Terms of Service

This is an agreement between You, the Customer identified in the signature block of the Appendix II of the Master Services Agreement (hereinafter referred to as “Customer” or “Licensee”), and Opus Health Inc. (hereinafter referred to as “OPUS” or “Licensor”). This document describes and defines the services to be provided to the Customer should Customer choose to contract with OPUS and its partner, SAIcle One Solutions, LLC (hereinafter referred to as "SAI") through the Master Subscription Agreement. It also describes and defines the roles, restrictions, penalties, and other terms that Licensor agrees to abide by during, and sometimes after, the Term provided in Customer’s Master Subscription Agreement ("MSA").

1. Scope of Work:
   SAI will apply its best efforts to obtain reimbursement for Customer’s charges for all professional medical services, clinical procedures, ancillary medical services, durable medical equipment, medical supplies and related services, equipment and supplies (“Medical Services”) rendered or provided by or on behalf of Customer on or after the Effective Date, through billing of patients and third-party payors and the management of Customer’s accounts receivable (the “Services”), all in accordance with the provisions of the Comprehensive RCM Package outlined below, beginning on or after the Effective Date. The customer authorizes SAI to act as its agent solely to the extent necessary for SAI to perform the Services, and as otherwise set forth in the Agreement. SAI may perform such Services through any one or more entities affiliated with SAI, provided that SAI shall remain obligated to Customer for the performance of all such Services in accordance with the terms of this STATEMENT OF WORK Appendix I - Professional Billing Services (RCM) ("SOW").
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   In-Scope Services:
   Comprehensive RCM Package
   1. Transition services, including standard operating procedure documentation to be mutually agreed upon by SAI and Customer
   2. During the initial project transition, complete EDI, ERA, and EFT enrollment with all payors
   3. Receipt of super bills/ charge information via Customer’s electronic health record software
   4. Front-end charge scrubbing to ensure coding is accurate and supports the selected E/M level.
   5. Electronic claims transmission to appropriate federal and commercial payors
   6. Fixing EDI rejects as necessary
   7. Generating and mailing non-electronic insurance claims
   8. Secondary claims billing with primary EOBs
   9. Posting payments and adjustments to appropriate accounts for both insurance and patient payments
   10. Aging AR follow up on the following schedule:
       
       1. 30 days for electronic claims
       2. 45 days for paper claims
   11. Performing denials management, including research and resubmission with primary EOB as necessary
   12. Generating and mailing patient statements for all open accounts
   13. Soft collection patient calls for patients with a dollar balance over $250.00, beginning 30 days after receipt of the first statement, and conducted at least one time in accordance with SAI customary service levels and Customer policy until balance is paid in full, a payment plan is instituted, charity or discount care is instituted, or the balance is written-off according to Customer’s policy.
   14. Issuing pre-collection letters as applicable under Customer’s policy
   15. Reconciling credit balance accounts
   16. Processing refund requests to payors
   17. Providing standard month-end reports including:
       
       1. Standard AR Summary, with break-down categorizations including, but not necessarily limited to, state, sub-organization, payor, specialty, provider type, self-pay/patient responsibility type, and service type
       2. Suspense Summary – overview of claims with pending requests for demographics, insurance information
   18. Facilitating governance meetings on a quarterly basis, to review performance, billing compliance matters, billing policy efficacy, and financial trend analysis
   19. Access to SAI’s proprietary analytics and reporting platform, navigatEHR Basic through the electronic health record platform.
   20. Providing a dedicated local inbound number for patients.
   21. Providing a toll-free fax line for super bill submissions and/or to send other materials and information.
   22. Secure File Transfer Protocol (SFTP) or other secure file-sharing software set up for scanning documents to SAI.
   23. Upon request, SAI will hold specific claims at the beginning of the calendar year for a defined period of time specified by the Customer.
       1. For held Medicare claims, SAI will review patient deductibles and for those accounts whose deductibles have been met within the specified period, claims will be submitted.
   24. Optional: HL7 Integration with a third-party system (RCM or Practice Management System/ACO/ISNP/Custom).
2. Out-of-Scope Services:
   The following services are currently out of scope but may be included within scope if desired for an additional fee. Except where indicated, such services will be billed under the same hourly rate structure outlined in Fee Section 6, and any associated processing fees will be billed directly to Customer, or an additional SOW may be required.
   1. Requests for additional work to complete EDI. ERA and EFT enrollment with payors, post-transition, will be billable under the fee structure identified in Section 6, Additional Fees, #3 of this Agreement.
   2. Coding and compliance audit services per chart audited will be billed separately.
      1. CPC coders conduct internal chart audits for each Provider by random selection and audit those charts per CMS compliance guidelines.
      2. SAI will provide feedback to providers with recommendations for improvement.
      3. Audits are completed at least semi-annually.
      4. Follow LCD/NCD prior to claims submission.
   3. Lock box services for document scanning and remote deposit capture are available and will be separately quoted and direct billed.
   4. Patient payment portal and credit card processing services are available and will be separately quoted and invoiced.
   5. SAI may provide the following services on a per-project basis, to be agreed to in writing prior to the start of work:
      1. Consultative practice analysis.
      2. Other healthcare IT consulting services.
      3. CMS EHR and quality incentive attestations.
      4. Advice on regulatory compliance as it pertains to MACRA/MIPS.
      5. HIPAA Security and compliance audits/assessments.
      6. Software interface development.
   6. Costs imposed by a prior medical billing vendor for data migration services are the responsibility of the Customer.
   7. Professional payor enrollment services (credentialing with insurance companies) will be described and quoted under a separate SOW.
   8. Facility access agreements and medical staff privileging, and credentialing are Out-of Scope.
   9. Professional provider licensing services will be described and quoted under a separate SOW.
   10. Other work not mentioned above.
3. Customer Responsibilities:
   Customer agrees that during the term of this Appendix, all insurance claims to be filed on behalf of patients for the Services shall be handled exclusively by SAI, unless otherwise mutually consented to by the Parties. Commencing on or before the Effective Date of this Agreement and continuing during the term of this Agreement, Customer shall provide to SAI, in a format acceptable to SAI and updated whenever appropriate:
   1. All applicable fee schedules for the Services.
   2. A list of insurance companies accepted for patient claims, indicating participation status and any special billing policies specific to a given insurance company or procedure code.
   3. Complete patient identification, third-party payor/insurance information, and all related data reasonably necessary for SAI to bill patients ("Patient Information").
   4. The date of service, Current Procedural Terminology (CPT) codes, and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnoses code for each patient for whom Billable Services are performed.
   5. Submission of Charges.  Customer agrees to provide to SAI, or to cause the facilities or other sites at which Customer provides Medical Services to provide to SAI, at no cost to SAI, accurate, complete, and timely information regarding the Medical Services provided by Customer. Customer acknowledges that SAI will rely on the Information in providing the Services and that the timing and amount of Net Collections generated by the Services are affected by the completeness, timeliness and accuracy of the Information and other variables, all of which are within the control of Customer.
   6. Records of all receipts by Customer from patients for whom the Services are performed including insurance checks, copays and deductibles, and any other patient checks or cash received in the Customer’s office, and any credits and adjustments applied to patient accounts.
   7. Any special codes that may be required by Health Maintenance Organizations or Health Care plans.
   8. Identification of any patient for whom charity care or a special discount is to be allowed.
   9. Access to any data necessary to process patient insurance claims and statements, including access to or information from previous billing companies, practice management systems, and/or electronic medical records (EMR).
   10. Customer agrees to maintain a permanent mailing address in order to receive physical copies of explanations of benefits (EOBs), patient payments (check or cash), and other official correspondence from federal payors, commercial payors, and patients. Customer shall furnish SAI with electronic copies of these documents, if required, in order for SAI to perform the Services.
4. Fee for In-Scope Services:
   The monthly fee for the Comprehensive Service Package will be per SAI pricing table (XX%) of the Net Collections for each month as stated on the "Cash Receipts" line of the Customer’s monthly management report (as supplied by SAIcle One), or $500.00 per Customer named provider, whichever is greater.
   
   For the purposes of this SOW, “Net Collections” shall be defined as the total sum of all monies collected (including collection agency recoveries) for the Services, regardless of the location of collection, including any and all payments in any form received from patients, insurers, or other parties responsible for payment on the Services, less refunds or credits to patients or third party payers as a result of overpayments, erroneous payments, bad checks, insurance coverage denials, or other reductions or discounts that reduce the funds collected by SAI for the Services.
   
   Additional Fees:
   
   1. The startup fee will be as outlined in the MSA per tax ID number due upon execution. This fee covers the costs of initial data migration to SAI’s billing system to establish the charge master, insurance master, provider master, facility master and initial patient load.
   2. Any costs imposed by Customer’s prior medical billing vendor or affiliate associated with migrating historical demographic, insurance, billing, or other data shall by covered by Customer.
   3. If requested by the Customer, other services not covered under the contracted RCM Package will be charged at the rate of $40.00/hour offshore, $90.00/hour onshore/domestic resources. All requests for additional work shall be incorporated into the Agreement through a separate Statement of Work.
   4. Application integration services will be charged at the rates of $200/hour for Senior Technologist, $150.00/hour for Technologist and $45.00 per hour for Offshore Specialist.
   5. Hourly rates and reasonable travel expenses will be invoiced if SAI staff members need to travel to Post Office or to Customer’s location to provide services or collect items required for performing its billing duties.
   6. Customer is also responsible for any postage, mailing or courier costs related to the materials sent to payors.
   7. Customer shall pay all applicable state and local taxes, including all excise, use and other taxes (excluding any taxes imposed on the net income of SAI or franchise taxes) imposed in connection with the Services.
   8. HL7 Setup and Implementation fee will be $2,500 for up to two (2) API/HL7 Interface(s). $30 per provider per month for Support and Maintenance for each third-party integration.
   Optional Services:
   
   1. Aged Accounts Receivable, defined as accounts receivable that were billed for dates of service more than ninety (90) days prior to the Effective Date, and collected on by SAI, will be subject to a twenty-five percent (25%) fee of the Net Revenue collected for insurance and patient accounts.
   2. Fee for obtaining authorizations on Customer’s behalf will be $40.00 per hour for work performed offshore and $90.00 per hour for work performed onshore.
   3. Patient coverage determination services will be billed at $3.50 per successful coverage determination result.
5. Term and Termination:
   This Statement of Work will remain in effect with SAI, or its successor, for the period outlined in Term section of the SOW beginning on the Effective Date of this SOW (the “Initial Term”), unless sooner terminated in accordance with the Agreement. The term of this SOW shall automatically renew for an additional two (2) years (each a "Renewal Term" and together with the Initial Term, the "Term"), unless either party provides the other with written notice of termination no less than ninety (90) days before the expiration of the Initial Term or any Renewal Term, or unless sooner terminated.
   
   1. Obligations Following Termination or Expiration.  SAI shall have no further obligations to provide Services to Customer under this Agreement following the termination or expiration of this Agreement. SAI shall be compensated for all amounts collected by SAI or Customer on charges submitted by SAI during the term of this Agreement for Medical Services rendered or provided prior to the date of termination or expiration (the “Existing Accounts Receivable”) and received during a one hundred and eighty (180) day period following the termination or expiration of this Agreement (the “Wind Down Period”). During the Wind Down Period, SAI will continue to provide Services in connection with the collection of the Existing Accounts Receivable. Customer expressly agrees to cooperate with SAI during the Wind Down Period by timely reporting, or causing to be reported, all payment received by Customer on the Existing Accounts Receivable for which SAI is responsible. Except with respect to providing Services on the Existing Accounts Receivable, or for such other matters as the Parties may agree to in writing, after the effective date of termination or expiration, SAI shall have no further obligations to provide Services to Customer under this Agreement following the termination or expiration of this Agreement. The Parties’ rights and obligations under this Section 7.1 shall survive the termination or expiration of this Agreement.
6. Additional Terms and Conditions:
   
   1. SAI reserves the right to update its pricing and rates for services at the renewal of each term.
   2. Travel Expenses incurred during the implementation and onboarding period will be billed monthly to the Customer at cost.
   3. Key Contact.  The Key Contact(s) shall be deemed the agent(s) of Customer for the purpose of communications and consents between the Parties under this Agreement. In particular, the Key Contact(s) shall have the power to agree, on behalf of the Customer, to resolve issues arising under the Agreement and, at SAI’s request, to receive confirmation memoranda or letters. In addition, the Key Contact(s) will respond to inquiries or requests from SAI in three (3) business days prior to such change.

This version of the Terms of Service has been effective and updated on this website since November 29. 2023 9:51 AM ET. These Terms of Service supersede previous Terms of Service posted on this site.