Claims Submission

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.