NEMO Health Availity Order Form
 
 
 
 
 
Purchasing Information
 
 
Practice Name*
 
 
 
 
Practice ID
 
 
 
 
Site ID
 
 
 
 
Contact First Name*
 
 
 
 
Contact Last Name*
 
 
 
 
Job Title*
 
 
 
 
Phone*
 
 
 
 
Street Address*
 
 
 
 
Fax*
 
 
 
 
City*
 
 
 
 
State / Province / Region*
 
 
 
 
ZIP / Postal Code*
 
 
 
 
Fed Tax ID*
 
 
 
 
Provider Count*
 
 
 
 
Email*
 
 
 
 
SPECIAL COST-SAVING PACKAGE: $99 per provider / per month
 
 
(30% less than Trizetto)
 
 
 
 
 
Includes the following bundled services for successful Revenue Cycle Management:
 
 
 
 
 
• Claim Submission and Management – Submit claims online to over 2,000 payers. Submission of single, co-mingled claims online. Submission of integrated, direct online and EDI payers, follow-up and resubmission of rejected claims.
 
 
 
 
 
• Eligibility – Real-time batch and individual eligibility verification, with deductible, co-payment and overage limits. Manage your knowledge of patient benefits before your patient’s appointment.
 
 
 
 
 
• Edit/Error Management – Multiple levels of online interactive claim editing - standard data validations, HIPAA-related edits, CCI edits, Medicare edits. Auto-population from payer claim headers results in dramatic reduction of eligibility errors.
 
 
 
 
 
• Claim Status – Real-time claims status with auto refresh of information up to the minute.
 
 
 
 
 
• Remittance and Payment – 835 Electronic Remittance Advice from payers for auto-posting and PDF for manual posting.
 
 
 
 
 
• Reporting – Robust, customizable reports that can be scheduled to run automatically. Tracking of transactions, expose error patterns.
 
 
 
 
 
• Security and Administration – Manage office settings for user preferences and secure feature access by office roles
 
 
 
 
 
Click here to accept bundled services*
 
 
 
 
 
 
 
ADDITIONAL SERVICES FEES (Optional)
 
 
 
 
 
1. Patient Statement Service Fee
 
 
 
 
 
• $0.66 first page (subject to increases or decreases by the USPS)
 
 
 
 
 
• $0.10 for each additional page
 
 
 
 
 
• $0.01 View statement after printing
 
 
 
 
 
Click here to accept patient statements
 
 
 
 
 
 
 
2. Workers Compensation Service Fee
 
 
 
 
 
• USPS First Class postage rate, subject to increases or decreases by the USPS, plus $0.08 per workers compensation claim
 
 
 
 
 
Click here to accept worker's compensation claims
 
 
 
 
 
 
 
This Sales Order hereby incorporates by reference the NEMO Health Master Terms of Service (available at www.nemohealth.com/terms-of-service), a copy of which will be provided to Client upon request. By executing this Sales Order below, Client acknowledges that: (1) Client accepts and agrees to be bound by the terms of service, including sections 13.5 and 14.6 thereof, which provide that the parties desire to resolve any and all disputes relating to the TRAKnet® subscription and subscription enhancements in courts located in Michigan; and (2) Client is giving up various rights, including the right to trial by jury, and any claim for compensatory, consequential, indirect, special, incidental, exemplary, or punitive damages, or any damages in excess of the subscription fees paid by Client during the three (3) month period immediately preceding the date the applicable cause of action arose. Availity EDI services, this Sales Order also incorporates by reference the RealMED Terms and Conditions (available at www.nemohealth.com/availity-terms-and-conditions), a copy of which will be provided to Client upon request. By executing this Sales Order below, Client is giving up various rights, including any claim for damages in excess of the EDI fees paid by Client during the twelve (12) month period immediately preceding the date the applicable cause of action arose. The amount of any applicable state and/or local sales, use, or excise taxes shall be added to the price(s) quoted above.
 
 
 
 
 
Electronic Signature*