2021-04-04 *Rates and Payer List are subject to change
Definitions
• A successful claim transaction is defined as each electronic claim submitted by Office Ally to a UHIN Payer where UHIN
assesses a per claim/remittance advice fee for that Payer.
• Payers that fall under this service will be indicated on Office Ally’s Payer List.
• Claim transactions that fall under this service will not be counted as Non-Par claims for the purpose of calculating the Non-Par
processing fee.
Fee for Service*
User will incur a charge for each successful claim transaction, per the fee
schedule to the right. Office Ally will invoice User at the beginning of each
calendar month for the number of successful claim transactions conducted in
the previous calendar month.
Some payers require providers to complete pre-enrollment prior to being able
to submit claims/receive remittance advice electronically. User is responsible to ensure that they have completed and payer has
approved all necessary pre-enrollment prior to submitting claims to these payers. Claims that are rejected at Office Ally prior to
being sent to the payer will not be counted in the calculation of this fee.
Termination of Services
If User wishes to cancel this service it must complete the product cancellation form. Upon request to cancel Office Ally will
send the product cancellation form to User. User shall not consider the cancellation complete until the time that it has
received an email confirmation to the email address on the account. Cancellation can only be requested by the Office Ally
account owner. Additionally, User acknowledges that any unpaid account balance must be paid prior to Office Ally
processing the cancellation request and said unpaid balance may delay the processing of the cancellation.
I have read and understand this agreement and wish to be able to submit electronically to UHIN Payers that assess Office Ally
a fee for claims/remittance advice. I am authorized to sign this agreement on behalf of my business. This UHIN Pass-Through
Fee User Agreement is only required if I want to submit claims electronically to UHIN Payers that assess Office Ally a fee for
claims/remittance advice. If I am signing this agreement electronically in my Office Ally account, I understand this option will
be activated on my account within 1-3 business days of signing. If I submit my signed agreement via any other method, I
understand this option will be activated on my account within 1-3 business days of Office Ally receiving, reviewing and
approving this signed agreement.
Date Signed
(If not a current Office Ally user you must
complete a separate enrollment form and authorization sheet.)
P
lease submit the completed Agreement by fax to (360) 314-2184 or by email to: EnrollmentAdmin@OfficeAlly.com
.
For questions call (360) 975-7000 opt. 3.
# of Successful
Claim Transactions
Fee for Service*
6+
$0.15 per Successful
Claim Transaction
User Agreement
