NEMS MSO accepts claims submitted electronically through a partnered clearinghouse, or on paper by mail.

Electronic Claims Submissions (Recommended)

NEMS MSO accepts EDI claims submission from with these below clearinghouses:

  • ClaimRemedi
  • Experian Health
  • eSolutions, Inc.
  • nThrive, Inc.
  • Office Ally, Inc.
  • Trizetto Provider Solutions, LLC.
  • ViaTrack
  • Waystar
  • ZirMed, Inc.

To inquire about clearinghouses that are not listed, please contact the NEMS MSO Provider Relations at [email protected].

Paper Claims Submission

Providers who are unable to submit claims electronically may submit paper claims by mail. Paper claims must be on the current and standard original claim forms and mailed to NEMS MSO. NEMS MSO does not accept faxed copies of claims. Paper claims submission requirements are described below:

  • The most current and standard CMS-1500 (HCFA-1500) or CMS-1450 (UB-04) claim form must be used. The form needs to be in Flint OCR Red, J6983 (or exact match) ink. NEMS MSO does not supply claim forms to providers. Providers should purchase these forms from a supplier of their choice.
  • Although a copy of the claims forms can be downloaded, photocopies of the claims form cannot be used for submission of claims since a copy may not accurately replicate the scale and Optical Character Recognition (OCR) color of the form.
  • Medical coding, or the claims information, must be typed in black ink with 10-point or 12-point Times New Roman font on the required original red and white version to ensure clean acceptance and processing.
  • Claims submitted on black and white, handwritten, or nonstandard forms will be rejected, and a letter will be sent to the provider indicating the reason for rejection. These claims will not be returned to the provider.
  • To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions.

CMS-1500 and CMS-1450 completion and coding instructions are available on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov.

Paper claims and supporting documents shall be mailed to the appropriate entity:

 Network Name  Claims Mailing Address
SFHP – NEM
SFHP – NMS
SCFHP – NEMS		 Professional Claim  Hospital/Facility Claim
 NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577		  NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577
 Anthem Blue Cross – NEMS  Professional Claim Hospital/Facility Claim
 NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577		 Anthem Blue Cross
PO Box 60007
Los Angeles, CA 90060-0007
 Alignment Health Plan – NEMS  Professional Claim Hospital/Facility Claim
 NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577		 Alignment Health Plan
Attn: Claims Department
PO Box 14012
Orange, CA 92863-1412
 Health Net/GBHP – NEMS  Professional Claim Hospital/Facility Claim
 NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577		  NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577
 NEMS PACE  All Claims
NEMS MSO Claims
PO BOX 1548
San Leandro, CA 94577

Acknowledgement of Claims

  • NEMS MSO acknowledges electronically submitted claims, whether or not the claims are complete, within two business days, via TA1 and 997/999 transaction to submitters to acknowledge the receipt of claims and to report syntax errors related to any transactions following receipt of the EDI file.
  • NEMS MSO acknowledges paper claims within 15 business days following receipt.
    • If a paper claim is paid or denied within 15 days, the Remittance Advice (RA) is the acknowledgment of claims receipt. Providers with access to the NEMS MSO Provider Portal may check claims status online 24/7 here.
  • Claims received from a provider’s clearinghouse are acknowledged directly to the clearinghouse in the same manner and time frames noted above.

NEMS MSO follows the Timely Claims Payment rule according to 42 CFR Ch. IV, HHS, §447.45 and Title 28 CCR § 1300.71:

  • 90% of clean provider claims must be paid, contested, or denied within 30 calendar days of the first received date.
  • 95% of claims must be paid, contested, or denied within 45 business days.
  • If claims are paid beyond 45 business days, the claim will automatically include interest per AB1455 for the period of time that the payment is late.
  • 99% of all clean provider claims must be paid within 90 days of the date of receipt.
  • The timely payment period is the same for both electronic and paper claims.

Balance Billing

Balance billing is strictly prohibited by NEMS policy, Health Plans, and state and federal law.

Providers are prohibited from billing covered members for fees and surcharges above and beyond a member’s copayment and coinsurance responsibilities for services covered under a member’s benefit program, or for claims for such services denied by NEMS MSO. Providers are also prohibited from initiating, or threatening to initiate, a collection action against a member for non-payment of a claim for covered services. Participating providers agree to accept reimbursement from NEMS for services as payment in full and final satisfactory, except for applicable copayments, coinsurance, or deductibles.

Billing Medicare–Medi-Cal Members Prohibited

Providers are prohibited from collecting Medicare Parts A and B deductibles, coinsurance, or copayments from members enrolled in the qualified Medicare beneficiaries (QMB) program, which exempts members from Medicare cost-sharing liability. For members enrolled in the Health Net Medicare Advantage program and assigned to NEMS PPG, providers can either accept the NEMS MSO payment as payment in full or bill the state for applicable Medicare cost-sharing for members who are eligible for both Medicare and Medicaid. This prohibition applies to all Medicare Advantage (MA) providers, not only those that accept Medicaid. In addition, balance billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts.

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. Provider may obtain a PDR form here. 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.