This agreement is made this _____ day of ____________, 20____, by and between Office Ally, LLC (“Business Associate”)
and ___________________________________________ (“Covered Entity”).
Please fax completed User Agreement to (360) 314-2184. For questions call (866) 575-4120 opt. 3.
2011-07-06 *Rate are subject to change
Terms and Conditions
Definitions
o A transaction defined as an electronic request for eligibility verification (270) submitted to the payer
o A successful transaction is defined as an eligibility verification submission (270) for a patient where a response (271) is returned.
The response may be that the patient is eligible, not eligible or that there was an unsuccessful response due to the lack of patient or
provider information in the request. These responses will count towards the total number of transactions.
o Manual Eligibility Verification – Manual Eligibility Verification uses data manually entered into the eligibility tool. Covered
Entity will be required to enter patient and provider data in this tool to obtain results.
o Automated Eligibility Verification – Automated Eligibility Verification uses the data in the Eligibility insurance
section of the patient record within Practice Mate™ and EHR 24/7™ to verify eligibility. The group of patients to be
checked for eligibility is based on the appointments scheduled from the calendar and the active appointments on the
calendar for a particular day.
Fee for Service
Covered Entity will incur charges of ten dollars ($10.00) for up to the first one-hundred (100) transactions (eligibility
verifications/270s) and an additional $0.10 for each transaction thereafter within one (1) calendar month. For example, any number of
transactions from 1 to 100 will cost $10.00, however if you perform 101 transactions it will cost $10.10 which is the flat rate of $10.00
plus the 1 additional transaction charged at $0.10. Business Associate will invoice Covered Entity at the beginning of each calendar
month for the number of successful transactions conducted in the prior calendar month. Eligibility verifications that are unsuccessful
due to a lack of patient or provider information will count towards the total number of transactions. Covered Entity will not be charged
for a submitted transaction (270) when a response (271) is not returned.
Termination of Services
Covered Entity may at any time terminate use of Automated Eligibility Verification by submitting a written, signed 30-day
cancellation notice. Covered Entity is responsible for all charges incurred up until receipt of e-mail confirmation from the
Business Associate. Business Associate agrees to send email confirmation of the cancellation request to Covered Entity within 3
business days from the date the letter was received by Business Associate.
NPI Validation
Office Ally has contracted with Ability® to provide connectivity for Medicare Eligibility Verification services. There is no additional
paperwork required by Ability®; however, a valid, active NPI is required to submit Eligibility Verification requests (270s) to
Medicare. Ability® must validate your NPI numbers before you can begin using either Eligibility Verification tools (manual/
automated) for Medicare Eligibility Verification request(s). For information on how your NPI #(s) will be validated see
Appendix A: Ability (Vision Share) NPI Validation Process.
I have read and understand this agreement and wish to be able to verify eligibility with this automated eligibility verification tool.
I am authorized to sign this agreement on behalf of my business. This Automated Eligibility User Agreement is only required if
you want to perform Automated eligibility checks/transactions.
Covered Entity Business Associate
Brian P. O’Neill
Name Name
Signature Signature
Company Office Ally Representative
Phone Number
Office Ally User Name (If not a current Office Ally user you must
complete a separate enrollment form and authorization sheet.)
Eligibility Verification
User Agreement
