Healthcare Eligibility Services Agreement

HEALTHCARE ELIGIBILITY SERVICES AGREEMENT

Parties and Effective Date

This Healthcare Eligibility Services Agreement is entered into by and between:

Effective Date:

Recitals and Definitions

WHEREAS, Client operates a healthcare delivery practice and requires verification of patient insurance eligibility and benefits; and WHEREAS, Service Provider maintains systems and personnel to perform eligibility verification services on behalf of Client; NOW, THEREFORE, in consideration of the promises and mutual covenants contained herein, the parties agree as follows.

Scope of Services

Service Provider will perform the following services for patients designated by Client. Services include obtaining insurance eligibility, benefit summaries, authorization status, and related payer communications.

Eligibility verification
Benefit estimation and patient responsibility calculation
Prior authorization assistance
Coverage and plan change monitoring
Claims status checks and payer inquiries

Client Responsibilities

Client shall: (a) authorize Service Provider in writing to act as Client's agent for eligibility inquiries; (b) supply accurate patient demographic and insurance information in a timely manner; (c) notify Service Provider of patient record updates; and (d) obtain and maintain any required patient authorizations for release of protected health information prior to submission.

Service Provider Responsibilities

Service Provider shall perform services with commercially reasonable skill and care in accordance with industry standards, maintain records of verifications, and provide written or electronic reports to Client as specified in this Agreement.

Fees and Payment

Client agrees to pay Service Provider the fees set forth below for the services performed. Fees are exclusive of applicable taxes and any third-party payer fees.

Confidentiality and HIPAA Compliance

Both parties acknowledge that, in the performance of this Agreement, Service Provider may create, receive, maintain or transmit Protected Health Information (PHI). The parties shall comply with all applicable federal and state privacy and security laws, including required safeguards for PHI and timely breach notification. Service Provider agrees to act as a Business Associate when applicable and to enter a separate Business Associate Agreement where required.

Client confirms that it will obtain all required authorizations from patients to permit Service Provider to access PHI for the purposes described in this Agreement.

Client confirms Business Associate Agreement executed:

Data Security and Records Retention

Service Provider will implement administrative, physical and technical safeguards appropriate to the size and complexity of its operations to protect client data. Service Provider will retain verification records for a period consistent with applicable law and the retention terms below.

Term and Termination

The initial term shall commence on the Effective Date and shall continue for a period of months. Thereafter, the Agreement shall automatically renew for successive periods of months unless either party provides written notice of nonrenewal at least days prior to the end of the then-current term.

Either party may terminate this Agreement for material breach if such breach is not cured within 30 days after written notice.

Liability and Indemnification

Each party shall indemnify, defend and hold harmless the other party from third-party claims arising out of the indemnifying party's negligence or willful misconduct. In no event shall either party's aggregate liability exceed the fees paid to Service Provider under this Agreement in the twelve (12) months preceding the claim, except for liabilities arising from gross negligence, willful misconduct, or breaches of PHI.

Audit Rights

Client may audit Service Provider's processes and records relevant to performance of this Agreement upon reasonable prior notice and during regular business hours. Audit scope and frequency shall be limited to no more than one audit per calendar year unless material noncompliance is discovered.

Client acknowledges that any on-site audit must be conducted in a manner that does not unreasonably disrupt Service Provider's operations.

Notices

All notices required under this Agreement shall be in writing and delivered to the addresses below.

Representative Patient Record (Initial Enrollment)

The following patient record fields identify the initial patient(s) for whom Client authorizes Service Provider to obtain eligibility information under this Agreement.

Date of Birth:    Gender:

Insurance Information (for Representative Patient)

Medical History (for Representative Patient)

Authorization and Acknowledgments

Client authorizes Service Provider to access patient insurance and eligibility information from payers and related third parties, to the extent necessary to perform the services described herein. Client represents that it has obtained any patient-level authorizations required by law for disclosure of such information to Service Provider.

Client authorizes access for initial patient(s):

Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements. Any amendment must be in writing and signed by authorized representatives of both parties. This Agreement shall be governed by the laws of the state specified below.

Execution

The individuals signing below represent and warrant that they have authority to bind their respective parties to this Agreement.

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