Definitions
• A transaction is defined as an electronic eligibility request (270) submitted to the payer.
• A successful transaction is defined as an eligibility request (270) for a patient where a response (271) is returned. The
response may be that the patient is covered, not covered 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 an eligibility request (270) where a response (271) is not returned at all. This can be
due to system issues or connection problems. Unsuccessful transactions will not be included in 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 eligibility requests. User is responsible
to ensure that they have completed and payer has approved all necessary pre-enrollment prior to submitting eligibility requests
to these payers. Eligibility 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 eligibility using the eligibility request protocol
offered by Office Ally. I am authorized to sign this agreement on behalf of my business. This Real Time Eligibility Request
270/271 User Agreement is only required if you want to perform Real Time Eligibility Requests (270) / Responses (271).
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 Eligibility Request 270/271
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
click to edit
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