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:
- Timeframe for PDR submission. 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.
- 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
- 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
2171 Junipero Serra Blvd., Suite #600
Daly City, CA 94014
- Acknowledgment. NEMS MSO will send a written acknowledgment of a PDR request within fifteen (15) working days of receipt of a paper PDR, and within two (2) working days of receipt of an electronic PDR request.
- 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 within thirty (30) working days from receipt of the PDR, specifying the information requested. Provider has thirty (30) working days from receipt of request for additional information to submit an amended PDR with the required information. NEMS MSO will not request providers to resubmit additional information or supporting documents if these were previously submitted as part of the claim adjudication process.
- PDR Resolution. After its review, NEMS MSO will issue a written determination, including a statement of the pertinent facts and reasons, to the provider within forty-five (45) working days from receipt of the provider dispute.
- 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.
- 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.
- 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.
- 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.
- No Discrimination. NEMS MSO shall not discriminate or retaliate against a provider due to a provider’s use of the provider dispute process.
- 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.