Claims Disputes

NEMS MSO has set up the Provider Claim Dispute Resolution Mechanism to handle any claims disputes from a contracted provider. Providers may submit a claims dispute through the mechanism for the following reasons:

  • To appeal or request reconsideration of a claim that has been reimbursed, adjudicated or denied
  • To seek resolution of a billing determination
  • To dispute a request for reimbursement of an overpayment of a claim

NOTE: Claims that are denied due to provider's claim submission error or omission (e.g. missing modifier, incorrect CPT / ICD-9 or place of service code, etc.) do not qualify for the Provider Claim Dispute Resolution Mechanism. These claims should be resubmitted within the time period for claims submission as a "corrected claim." Please include a brief explanation of the error either noted on the claim or as an attachment.