The Texas Medical Association and additional plaintiffs have brought four Administrative Procedure Act (APA) challenges to the rules and guidance implementing the No Surprises Act (NSA) (termed TMA I, II, III and IV). The plaintiffs filed all four challenges in the US District Court for the Eastern District of Texas, Tyler Division. District Judge Jeremy Kernodle heard all four actions and released his opinion in TMA III on August 24, 2023. The US Department of Justice (DOJ) has not yet stated whether it will appeal or seek a stay of TMA III. If TMA III stands, it will have a significant impact on processing and payment of out-of-network claims, out-of-network cost sharing paid by patients and operation of the federal independent dispute resolution (IDR) process. This report summarizes the TMA III court decision and assesses the potential next steps available to the US Departments of Health and Human Services, Labor and Treasury (the Departments).