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
- 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 providerís 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.
Provider Claims Dispute Resolution Mechanism
If a provider wants to dispute a claim payment or denial, the provider can submit
a completed Provider Dispute Resolution Request (PDRR) Form within 365 days
of the last adjudication of the claim.
- Download a PDRR Form ( Word | PDF )
- Download a PDRR Instructions ( Word | PDF )
Completed PDRR Forms should be mailed to:
North East Medical Services
Attn: MSO Provider Claims Dispute
369 Broadway Street
San Francisco, CA 94133
Dispute Resolution Timeline
NEMS will acknowledge the receipt of the PDR within fifteen (15) working days of receipt of the dispute.
NEMS will issue a written determination, including a statement of the pertinent facts and reasons, to the provider within forty-five (45) working days after receipt of the provider claim dispute.
If the initial submission of the PDRR is incomplete, NEMS will return it to the provider with identification of the missing information. Provider has fifteen (15) working days to resubmit an amended PDRR with requested information.
NEMS will issue a written determination to the provider within forty-five (45) working days after receipt of the amended PDRR.