surprises Act of 2020 (NSA).
Zelis’ solutions use AI to automate payer workflows from claim recalculation, public negotiation, dispute prevention, case management, and IDR resolution. Executives said the company announced the new solution as payers’ operations are strained by dispute volume, compliance requirements and procedural deadlines.
In late May, the Centers for Medicare and Medicaid Services finalized changes to the No-Surprise Act dispute resolution process. The rule, a joint effort by the Departments of Health and Human Services, Labor and Treasury, and the Office of Personnel Management, lowers administrative fees for disputes from $115 to $15, which federal officials say 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 aimed at reducing ineligible disputes and improving the efficiency of the overall federal dispute resolution process.
The rule requires payers to use standardized billing codes in out-of-network medical communications, which allows providers to easily identify whether a particular claim is subject to an IDR.
Zelis says its new solution supports evolving requirements under the NSA, including changing deadlines, reporting obligations, and process complexity.
The solution automates workflows, reduces operational blind spots throughout the IDR process, and streamlines out-of-network claims processing. The company says the solution enables payers to move from manual, disaggregated dispute management to a more strategic, data-driven operating model.
The solution uses automated ingestion, documentation, alerting and escalation workflows to ensure cases progress on time, reducing the risk of missed deadlines, unnecessary fees and avoidable financial leaks, company executives said. The solution features real-time dashboards, qualified payment amount (QPA) comparative analysis, a complete communications audit trail, and evidence-based pricing recommendations.
It also features predictive intelligence for customized case submissions, contests ineligible disputes, and uncovers independent dispute resolution organization (IDRE) behavior and provider patterns to optimize settlement strategies and drive improved performance, the company said.
“While rule changes by CMS and HHS have improved NSA efficiency and long-term sustainability, payers are overwhelmed by the complexity and cost associated with the IDR process,” Jim Bridges, president of price optimization at Xeris, said 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 at every step of the process to identify risks early, reduce avoidable disputes, and replace guesswork with predictable outcomes.”
Far more claims were pushed into the IDR stage than the Fed originally anticipated when setting up the No-Surprises Act process. When it first opened in 2022, the federal IDR portal was flooded with nearly 14 times as many disputes as originally predicted, and the annual caseload is now more than 100 times that forecast, according to a 2025 HHS fact sheet (PDF).
According to CMS, more than 5 million disputes have been sent to IDR since April 2022, when the process was established.
Payers have criticized this trend, citing data showing that a small number of providers account for the majority of disputes that result in IDRs. And when the case goes to arbitration, the provider has an overwhelming chance of winning and making a lot of money.
Following court rulings that revised the guidance CMS provides to third-party arbitrators, IDR has largely favored providers over payers. For example, in the second quarter of 2025, the rates offered by providers during IDR disputes were selected in approximately 87% of closed disputes.
Zelis says its new solution builds on its experience in claims processing, including saving $2.39 billion processing NSA claims in 2025, with only about 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 health care providers and consumers.
