Knowledge Center

New Jersey took a major step toward protecting patients on June 1, 2018, when Governor Phil Murphy signed the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act, better known as the NJ Surprise Bill Act. The law bans balance billing and sets stricter rules for how providers disclose network and billing information.

At its core, this law shields patients from unexpected medical bills that arise when care is delivered by an out-of-network provider often in emergency, urgent, or inadvertent care settings. These are the situations where patients, through no fault of their own, once faced charges for the gap between a provider’s billed amount and the insurer’s payment.

The Act applies to fully insured health plans, the State Health Benefit plans, and self-funded plans that have chosen to be governed by New Jersey law. Beginning January 1, 2022, the Federal No Surprises Act (NSA) took effect, covering self-funded plans that did not opt in, as well as fully insured claims for services not addressed by the state law, for example, post-stabilization care.

As of January 28, 2021, 137 self-funded plans had joined New Jersey’s arbitration process.

Among them: NJ Manufacturers, Kearny Bank, CentraState Healthcare System, Redfin Corporation, and Roosevelt Paper Company.

A full list is available through the NJ Department of Banking and Insurance (DOBI).

What the Law Requires

The NJ Surprise Bill Act introduced a number of obligations that every healthcare facility and provider needs to understand:

1. Disclosure and notification
   Before scheduling non-emergency or elective procedures, facilities and providers must disclose their network participation, applicable medical codes, and expected fees.
2. Balance billing prohibition
   Patients can no longer be billed beyond their in-network deductible, copay, or coinsurance when services are medically necessary and provided during emergencies, urgent visits, or inadvertent out-of-network situations.
3. Mandatory assignment of benefits
   When a patient receives emergency or inadvertent out-of-network care, benefits are automatically assigned to the provider. The patient does not need to take any further action.
4. Arbitration process
   If a payment dispute exceeds $1,000 and negotiations fail, either the provider or the payor can trigger a binding “baseball-style” arbitration. The arbitrator must choose one of the two final proposed reimbursement amounts within 30 days.
5. Prohibition on cost-sharing waivers
   Out-of-network providers are prohibited from waiving patient cost-sharing obligations to encourage the selection of their services. The only exceptions are activities that qualify under specific federal safe harbor provisions.

What This Means for Independent Surgeons

For out-of-network surgeons, the NJ Surprise Bill Act changed more than billing, it reshaped how claims are managed and negotiated. Independent providers now face compressed timeframes and stricter procedural requirements.

• Carriers have 20 days to either pay a bill or notify the provider that the charge is excessive.
• Providers then have 30 days to contest the insurer’s position and negotiate payment.
• If the two sides still cannot agree, either party may move to binding arbitration, where an independent arbitrator must select one of the two final payment proposals within 30 days.

CHRMS supports surgeons through every step of this process. Our team monitors filing deadlines, manages negotiations, and leads arbitration when needed ensuring independent providers don’t leave legitimate reimbursement on the table. This is where expertise, strategy, and advocacy combine to protect what you’ve earned.

The Federal No Surprises Act and State Precedence

The Federal No Surprises Act (NSA) became effective January 1, 2022, establishing national protections against balance billing. However, when a state like New Jersey has its own dispute-resolution system in place, the state law takes precedence. Which law applies depends on the type of plan and the services rendered.

Because the NSA introduces tighter filing windows and more narrowly defined negotiation and arbitration processes, timing now plays a critical role in claim success. Independent surgeons must act quickly and accurately to protect reimbursement opportunities.

CHRMS: Empowering Independent Surgeons to Navigate With Confidence

Since New Jersey’s law went into effect, CHRMS has guided out-of-network surgeons through every change in surprise billing legislation. We help providers understand the nuances of both state and federal requirements and use that knowledge to secure fair, lawful reimbursement.

Our mission is to empower independent surgeons: to remove administrative roadblocks, to handle complex payer disputes, and to ensure compliance without compromising recovery.

Have questions about the NJ Surprise Bill Act, the Federal No Surprises Act, or how either impacts your revenue?

CHRMS can help.

We provide clarity, structure, and expert representation, so you can focus on what matters most: caring for your patients and sustaining your practice.