Is this claim eligible, and where does it go?

The No Surprises Act protects three kinds of out-of-network care:

1. Emergency services, including care in a freestanding ER and post-stabilization care until the patient can be moved.
2. Non-emergency services at an in-network facility by an out-of-network provider. This is where anesthesia, radiology, pathology, assistant surgeons, hospitalists and ED physicians live. One exception: the patient can sign a notice-and-consent waiver for some services, but not for emergency care, anesthesia, radiology, pathology, lab, neonatology, assistant surgeons, hospitalists or intensivists.
3. Air ambulance.

Out-of-network care at an out-of-network facility, or elective care the patient chose knowingly, isn’t protected. Those claims have no IDR path.

Self-funded or fully insured is the single most important fact, and it’s often on the card.

• New York. Fully insured, state-regulated plans must say so on the card. If it doesn’t say “fully insured” or name a New York license, treat it as self-funded until proven otherwise.
• Texas. State-regulated plans carry “TDI” or “DOI” on the card. No TDI or DOI marking usually means self-funded (federal) or a plan from another state.
• New Jersey. A self-funded plan that opted in to the New Jersey process must print “SELF-FUNDED” on the card, with a statement that it opted in. No marking is a hint the plan is fully insured, not proof.
• Any state. Words like “ASO,” “administered by,” “plan sponsor” or “benefits administrator” point to self-funded. A group number plus a large employer name is a hint, not proof.
• Still unsure? Call the number on the card and ask: “Is this plan fully insured or self-funded, and in what state is it issued?” Write the answer on the claim. The 2027 remark codes will also help (below).

A state law replaces federal IDR only when all three are true: the plan is regulated by that state, the provider is in that state, and the service happened there. Self-funded plans skip state law unless they opted in. Out-of-state plans skip it too.

Other states have their own laws. Some use a payment standard instead of arbitration, which means no dispute path at all. Maryland, Pennsylvania and Vermont have all-payer model agreements for some services. Ask us before filing anywhere not listed here.

Practical rule: self-funded (ERISA) plans are usually the cleaner target. Unless the plan opted in to a state process (possible in New Jersey, Virginia and Texas, never in New York), they go federal, the batching rules apply, and the state quirks above don’t.

Starting with services on or after January 1, 2027, insurers must include one of nine No Surprises Act remark codes (RARCs) on every out-of-network line, on paper and in the 835. The code answers one question: can this payment go to federal IDR?

• N876 and N877 mean the line is subject to the Act and federal IDR is open after open negotiation. These are your signal to start the 30-business-day clock.
• N871 means a state law set the payment. Work the state process, not federal IDR.
• The other codes mean not eligible: the plan doesn’t cover the service, a waiver applies, a state payment standard applies, and so on.

Why the codes aren’t a screen on their own:

1. They only start in 2027. Any service in 2026 or earlier has no required code. Absence of a code isn’t a no.
2. The insurer picks the code. Federal audits posted in October 2026 found insurers using the wrong inputs for the qualifying payment amount on hundreds of claims. A code is the insurer’s opinion, not a ruling.
3. A “not eligible” code can be wrong. If the card says self-funded and the service was at an in-network facility, question an N871 or a “state law” code.
4. The code doesn’t tell you the deadline. It tells you the door is open. Open negotiation still has to start within 30 business days of the initial payment or denial.

Use the code to triage. Use the card and the facility status to decide.

1. Service protected? (Emergency, OON at in-network facility, or air ambulance.) If no, stop.
2. Right kind of coverage? (Not Medicare, Medicaid, MA, TRICARE, VA, comp.) If no, stop.
3. Self-funded? Federal IDR. Go to batching.
4. Fully insured in a state with its own law, and provider and service in that state? State process.
5. Fully insured anywhere else? Federal IDR.

Eligibility is the first thing we check in the free claims review of your last 60 days of remittances. You get a list of which claims can go federal, which belong in a state process, and which shouldn’t be filed. Your group approves what moves forward, and we agree roles with your billing team before anything is filed.