eCare Online Provider Agreement

This Provider Agreement (the "Agreement") is made and entered into as of  (the "Effective Date")

by and between Nebo Systems, Inc., a Subsidiary of Passport Health Communications ("NEBO") and

located at address

.

(Required  - Enter your Client Facility Name)

(Required - Enter your Street Address, City, State, Zip)


TERMS AND CONDITIONS

Please Read the Following Terms and Conditions:



I have read and agree to the terms and conditions of this agreement.
(Required)

By checking this box, I certify that I am over the age of eighteen (18) and I certify that I have read these terms and conditions and that all information is complete and accurate. I further certify that I am authorized to sign and contractually bind the Customer and facility listed above for the products and services referenced herein and any associated fees.


ACCEPTED AND AGREED TO:

A manager from your facility must review and accept this form.
 

Accepted By:

(Required)

Title:

(Required)

Area Code and Telephone:

(Required)

Email:

(Required, if no Email, enter None)

 

EXHIBIT A
Service Description (Provider Agreement)

SERVICES provided by NEBO to Customer under this Agreement are marked below, and the Services may be amended and/or updated from time to time by mutual agreement of the parties hereto. Any amended Exhibit A shall be evidence of the mutual agreement of the parties hereto and shall thereafter be incorporated by reference into the Agreement and replace all and any prior Exhibit A, with such services listed in the amended Exhibit A being referenced thereafter as the "Services."

User IDs will be provided with access to the following functions:

  • Eligibility Verification: This transaction allows a provider to submit either a batch or a real-time online request for verification of patient eligibility status. Responses to this request will minimally include validation of the request, patient demographics, member and subscriber ID, effective date and termination dates.

  • Claim Status Inquiry: This transaction allows a provider to submit a real-time online request regarding the status of a claim previously submitted. Responses will include an indicator of receipt and the disposition status of the claim.

  • Address Verification: This transaction allows a provider to submit a name and address for address verification.

  • NPI lookups: This transaction returns an NPI for a submitted provider name.

CUSTOMER RESPONSIBILITIES

Customer is responsible for providing the following services to its end users within its organization and to NEBO where applicable. These services are not included under the definition "Services" as used in the Agreement.

1. Provide information necessary for registering the Customer organization and its end users.

2. Cause all employees of Customer organization to comply with the terms and conditions of the Agreement, including but not limited to insuring that access to the product, Services and System is limited to specifically authorized personnel currently employed by the Customer organization.
 

EXHIBIT B
Statement of Charges (Provider Agreement)

Customer will be charged the following prices for the Services provided hereunder, which may be amended or modified from time to time, under the terms of the Agreement. This Statement of Charges may also be amended from time to time by mutual agreement of the parties hereto. Any such amended Exhibit B shall be evidence of the parties' mutual agreement and shall thereafter be incorporated by reference into the Agreement and replace all and any prior Exhibit B, with such statement of charges listed in the amended Exhibit B being referenced thereafter as the "Payments."

1. Monthly Minimum Fees
ServiceFee

eCare® Online $ 20.00

$20.00


2. Eligibility Transaction Fees
PayerEligibility Fee
per Transaction

Blue Cross Blue Shield (BCBS)

 

     ILLINOIS

$0.02

     TEXAS

$0.02

     NEW MEXICO

$0.02

     LOUISIANA

$0.02

     MICHIGAN

$0.15

     Anthem

$0.15

     Regence

$0.15

     Capital

$0.15

     HighMark

$0.15

     Wellmark

$0.15

Medicaid

 

     ILLINOIS

$0.15

     INDIANA

$0.20

     Amerigroup

$0.25

     Other States (as available)

$0.25

Medicare

 

     Medicare A/B

$0.12

     AARP

$0.25

TRICARE

$0.25

UNICARE

$0.15

GEHA

$0.25

Molina

$0.25

UPMC

$0.25

CareSource

$0.25

Commercial Payers*

$0.02


*Commercial Payers
Aetna, America/Health Assurance of PA, AssurantHealth, BGFH, Butler, Cigna, Core Source, Coventry, FirstHealth, GreatWest, HAMP, Humana, MMOH, PacifiCare, Principal Financial, Trustmark, and UHC.

Additional Services
ServiceFee per Transaction

Address Verification

$0.40 

NPI LookupFREE


3. CLAIM STATUS FEES
(for BCBSIL, BCBSTX, BCBSNM, and Commercial Payers*)
 
Number of Claim Status
Transactions
Claims Status Fee
1 to 5,000 $38
5,001 to 10,000 $100
10,001 to 50,000 $200
50,001 to 100,000 $500
More than 100,000 $1,000

There will also be a $0.01 charge for each transaction
exceeding 100,000 transactions in a given month.


*Commercial Payers
Aetna, America/Health Assurance of PA, Assurant Health, BGFH, Butler, Cigna, Core Source, Coventry, First Health, GreatWest, HAMP, Humana, MMOH, PacifiCare, Principal Financial, Trustmark, and UHC.


4. CLAIM STATUS FEES (Other Payers)
FOR THE BELOW PAYERS ARE COMBINED WITH THE ELIGIBILITY TRANSACTIONS UP TO THE MINIMUM FEE.
 
Number of Claim Status
Transactions
Claims Status Fee

Illinois Medicaid

$0.15

Indiana Medicaid $0.20
Other State’s Medicaid
(as available)
$0.25
Anthem BC$0.15


 

NOTE: eCare® Online requires Microsoft Internet Explorer 8.0 or higher and Windows XP or newer. Google Chrome or Firefox browsers are not supported.  eCare® Online is not supported on Apple computers.


Demographic Info: (Contact Information)
Contact First Name: (Required)
Contact Last Name: (Required)
Department:
Contact Address: (Required)
City: (Required)
State: (Required)
Zip: (Required)
Area Code and
Telep
hone Number:
(Required)
Fax Number:
Email Address:
(Required, if no Email, enter None)


Invoicing Information:
This is where your invoice will be sent.

Click here if Contact Information is the same as Invoice Information.
(If necessary, you may change the information below)
 
Company Name:
Attention First Name: (Contact First Name)
Attention Last Name: (Contact Last Name)
Department
Address:
City:
State:
Zip:
Area Code and
Telep
hone Number:
Email Address:

 

Access Information:
We assign ONE user ID per person. Sharing IDs is NOT permitted. This is a HIPAA Requirement.

How many User IDs are you requesting?
  (Required)
 

Please enter your Tax ID.

  (Required)


Please enter your Group NPIs in the fields provided.

 

NPI Number:

  NPI Provider Name:

1.


(Required, 10-digits)

 
(Required)

2.

 

3.

 

4.

 

5.

 

6.

 

7.

 

8.

 

9.

 

10.

 


If you would like access to Illinois Medicaid, please enter your Illinois Medicaid provider numbers and their provider names.

  Illinois Medicaid Provider Number/State License Number (Non-NPI): 

Provider Name:

1.


(Optional, 9 or 12-digits)

 
(Required, if Provider ID Supplied)

2.

 

3.

 

4.

 

5.

 

6.

 

7.

 

8.

 

9.

 

10.

 

 

Please select the resource(s) you would like.

(At least one checkbox must be selected in order to submit this form.)


COMMERCIAL
Click here if you want all Commercial payers or select the individual payers below.

AETNA ASSURANT HEALTH
BLUEGRASS & FAMILY HEALTH BUTLER
CIGNA CORE SOURCE
COVENTRY FIRST HEALTH
HEALTH ALLIANCE HUMANA
MEDICAL MUTUAL OF OHIO PACIFICARE
PRINCIPAL FINANCIAL TRUSTMARK
UHC  


BLUE CROSS BLUE SHIELD
Click here if you want all BCBS payers or select the individual payers below.

ILLINOIS TEXAS
NEW MEXICO LOUISIANA
MICHIGAN ANTHEM (Only check if you are an authorized Anthem provider.)
REGENCE CAPITAL
WELLMARK HIGHMARK


MEDICARE

Click here if you want all Medicare payers or select the individual payers below.

MEDICARE AARP

 

OTHER PAYERS
Click here if you want all Other payers or select the individual payers below.

UNICARE TRICARE
GEHA MOLINA
CARESOURCE UPMC
GREATWEST   

 
MEDICAID

Click here if you want all Medicaid payers or select the individual payers below.


Note:  You must have a valid NPI for the state you are requesting.
(Please verify that you completed the Illinois Medicaid section above, if requesting Illinois Medicaid)

ALABAMA   MISSOURI  
AMERIGROUP  NORTH CAROLINA  
ARKANSAS   OHIO (Enter Ohio Medicaid
7-Digit Provider Number)

(Required, if checked)
ILLINOIS   OKLAHOMA  
INDIANA   PENNSYLVANIA  
IOWA   TEXAS  
KANSAS   VIRGINIA  
KENTUCKY   WASHINGTON  
LOUISIANA   WEST VIRGINIA  
MICHIGAN   WISCONSIN  
MISSISSIPPI   WYOMING  


ADDRESS VERIFICATION

ADDRESS VERIFICATION

Click here if you want Address Verification.


Complete the following for Texas Medicaid Claims Status Access
(For Acute Care Providers ONLY.  Call the helpdesk at 866-810-0000 if you are a Long Term Care Provider or if you have more than 10 TPI and NPI Numbers.)

  Texas Medicaid Provider Name   7-Digit Billing
TPI Base Number
 

10-Digit Billing NPI/API*

1.

   
  (Must be the name associated with the 7-digit TPI Base Number listed at the right)   (The first 7-digits of the
9-digit TPI number*)
   

2.

   

3.

   

4.

   

5.

   

6.

   

7.

   

8.

   

9.

   

10.

   
*NOTE: Performing TPI and NPI/API numbers do not have Claim Status Inquiry access.
Enter only BILLING TPI and NPI/API numbers.