Outsource MedClaim Terms and Conditions

Claim Management: Preparation, scrubbing, and electronic submission of professional and/or institutional claims to third-party payers.

Denial Management: Systematic tracking, correction, and resubmission of denied or rejected claims.

Payment Posting: Accurate entry of ERAs (Electronic Remittance Advice) and EOBs (Explanation of Benefits) into the Client’s EHR/PMS.

A/R Follow-up: Proactive pursuit of outstanding accounts receivable over 30, 60, and 90 days.

Virtual Assistance: Provision of trained, bilingual VMAs for tasks such as eligibility verification and patient scheduling.

Provide Accurate Data: Supply complete and accurate patient demographics, insurance information, and clinical documentation (superbills/encounters) in a timely manner.

Maintain Credentials: Ensure all providers maintain active NPIs, state licenses, and required payer enrollments.

Clinical Coding Responsibility: While Outsource MedClaim provides coding review, the Client remains ultimately responsible for the medical necessity and clinical accuracy of the codes submitted.

System Access: Grant secure, remote access to the practice’s EHR/PMS (e.g., Epic, Cerner, athenahealth) for the purpose of performing the agreed services.

Performance-Based Fee:

The Client shall pay a service fee based on a percentage of Net Collections (typically 4%–8%), unless a flat-fee arrangement is otherwise specified in the Service Agreement.

Invoicing:

Outsource MedClaim will invoice the Client monthly for services rendered in the preceding month. Payments are due within 30 days of the invoice date.

Late Fees:

Unpaid balances beyond the 30-day term may be subject to a late fee or monthly interest as permitted by state law.

Business Associate Agreement (BAA): Both parties will execute and abide by a BAA in accordance with our HIPAA Compliance Standards, ensuring all Protected Health Information (PHI) is handled in strict accordance with HIPAA and HITECH regulations.

Data Protection: Service Provider will maintain enterprise-grade security, including 256-bit encryption for data in transit and at rest.

Term: This agreement commences on the Effective Date and continues until terminated by either party.

Termination for Convenience: Either party may terminate the relationship by providing 30 to 90 days written notice.

Effect of Termination: Upon termination, the Client is responsible for fees accrued for all claims processed or collected up to the final date of service. Outsource MedClaim will ensure an orderly transfer of data back to the Client.