January 1, 2020, with further alignment to the federal No Surprises Act (NSA) in 2022.

The District of Columbia (Washington, D.C.) enacted comprehensive balance billing protections shortly before the federal NSA took effect. D.C. law provides strong patient protections, but does not establish its own out-of-network (OON) payment benchmark or independent arbitration process recognized by CMS.

As a result, D.C. relies on the Federal NSA IDR system for resolving OON payment disputes.

D.C. law protects patients who receive care from an OON provider in emergency or unintentional OON scenarios. Under D.C. statute:

• Patients can only be billed in-network cost sharing for covered emergency and certain non-emergency situations.
• Providers must submit OON claims directly to the health carrier, not the patient.
• Carriers must make a reasonable and timely initial payment based on their standard methodology.

D.C. does not set a fixed payment benchmark (e.g., APCD, UCR, or state fee schedule).
Once the NSA took effect, most applicable claims defaulted to the federal QPA methodology.

D.C. does not run its own state IDR or arbitration program related to surprise billing.

Therefore:

• Federal NSA IDR governs all qualifying OON disputes.
• There is no D.C. “Specified State Law (SSL)” for determining payment rates.
• Providers must use the federal IDR portal for eligible claims.

This includes disputes involving:

• Emergency OON services
• Non-emergency OON services rendered at in-network facilities
• Air ambulance services
• Claims involving QPA-based initial payment disagreements

D.C. adopts the federal NSA negotiation timeline, requiring:

• A 30-day negotiation period after initial payment or denial.
• Both parties to participate in good-faith discussions.
• Submission to Federal IDR if unresolved.

D.C. law does not impose additional, state-level negotiation steps.

Because Washington, D.C. relies on the federal arbitration process, the IDR entity reviews the federal statutory criteria, including:

• Qualified Payment Amount (QPA) — primary factor
• Provider experience, education, and patient acuity
• Contracting history between provider and plan
• Market share of the provider or carrier
• Complexity and circumstances of the service
• Good-faith contracting behavior

D.C. law does not introduce any additional arbitration standards.

D.C.’s balance billing protections and insurance requirements are contained in:

• D.C. Code § 31–3171.01 et seq. (Surprise Billing Protections)
• Department of Insurance, Securities and Banking (DISB) regulations
• Adoption of federal NSA requirements under 45 CFR 149.510 & 149.520

These statutes establish strong patient protections but do not provide a separate OON payment methodology.

CMS has determined that Washington, D.C. does not maintain a Specified State Law (SSL) for OON payment rate determination.

• Fully insured commercial plans
• Individual health insurance policies
• Group health coverage
• Self-funded ERISA plans (unless opting into another SSL — extremely uncommon)

• The QPA is the controlling benchmark for OON payment disputes.
• All eligible disputes must proceed through Federal IDR.
• D.C. carriers must follow NSA timelines, disclosures, and payment processes.
• D.C.’s state law enhances patient protections but does not alter NSA payment methodology.