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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:
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. 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. Completed PDRR Forms should be mailed to:
North East Medical Services 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. |
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