Administrative Denials

All claims for services submitted without the required prior authorizations will be processed as Administrative Denials for reimbursement. A Remittance Advice will be sent to the service provider with a detailed explanation of the claims adjudication, and guidelines for a provider claims dispute.

If an Advanced Outpatient Procedure is required on an urgent basis, or Prior Authorization cannot be obtained because it is outside of NEMS MSO’s normal business hours, the service may be performed, and authorization should be requested retroactively within two (2) business days of the service. Documentation must include an explanation as to why the procedure was required on an urgent basis and/or could not be pre-authorized during NEMS MSO’s normal business hours. Please refer to the "Retroactive Authorization Requests" section below.