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MERCY CARE PROVIDER WEB PORTAL REGISTRATION FORM Tha (Mercy Care)

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Page 1 of 5
MERCY CARE PROVIDER WEB PORTAL
REGISTRATION FORM
Tha
nk you for your interest in registering for the Provider Web Portal owned or operated by Aetna. We are
committed to protecting the privacy of our Providers. We will use our best efforts to ensure that the information
you submit to us is used only for the purpose of obtaining access to the Provider Web Portal and remains
confidential. We do not disclose any of the information you provide to us to any outside parties, except to
manage the health plan or when we think the law may require it.
Registration Instructions: The information below and acceptance of the attached Provider Web Portal
Agreement is required to complete registration.
Contracted Provider Name:
Provider Office Name:
Provider Office Contact Name/Office Manager Name:
Provider Office Contact Name/Office Manager E-Mail:
Provider Tax ID # (TIN):
We caution against using your SSN in lieu of a TIN, as it presents unnecessary risks to your identity.
National Provider ID # (NPI):
Address:
City:
State:
Zip:
Phone #: Fax #:
Provider must designate a Primary Representative from their office (see attached Provider Web Portal Agreement
for full definition). The Primary Representative may have the ability to add authorized representatives within
Provider’s office to Provider’s account. Please provide the following information for the Primary Representative:
Primary Representative Name:
Phone #: Fax #:
Billing Company:
Yes No
Provider Office:
Yes
No
E-Mail address at Provider’s Office:
To submit a request for registration, please fax or e-mail your completed form and the attached signed
Provider Web Portal Agreement to: Mercy Care at 860-975-3201.
Please contact your Provider relations representative with any questions at: 602-263-3000 or 800-624-3879.
Signature:
________________________________ ____________________________
Print Name:
Provider Group Administrator or Contracted Physician Date:
_________________________________
IMPORTANT: A signed prov
ider’s Web Portal Agreement (attached) must accompany this form before
registration can be completed. Thank you.
Version 10.19.15
Version 10.19.15 Page 2 of 5
MERCY CARE PROVIDER WEB PORTAL AGREEMENT
This
Provider Web Portal Agreement (“Agreement”) contains the terms and conditions that govern Provider’s use
of the web portal service to access certain Plan member information. By signing the Provider Web Portal
Agreement, you acknowledge that you understand and agree to follow the terms and conditions outlined herein.
Definitions
When used in this Agreement, all capitalized terms shall have the following meanings:
“Administrator” means any Aetna administrator, such as Aetna Medicaid Administrators, LLC, and any owners,
affiliates or direct or indirect subsidiaries that administer or maintain the Service for a Plan.
“Authorized Representative” means a person that Provider has authorized to use the Service under this
Agreement on Provider’s behalf.
“Plan” means a member’s health care benefits as set forth in the state contract with the government sponsor,
which is administered by Plan or an Administrator.
“Primary Representative” means the Authorized Representative in Provider’s office with responsibility for
adding, deleting, and maintaining the names of Provider’s Authorized Representatives on Provider’s behalf.
“Provider” means the person or entity contracted with Plan or Administrator to provide medical services or
supplies to Plan enrollees.
“Service” means the web portal service under this Agreement and the website that supports it.
Provider’s Use of the Web Portal Service
The Service provides internet access to information on Plan member eligibility, claims payments, Plan or
Administrator policies and prior authorizations. Provider shall use the Service solely in connection with the
provision of health care services to Plan members under the provider’s care. The Primary representative and each
Authorized Representative shall use the Service solely in the course and scope of employment or agency with
Provider. Provider, the Primary Representative, and each Authorized Representative shall use the Service subject
to the following conditions:
1. The terms and conditions of this Agreement; and
2. If applicable, the provisions of Provider’s contract with Plan or Administrator to provide health care
services to Plan members (the “Provider Contract”). The applicable provisions of the provider Contract
include, but are not limited to, use and disclosure of protected health information under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards, member eligibility
verification, utilization management standards within Plan policies and the provider manual, and
timelines for submission and resubmission of claims.
3. In the event of a conflict between the terms and conditions of this Agreement and those contained in the
Provider Contract, this Agreement shall govern.
Provider shall, and shall require the Primary Representative and each Authorized Representative to:
1. Keep confidential and not disclose the Provider’s Service password to any person except Provider or the
Primary Representative;
2. Use the Service solely in connection with provider’s health care services to members of Plan, and within
the course and scope of employment or agency with Provider; and
3. Use the Service pursuant to the terms and conditions of this Agreement.
Version 10.19.15 Page 3 of 5
Upon learning that the Primary Representative or an Authorized Representative has violated (1), (2) or (3), or no
longer works for, or represents Provider, Provider shall immediately revoke such Primary Representative’s or
Authorized Representative’s access to the Service. Provider shall also promptly notify Administrator or Plan
when it has revoked a Primary Representative’s or an Authorized Representative’s authority to use the Service for
any reason. Further, Provider agrees to revoke the Primary Representative’s authority to use the Service if
directed to do so by Administrator or Plan.
If an Authorized Representative’s authority is revoked, the Primary Representative shall immediately delete such
person’s access to the Service following Plan or Administrator procedures. If the Primary Representative’s
authority is revoked, Provider shall immediately delete such person’s access to the Service and designate a new
Primary Representative following Plan or Administrator procedures.
Site System Integrity
Provider may not use any device, software routine or agent to interfere, or attempt to interfere, with the proper
working of the Service. Provider may not take any action that imposes an unreasonable or disproportionately
large load on Administrator’s or Plan’s infrastructure. Provider may not disclose its password to third parties,
except an Authorized Representative. Provider shall take reasonable precautions to secure its password from any
unauthorized use. Provider may not attempt to log in with a user name or password other than its own.
Confidential Information
“Confidential Information” means any information that identifies a member and relates to the member’s
participation in a Plan, the member’s physical or mental health or condition, the provision of health care to the
member, or payment for the provision of health care to the member. Confidential Information includes, without
limitation, “individually identifiable health information,” as defined in 45 C.F.R. § 160.103 of HIPAA and “non-
public personal information,” as defined in laws or regulations promulgated under the Gramm-Leach-Bliley Act
of 1999
Provider acknowledges that Administrator or Plan will provide Confidential Information to Provider solely for
Provider’s use in performing agreed upon health care services. Accordingly, Provider agrees to:
1. Comply with all applicable state and federal laws, rules, regulations, licensing or regulatory requirements
for each state in which services are provided;
2. Maintain a data privacy and security program and process that complies with all applicable laws and
regulations;
3. Implement administrative, physical, and technical safeguards to protect any and all Confidential
Information from unauthorized access, use and disclosure; and
4. Not to use or disclose Confidential Information for any purpose other than as specifically permitted
herein.
Provider acknowledges that certain laws, including 45 C.F.R. 164.504(f), may prohibit certain uses or
redisclosures of Confidential Information. Accordingly, Provider agrees that in no event shall Provider use or
redisclose Confidential Information in any manner or for any purpose prohibited by applicable law, regulation, or
other legal mandate. Provider may not disclose Confidential Information to any third party whatsoever, including,
but not limited to, any broker, consultant, auditor, reviewer, administrator or agent unless Administrator or Plan
provides advance written consent of such disclosure.
Provider agrees to accept and comply with policies of which Provider knows or reasonably should have known
(e.g., clinical policy bulletins or other policies made available to Provider). Provider will utilize electronic real
time HIPAA compliant transactions, including but not limited to, eligibility, precertification and claim status
inquiry transactions, if available and applicable and to the extent such electronic real time features are utilized by
Plan or Administrator.
Version 10.19.15 Page 4 of 5
Provider shall promptly notify Administrator or Plan in the event of: 1) any loss, accidental, or unauthorized
disclosure of Confidential Information; 2) any unauthorized access to the Service; 3) any breach of Provider’s data
privacy, security program and policies, or safeguards affecting access to the Service and information therein.
Changes to the Web Portal Service or This Agreement
Administrator or Plan may, at any time, make changes to the Service, the terms and conditions of this Agreement,
or any other policies or conditions that govern the use of the Service at any time. Provider should review the
Service and these terms and conditions periodically for any updates or changes. Provider’s continued access or
use of the Service shall be deemed Provider’s notification and acceptance of such changes.
No Warranties or Liabilities
There is no implied warranty of any kind under this Agreement, including of representation about the accuracy,
completeness, or appropriateness or fitness for a particular part of the Service, and non-infringement. Provider
assumes full responsibility for using the Service, and understands and agrees that neither the Plan nor
Administrator are responsible or liable for any claim, loss, or damage resulting from, or related to, Provider’s use.
Provider uses the Service at its own risk, and agrees to use the Service on an “AS IS” and an “AS AVAILABLE”
basis. Neither Plan nor Administrator will be liable for any delay, difficulty in use, inaccuracy or incompleteness
of information, computer virus, malicious code, loss of data, compatibility issues, or otherwise. Plan and
Administrator will not be liable for any direct, indirect, incidental, consequential, or punitive damages arising out
of the Provider’s use of, or access to, the Service, or any link provided to another site, even if Plan or
Administrator was advised of the possibility of such damages, or even if such damages were foreseeable.
Ownership, License and Restrictions on Use of Materials
All right, title and interest (including all copyrights, trademarks and other intellectual property rights) in the
Service belong to Plan or Administrator. In addition, the names, images, pictures, logos, and icons are proprietary
marks that belong to Plan or Administrator. Except as expressly provided below, nothing contained herein shall
be construed as conferring any license or right under copyright or other intellectual property rights.
Provider is hereby granted a nonexclusive, nontransferable, limited license to view and use information retrieved
from the Service solely in connection with the provision of health care services to Plan members.
Except as expressly provided above, no part of the information in or about the Service, including but not limited
to materials retrieved from it and the underlying code, may be reproduced, republished, copied, transmitted,
distributed, or modified in any form or by any means. In no event shall information or materials from the Service
be stored in any storage or retrieval system without prior written permission from Administrator or Plan.
Provider’s use of the Service allows Plan and Administrator to gather certain limited information about Provider
and its use of the Service. Provider agrees and consents to the use of such information in aggregated form.
Termination
Provider, Plan or Administrator may terminate this Agreement for any reason at any time.
Plan or Administrator may issue Provider a warning, temporarily suspend, indefinitely suspend, or cancel this
Agreement with Provider and Provider’s access to the Service if, in the sole discretion of Plan or Administrator,
Provider breaches this Agreement. Plan and Administrator reserve the right to immediately suspend or deny, in
their singular or joint discretion, Provider’s access to all, or any portion of, the Service with or without prior
notice. Provider acknowledges and agrees that Plan or Administrator may immediately bar any further access to
the Service. Provider agrees that neither Plan nor Administrator shall be liable to Provider or any third-party for
any termination of Provider’s access to the Service.
Page 5 of 5
Upon termination of this Agreement, Provider agrees to destroy all information and materials, in any format or
capacity, obtained or retained from the Service.
Governing Law
This Agreement and the rights and obligations of the Provider and Plan or Administrator shall be construed,
interpreted, and enforced in accordance with, and governed by, the laws of the state where Plan is located. Before
Provider may seek legal recourse for any harm Provider believes it has suffered from use of the Service, Provider
will give Plan or Administrator written notice specifying the harm and allow Plan or Administrator thirty (30)
days from the date of notice to cure the harm. Provider must initiate any cause of action under this Agreement or
related to the Service within one (1) year after the claim has arisen or Provider is barred from pursuing any cause
of action.
Entire Agreement
This Agreement (including any attached schedules, appendices and/or addenda) constitutes the complete and sole
agreement of between Provider and Plan or Administrator regarding the subject matter described herein and
supersedes any and all prior or contemporaneous oral or written representations, communications, proposals or
agreements not expressly included in this Agreement and may not be contradicted or varied by evidence of prior,
contemporaneous or subsequent oral representations, communications, proposals, agreements, prior course of
dealings or discussions of the Parties. The parties acknowledge that each Plan or Administrator is a third-party
beneficiary of this Agreement.
The signatory below represents and warrants that he or she has full authority to bind the Provider, including the
Provider’s owners, employees, agents and representatives, on whose behalf the person below signs.
Agreed and Accepted:
Signature:
Printed Name:
Title:
Contracted Provider Name:
Provider Office Name:
Provider Tax ID # (TIN):
We caution against using your SSN in lieu of a TIN, as it presents unnecessary risks to your identity.
National Provider ID # (NPI):
Date:
Version 10.19.15
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Completed 31 July 2021

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