Definitions
• A transaction is defined as an electronic claim status request (276) submitted to the payer.
• A successful transaction is defined as a claim status request (276) for a claim where a response (277) is returned. The response
may be that the claim is in process, paid, rejected or that there was an incomplete response due to the lack of patient or provider
information in the request, etc. These responses will count towards the total number of successful transactions.
• An unsuccessful transaction is defined as a claim status request (276) for a claim where a response (277) is not returned at all.
This can be due to system issues or connection problems. These transactions will not count towards the total number of
transactions.
Fee for Service*
User will incur a charge for each successful 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 transactions
conducted in the previous calendar month. Unsuccessful transactions
will not be included in either the total volume or the invoiced
amount. All transactions for payers where Office Ally is the designated
clearinghouse will be provided free of charge (these payers are identified
on our payer list by a notation in the Note column).
Some payers require providers to complete pre-enrollment prior to
being able to perform claim status requests. User is responsible to ensure that they have completed and payer has approved all
necessary pre-enrollment prior to submitting claim status requests to these payers. Claim status requests that are incomplete due to
a lack of patient or provider information/pre-enrollment are still defined as successful transactions and will be included in the total
number of successful transactions for which the User is invoiced.
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 check claim status using the claim status request protocol
offered by Office Ally. I am authorized to sign this agreement on behalf of my business. This Real Time Claim Status 276/277
User Agreement is only required if you want to perform Real Time Claim Status Requests (276)/Responses (277).
Owner of Account Name (Please Print)
(President/CEO/Owner of Entity who owns the Office Ally Account)
Owner of Account Signature
(President/CEO/Owner of Entity who owns the Office Ally Account)
Title of Signer (Please Print)
Contact Name / Contact Phone Number
Office Ally Representative
$0.10 per Successful Transaction
$0.09 per Successful Transaction
$0.08 per Successful Transaction
$0.07 per Successful Transaction
$0.06 per Successful Transaction
$0.05 per Successful Transaction
Real Time Claim Status 276/277
User Agreement
Please fax completed User Agreement to (360) 314-2184. Questions? Email: Sheila.Odeen@officeally.com
2016-11-11 *Rate are subject to change
click to sign
signature
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