Healthcare Medicaid Engagement Agreement

HEALTHCARE MEDICAID ENGAGEMENT AGREEMENT

Parties and Effective Date

Effective Date:

Client Name:

Representative Organization:

Client Information

Insurance & Medicaid Information

Medical History & Current Information

Engagement, Scope of Services, and Limitations

Representative will provide assistance to Client in connection with Medicaid eligibility, enrollment, renewal, benefits coordination, claims submission, and appeals as specifically requested and agreed in writing. The services may include, as applicable: document preparation and submission, communication with Medicaid or other benefit administrators, assistance with appeals and fair hearings, and coordination with medical providers to secure necessary supporting documentation.

Representative is not providing legal advice unless expressly stated in a separate retention agreement. Representative will act as Client's authorized agent for the limited purpose of obtaining and transmitting information necessary to perform the scope set forth herein.

Application and initial eligibility assistance
Renewal and redetermination assistance
Medical records and supporting documentation collection
Claims and billing coordination with providers
Administrative appeals and fair hearing representation support (non-attorney)

Authorizations and HIPAA Release

Client authorizes Representative to obtain, use and disclose medical, billing, eligibility, and benefits information as necessary to perform the services set forth in this Agreement. This authorization includes disclosure to Medicaid agencies, insurance carriers, medical providers, and their agents for the purposes of enrollment, claims, appeals, and coordination of benefits.

This authorization permits Representative to receive confidential health information necessary to determine and secure Medicaid eligibility and benefits and to appeal adverse determinations. Representative will not use or disclose information for purposes other than those described without additional written authorization from Client.

Client acknowledges receipt of Representative's Notice of Privacy Practices and understands how protected health information will be used and disclosed in the course of the engagement.

Fees, Billing and Payment

Client agrees to compensate Representative as set forth below. Unless otherwise agreed in writing, Client is responsible for fees and any costs advanced by Representative related to document procurement or expedited services.

Flat fee: $ (for defined services)
Hourly rate: $ per hour
Contingency or recovery-based fees are prohibited unless specifically authorized in a separate written agreement. Representative will not charge contingent fees for Medicaid determinations unless expressly permitted by law and documented herein.

Client Responsibilities

Client shall promptly provide accurate information and execute forms necessary for Representative to provide services. Client agrees to notify Representative of any material change in circumstances that may affect eligibility or benefits. Failure to provide requested documentation may result in termination of services.

Confidentiality, Limitation of Liability, and Indemnity

Representative will safeguard Client information in accordance with applicable law and Representative's privacy policies. Representative's liability for claims arising out of this Agreement shall be limited to direct damages and shall not exceed the total fees paid by Client to Representative under this Agreement for the services giving rise to the claim. Representative is not liable for consequential, incidental, special, or punitive damages.

Client agrees to indemnify and hold Representative harmless from third-party claims, except to the extent caused by Representative's gross negligence or willful misconduct.

Term, Termination and Notices

This Agreement commences on the Effective Date and continues until the completion of services or until terminated by either party with ten (10) days' written notice. Termination will not relieve Client of obligations to pay for services rendered and costs incurred prior to termination.

Appeals and Legal Representation

Representative may provide administrative appeals support and representation before benefit administrators or in fair hearings to the extent authorized herein. Client understands that legal counsel is separate and may be retained at Client's election. Representative will notify Client if a matter requires legal representation and will not provide legal advice unless Representative is an attorney and expressly agrees in writing to provide legal services.

Governing Law and Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the state in which Client resides, without regard to conflict of laws principles. Any dispute arising from this Agreement shall be resolved through negotiation and, if unsuccessful, through mediation prior to initiating litigation, except where injunctive relief is necessary.

Acknowledgements and Certifications

By signing below, Client certifies that the information provided is true and accurate to the best of Client's knowledge, authorizes Representative to act as described, and acknowledges understanding of fee arrangements, HIPAA authorizations, and the scope and limitations of services. Client further acknowledges receipt of a copy of this Agreement upon request.

Signature

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