AUTHORIZATION SHEET
Owner of Account / Practice Name*:
*Must match the Owner of Account / Practice Name on the Enrollment Form. The name listed here will be considered the Owner of the Office Ally Account. This field is required for the form to be processed.
To determine whether a payer is Non Par, please reference the TYP (Type) column of our Payer List. NP indicates a Payer is Non Par, while P indicates a Payer is Par.
TERMS & CONDITIONS:
NON-PAR CLAIMS POLICY:
INITIAL HERE*
Office Ally has zero tolerance for insurance fraud and reserves the right to refuse service to anyone who commits or is suspected of committing insurance fraud.
- Submitter ensures that all data submitted is valid and represents services performed accurately.
- I authorize and consent to my information being checked against the Office of Inspector General’s (OIG) and System of Award Management (SAM) lists
of excluded individuals/entities databases.
- I authorize and consent to background reports, including investigative consumer reports, to be ordered and reviewed for verification, validation or
other anti-fraud purposes.
Office Ally shall not be deemed responsible for any claims transactions that fail due to incorrect/invalid data and all such rejections shall be the sole responsibility
of the submitter for correction and resubmission.
21 Day Rule/Pending Claims: Office Ally will automatically reprocess all claims pended (for specific payers where Office Ally performs Patient Eligibility
checking) due to ‘Patient Not Found' and ‘Patient Not Covered (at time of service)’. Reprocessing will take place every 7 days for up to 3 tries after the
initial processing. Provider will be notified: 1) at the time of the original processing that the claim is pending, and 2) at the time that the claim is accepted,
or 3) after the last attempt to reprocess if the claim is still rejected. If the patient is found to be eligible after reprocessing, the received date will be the
date that Office Ally actually transmits the claim to Payer. This option is on by default, but can be turned off per user’s request.
Pre-Enrollment Requirement: Certain payers require pre-enrollment which must be completed and approved before claims can be sent electronically.
Submitter is responsible to ensure all necessary paperwork is completed. See our Payer List for a complete listing.
Financial Responsibility/Electronic Invoices: Owner of Account above agrees to be held financially responsible for all fees and/or finance charges
incurred by this account. Office Ally utilizes email for all correspondence, including accounting notices and invoices. It is your responsibility to ensure
Office Ally has a valid email address for you at all times.
Changes to Fees: Notwithstanding anything to the contrary, Office Ally may change the fees and charges at any time by providing at least thirty (30) days prior
written notice (the “Notice Period”) of such change to Customer. Any such change shall take effect at the expiration of the Notice Period. In the event that
Customer does not agree to the changes to the fees and charges, Customer may terminate this Agreement at any time by contacting the Cancellations Team.
The Non-Par processing fee is $35.00* and is calculated and charged per unique Tax ID + Rendering NPI combination whose claim volume is 50% or more
to Non-Par Payers (per our Payer List) in a month.
If no Rendering NPI is present, then for Institutional claims Attending NPI will be used. Otherwise, Billing NPI will be used for this calculation when
Rendering NPI/Attending NPI is not present.
For each unique Tax ID + Rendering NPI combination whose claim volume is less than 50% in a month, the Non-Par processing fee will not be charged for
that month.
CLAIM PRINTING POLICIES:
ELECT PRINTING OPTION: YOU ARE REQUIRED TO MAKE A CHOICE BELOW (CHECK ONLY ONE):
By signing below, you are acknowledging that you have read, understand, and agree to all terms/conditions in full.
All claims that Office Ally is able to submit electronically are transmitted electronically, free of any “printing” fees.
Any claims that Office Ally cannot send electronically can be printed and mailed automatically for a fee of $ 0.45 cents per claim* if you select this option below.
Claims that need to be printed and mailed to individuals (such as patients or attorneys), or to foreign countries are $0.55 per claim*
The submitter will be invoiced monthly via email for these paper claims.
to indicate that you fully understand the Non-Par Claims policy. Required regardless if applicable.
Do not print any claims for me. I understand that if I transmit claims that cannot be sent electronically, they will be rejected back to me.
I hereby allow Office Ally to print and mail claims that cannot be transmitted electronically as indicated on the payer list and the provider’s pre-enrollment
status. I agree to pay Office Ally $0.45/claim* for claims sent to insurance companies/payers and $0.55/claim* for claims sent to individuals (patients/
attorneys) or to foreign countries. I further understand it is my responsibility to ensure
that all pre-enrollment forms are properly completed, submitted
and approved, and that Office Ally is aware of the approval. Claims I submit to payers that require pre-enrollment, where the approval has not been
logged in Office Ally’s system, will be
printed and mailed at my expense.
Signature (Owner of Account or President/CEO/Owner of Practice/Facility)
Name (Owner of Account or President/CEO/Owner of Practice/Facility)
Main Contact Name / Phone Number
Training Contact Name / Phone Number (If different than Main Contact) – The person we
should contact for training appointment(s) for your office.
Date
Title (President/CEO/Owner of Practice/Facility)
Main Contact Email Address
Training Contact Email Address
Please submit the completed Authorization Sheet by fax to (360) 314-2184 or by email to:
EnrollmentAdmin@OfficeAlly.com.
For questions call (360) 975-7000 opt. 3.
*Rates and Payer List are subject to change
OA 2019-05-28
