Providers have the right to a fast, fair, and cost-effective dispute resolution process for disputes regarding a claim payment, denial, billing determinations, and contract issues. NEMS MSO will ensure timely acknowledgement and resolution of provider disputes.

NEMS MSO will not request that providers resubmit claim or supporting documentation that was previously submitted to NEMS MSO as part of the claim’s adjudication process unless NEMS MSO returned the information to the provider.

Provider Dispute Resolution (PDR) request is a written notice to North East Medical Services (NEMS) MSO appealing a claim that has been paid, adjusted, contested, or denied; or seeking resolution of a billing determination; or disputing a request for reimbursement of an overpayment of a claim.

NEMS MSO will not discriminate or retaliate against a provider due to a provider’s use of the Provider Dispute process. A provider dispute is processed without charge to the provider; however, NEMS MSO has no obligation to reimburse the provider for any costs incurred during the provider dispute process.

NOTE: Claims denied due to provider’s claim submission error or omission (e.g., missing modifier, incorrect CPT / ICD-10, or place of service code, missing EOB/EOMB or requested invoice, etc.) DO NOT qualify for the Provider Dispute Resolution Mechanism and should be resubmitted within the claim’s submission timeframe as a corrected claim. Please include a brief explanation of the error either noted on the claim or as an attachment.

NEMS MSO PDR Process:

  1. Timeframe for PDR submission.
    • Medi-Cal: If the dispute is for a claim that was denied, contested, or underpaid, provider must submit a Provider Dispute Resolution request in writing along with any relevant and supporting documentation within 365 days of the last claim decision or action. If provider is disputing NEMS MSO request for reimbursement (i.e. refund) of a claim overpayment, provider must submit a written dispute within thirty (30) working days from receipt of the Notice of Overpayment.
    • Medicare: Non-contracted provider disputes: Pursuant to federal regulations governing Medicare Advantage programs, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the provider contends that the amount paid by the payer for a covered service that is less than the amount that would have been paid under Original Medicare. To dispute a claim payment, submit a written request within 120 calendar days of the remittance notification date and include all required elements.
  2. Elements. The dispute must include:
    • Provider’s Name
    • Provider’s NPI and/or Tax ID Number
    • Provider Contact Information (Address and Phone Number)
    • Patient’s Name and DOB
    • Claim Number from NEMS Explanation of Benefit
    • Copy of original claim being disputed
    • Identification of the disputed item(s)
    • Explanation of the basis that provider believes the payment amount, adjustment, denial, or request for reimbursement is incorrect
    • Other pertinent documentation to support the appeal
  3. Where to submit. Providers will submit the written provider dispute to the following address:
    North East Medical Services
    Attn: MSO Provider Claim Dispute
    1710 Gilbreth Road
    Burlingame, CA 94010
    NEMS does not accept PDR Request submitted by fax or email.
  4. Acknowledgment. NEMS MSO will send a written acknowledgment of a Medi-Cal PDR request within fifteen (15) working days of receipt of a paper PDR request, and within two (2) working days of receipt of an electronic PDR request.Please note that no written acknowledgement will be sent for Medicare PDR requests.
  5. Request for additional information. If NEMS MSO requires additional information in order to review and make a decision, NEMS MSO will send a written request to the provider, specifying the information requested. Provider has fourteen (14) calendar days from receipt of request for additional information to submit an amended PDR with the required information. NEMS MSO will not ask providers to resubmit additional information or supporting documents if they were previously submitted as part of the claim adjudication process.
  6. PDR Resolution. After its review, NEMS MSO will issue a written determination, including a statement of the pertinent facts and reasons, to the provider.
    • For Medi-Cal disputes, a written resolution letter will be sent back to the provided address on the dispute request within forty-five (45) working days from receipt of the request.
    • For Medicare disputes, a written resolution letter will be sent back to the provided address on the dispute request within thirty (30) calendar days from the receipt of the request.
    • Invalid dispute requests. Invalid disputes will be returned to the provider with indication of why the dispute is invalid. A dispute is considered invalid based on one or more of the following reasons:
        1. There has not been a determination made on the claim being disputed
        2. There is no member or claim record for the claim being disputed
        3. The dispute is a true duplicate of a previously resolved dispute
        4. For Targeted Rate Increase (TRI) related disputes, provider was not eligible for TRI rates at the time of services
    • Appeals are forwarded to Plan. NEMS MSO is not delegated to process Medicare Appeals or second level provider disputes. Upon receipt of such requests, NEMS MSO is required to forward them to the corresponding health plan for processing.
  7. Goodwill Pay. If the determination finds that the original claim decision was correct, NEMS MSO may, upon its sole discretion, allow reconsideration based on certain extenuating circumstances and reprocess a claim for goodwill payment. Any payable amount for this claim will not warrant interest. Payment will be issued within five (5) working days from the date of the written dispute resolution.
  8. Overturned Claim. If a dispute determination is in favor of the provider, claim will be reprocessed and payment plus applicable interest shall be issued within five (5) working days from the date of the written dispute resolution.
  9. Penalty for failure to automatically pay interest. If NEMS MSO fails to pay interest due within 5 working days of the from written dispute resolution, additional penalty of $10 per claim shall be paid.
  10. Dispute Resolution Costs. A provider dispute is processed without charge to the provider; however, NEMS MSO has no obligation to reimburse the provider for any costs incurred during the provider dispute process.
  11. No Discrimination. NEMS MSO shall not discriminate or retaliate against a provider due to a provider’s use of the provider dispute process.
  12. Retention of records. Copies of provider disputes and determinations, including all notes, documents and other information upon which NEMS MSO relied to reach its decision, and all reports and related information shall be retained for no less than five (5) years.