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❑ Work Comp/Personal Injury/Auto Accident Claims $80.00 Monthly Minimum*** <br />***Client will be charged $80 per month for up to 100 electronic claims, $0.80 per electronic claim thereafter. Paper <br />Claims are $1.25 per claim. <br />o Allows Client to submit electronic attachments as additional documentation for workers' compensation, <br />personal injury, and liability claims. <br />ADDITIONAL INFORMATION <br />Please check the box next to the desired information below. <br />❑ Credit Card Services <br />o Please check the box if you are interested in receiving more information regarding Credit Card Services <br />from TSYS. Watch the video at 9'ittt)s:/.-..It).Lsys-,.coniltrizettoI <br />❑ Collect Online Payments <br />o Please check the box if you are interested in receiving more information regarding Online Payment <br />Collections services from TSYS. <br />❑ Credentialing Services <br />o Please check the box if you are interested in receiving more information regarding Credentialing Services <br />from TriZetto Provider Solutions <br />ADDITIONAL FEES <br />Initial Set-up Fee: $200 (Waived if Rec'd by 4/30/19) <br />Provider Add On Fee: $0 <br />Annual Renewal Fee: <br />NOTES <br />1. Go -Live date of 5/1/19; if client decides to change will communicate and then invoicing will be based <br />off of the new go -live date. Charges will not start until live claims are sent. If no Go -Live date is listed, <br />then invoicing shall begin 30 days after the Effective Date. <br />2. Do not invoice until first live claim file is sent <br />ADDITIONAL TERMS <br />The following additional terms (the "Additional Terms") shall apply to the Agreement. For any conflict between <br />the General Terms (including any incorporated document) and these Additional Terms, the Additional Terms will <br />govern. <br />1. Payment Terms. Notwithstanding the fifteen day period described in Section 6.2 Invoicing of the General <br />Terms, all invoices shall be payable within thirty (30) days of the invoice date. <br />2. Governing Law. Section 13.8 Governing Law of the General Terms attachment to the Agreement shall be <br />modified so that the Agreement is governed by the laws of the State of Indiana. <br />3. Public Sector Client. Because Client is a government or public sector entity, some provisions of the Agreement <br />may be invalid or unenforceable under state or other applicable law. If so, and notwithstanding anything to the <br />contrary in the Agreement, those invalid or unenforceable provisions of the Agreement are revised to render the <br />provisions both enforceable and consistent with the original intent of the parties to the maximum extent <br />permissible. <br />PO TRIZETTO CONFIDENTIAL/TRADE SECRET <br />201SO408 _ .,....,, <br />form r viewed <br />Page 2 of 4 9 M 1 EGAI p/ <br />�" F.'•SN�rrau�rrn� <br />