CENTRAL INTELLIGENCE BILLING

8416 S. 8th Avenue Suite 104

Inglewood, CA  90305

CONTRACT

 

 

Health Care Billing Agreement

 

Made this ________ day of  _____________.  20_________, by and between C.I.B. and

 

______________________________________________________________________.

 

Hereinafter “Physician”

 

            C.I.B. will provide a service to the above physician to effectuate the filing of medical insurance claims with governmental authorities and private commercial insurers through electronic and manual means (claims processing), and also offers direct billing services to the patient (billing services); and

 

            The physician desires to engage C.I.B. to provide claims processing and or billing services as set forth herein.

 

            In consideration of the foregoing recitals, incorporated herein and in consideration of mutual promises contained herein C.I.B. and physician hereby agree to the following:

 

1.      C.I.B.’s Responsibilities

 

  1. Claims Processing, Physician hereby engages C.I.B. to file, process and collect its medical insurance reimbursement claims.

 

  1. Billing Service, Physician hereby engages C.I.B. to bill patients for services rendered by physician.

 

2.      Physician Responsibility

 

  1. Claims Processing.  Physician agrees to obtain certain information regarding patients and their insurance coverage as C.I.B. may designate in writing, to enable C.I.B. to file and process medical insurance claims.  C.I.B. shall not be responsible for any delay in or inability to collect claims due to insufficient information provided by the physician.

 

  1. Billing services.  Physician agrees to submit timely all necessary billing information to enable C.I.B. to bill patients in the time frame required by physician.

 

 

 

 

 

 

3.      Physician’s Payment for C.I.B. Services

 

  1. One time set up fees:

 

i)                    Physician agrees to pay C.I.B. the sum of $25.00 as a one time basic start up fee for Claims Processing.

 

ii)                   Physician agrees to pay C.I.B. the sum of $25.00 as a one time start up fee

for Billing Services.

 

 

B.     Continuing Charges:

 

i)                    Physician agrees to pay C.I.B. the sum of $5 per insurance claim filed and processed.

 

ii)                   Physician agrees to pay C.I.B. the sum of $5 per billing prepared and sent to patient.

 

 

iii)                 In the event that a claim or billing must be resubmitted due to an error by C.I.B. the same shall be resubmitted at no additional cost to the physician.

 

iv)                 In the event that a claim or billing must be resubmitted without fault on the part of C.I.B.  the same shall be resubmitted by C.I.B. and the physician agrees to pay C.I.B. the charge of one half the charge set forth at i) or ii), as the case may be, as if such re-submission was an original submission.

 

 

(Physician or Practice Manager) X_______________________________________     Date_______________

 

 

(C.I.B. Staff Member) X_______________________________________     Date_______________