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Z IVA <br />aTRIZETTO <br />Provider Solutions' <br />A Cognizant Company <br />PURCHASE ORDER <br />CLIENT CONTACT INFORMATION <br />Company Name: South Bend Fire Department <br />Contact: Todd Skwarcan <br />Phone #: (574) 235-9255 <br />Fax #: <br />Email: tskwarca@southbendin.gov <br />Address: 1222 S Michigan <br />South Bend, IN, 46601 <br />TRIZETTO CONTACT INFORMATION <br />Sales Rep: Angie Rinderer <br />Phone #: (800) 969-3666 Ext. 1453 <br />Fax #: (314) 802-6822 <br />Email: angelica.rinderer@cognizant.com <br />Address: 3300 Rider Trail South <br />Earth City, MO 63045 <br />TERM <br />Initial Term: 12 months Renewal Term: 12 months <br />EDI SERVICE PACKAGES MONTHLY FEE <br />Please check the box next to the desired package. <br />❑ ELECTRONIC CLAIMS includes: <br />Electronic Remittance Advice <br />Claim Status Inquiry <br />$500 for up to 2,500 Claims <br />$0.20 per claim thereafter <br />(1st 3 Month Free if Rec'd by 4/30/19) <br />ANCILLARY EDI SERVICES MONTHLY FEE <br />Please check the box next to the desired ancillary services below. <br />❑ Paper Claims $0.59 per Claim <br />o Cost-effective solution for payers not accepting claims electronically. <br />❑ Secondary Claims $0.79 per Claim <br />o Options: COB Pass Through Secondaries7 <br />o The ability for the provider to automate the process of sending a secondary claim for payer <br />processing. <br />❑ Patient Statements $0.71 per Statement <br />o Simplifies the patient billing process through fast and accurate printing and mailing of professional <br />patient statements. <br />o $0.14 for each additional page, $0.50 NCOA fast -forward fee per encounter, $0.05 CASS fee maybe <br />incurred <br />❑ Advanced Coding Edits $10.00 per 200 Claims <br />o Submit cleaner claims by quickly and automatically identifying coding errors before they're <br />submitted to payers. <br />❑ Denials Workflow $10.00 per 200 Claims <br />o This solution allows for clients to create a workflow for their denials process with the ability to tag <br />accounts, notate accounts, and print automated appeal letters the functionality in this product will <br />assist our customers in managing their denial process. <br />PO - South Bend Fire Dept r v1—d rRIZE.TTO CONFIDENTIAL/TRADE SECRET <br />20150408 g'r.�c""'�/ CTSGL: 20190402 (JCS) Executable <br />Page 1 of 4 pq, <br />+" il.r;nrvww� <br />