Healthcare Billing Service Agreement

HEALTHCARE BILLING SERVICE AGREEMENT

Parties and Contact Information

Recitals and Effective Date

This Healthcare Billing Service Agreement (the Agreement) is entered into by and between Provider: and Billing Company: . The parties agree that the Effective Date of this Agreement is .

Definitions

For purposes of this Agreement: "Claims" means charges, claims, appeals, adjustments and other submissions for payment to payors; "PHI" means protected health information as defined by applicable law; "Remittance" means payment, explanation of benefits, and/or electronic funds transfer originating from payors to Provider or to which Provider is entitled.

Scope of Services

Billing Company will perform claim preparation, submission, monitoring, payment posting, denial management, patient billing and collections, and routine reporting (collectively, Services) on behalf of Provider in accordance with applicable law and industry standards. Specific services to be performed are set out in the Service Summary below and may be amended by written agreement.

Fees, Payment and Remittance

Provider shall pay Billing Company fees as compensation for Services. Fee structure: . Standard billing fee (percentage of collected funds) is %.

Remittance processing: Billing Company will transmit funds due to Provider, less agreed fees and authorized adjustments, on a basis. Unless otherwise agreed, Billing Company shall provide an itemized remittance report with each disbursement.

Authorization; Assignment of Benefits

Provider authorizes Billing Company to prepare and submit Claims to third-party payors and to receive payments and remittance information on Provider's behalf. Provider assigns to Billing Company the right to receive electronic explanations, payment information, and, where permitted, direct remittance of payor payments to the Billing Company for processing as described in this Agreement.

HIPAA Compliance and Confidentiality

Billing Company shall comply with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy and security laws. Billing Company will implement administrative, physical and technical safeguards to protect PHI and shall execute a Business Associate Agreement when required by law. Provider retains ownership of all PHI and clinical records.

Billing Company confirms the following obligations (check all that apply):

Data Security and Access

Billing Company shall maintain secure systems for electronic claims transmission and storage of PHI and shall limit access to authorized personnel. Provider will provide Billing Company reasonable access to clinical and billing records necessary to perform Services. Any subcontractor with access to PHI must be contractually bound to comply with this Agreement.

Provider Obligations

Provider represents and warrants that: (a) Provider will supply accurate and complete patient records and payor information in a timely manner; (b) Provider will cooperate in appeals and denials management when requested; and (c) Provider retains responsibility for clinical documentation and coding accuracy.

Denials, Appeals and Chargebacks

Billing Company will use commercially reasonable efforts to manage denials and appeals. Chargebacks or recovered payments resulting from Provider non-compliance, billing errors, or rescinded authorizations shall be charged back to Provider and may be withheld from future remittances.

Term, Renewal and Termination

The initial term of this Agreement is months commencing on the Effective Date. Thereafter the Agreement shall . Either party may terminate for convenience upon days' written notice. Termination for cause may be immediate as provided herein.

Indemnification and Limitation of Liability

Each party shall indemnify the other for losses arising from its gross negligence or willful misconduct. Except for liability arising from willful misconduct or breaches of confidentiality and PHI, neither party's aggregate liability shall exceed .

Insurance

Each party shall maintain commercial general liability and professional liability insurance appropriate to its operations and shall provide certificate evidence upon request.

Audits and Record Retention

Provider or an authorized auditor may audit Billing Company's billing records relating to Provider upon days' prior written notice during normal business hours. Billing Company shall retain records for a minimum of years or as required by law.

Notices

All notices required under this Agreement shall be in writing and delivered to the addresses set forth above or to such other address as a party designates by notice. Notice shall be effective upon delivery or, if sent by certified mail, three (3) days after mailing.

Miscellaneous

This Agreement constitutes the entire agreement between the parties and supersedes prior agreements. This Agreement may be amended only by a written instrument signed by both parties. Neither party may assign this Agreement without prior written consent of the other, except to an affiliate or successor by merger or sale of substantially all assets. Governing law shall be the law of the state chosen by the parties: .

Patient Data (Initial Setup Sample)

Provider acknowledges that the following patient information will be supplied for each patient to be billed by Billing Company in electronic or paper form as necessary.

Dispute Resolution

Except for injunctive relief or breach of confidentiality, disputes under this Agreement shall be resolved first by good faith negotiation and, if unresolved, by binding arbitration in accordance with the rules agreed by the parties. Venue for arbitration shall be in the county and state identified as governing law.

Signatures

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