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 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.

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.

MSO Contact Information:
MSO Main Phone Number:
Claims Processing & Payment:
Member/Provider Services & Eligibility:
Language Assistance:
TDD/TTY Services for deaf, hard of hearing,
or speech impaired:
Utilization Management:
415-352-5045
415-352-5041
415-391-9686 ext. 8160
415-352-5045

1-800-735-2929
415-352-5045

The following services are available for members and providers who have any Utilization Management (UM) issues, such as questions pertaining to treatment requests:
  • Staff are available during normal business hours from 8:30 AM to 5:00 PM to receive phone calls.
  • After normal business hours, members and providers can leave a message on voicemail. Calls will be returned within one business day.
  • Our staff are identified by name, title and organization name when initiating or returning calls.
  • Members who are deaf, hard of hearing, or speech impaired may call 1-800-735-2929 for TDD/TTY services.
  • Members may call 415-352-5045 for language assistance.