2010R34 - Gateway EDI, LLC for EMS ClaimsRESOLUTION NO. 10-R-34
A RESOLUTION BY THE CITY COUNCIL OF THE CITY OF
SCHERTZ, TEXAS AUTHORIZING A LICENSE AGREEMENT WITH
GATEWAY EBI, LLC, ANI3 OTHER MATTERS IN CONNECTION
THEREWITH
WHEREAS, the City staff of the City of Schertz (the "City") has recommended that the
City enter into a License Agreement with Gateway EDI, LLC ("Gateway") concerning the City's
use of Gateway's electronic data interchange system for processing EMS healthcare claims (the
"Agreement"); and
WHEREAS, the City Council has determined that it is in the best interest of the City to
contract with Gateway pursuant to the Agreement attached hereto as Exhibit A;
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SCHERTZ, TEXAS
THAT:
Section 1. The City Council hereby authorizes the City Manager to execute and
deliver the Agreement with Gateway in substantially the form set forth on Exhibit A.
Section 2. The recitals contained in the preamble hereof are hereby found to be true,
and such recitals are hereby made a part of this Resolution for all purposes and are adopted as a
part of the judgment and findings of the City Council.
Section 3. All resolutions, or parts thereof, which are in conflict or inconsistent with
any provision of this Resolution are hereby repealed to the extent of such conflict, and the
provisions of this Resolution shall be and remain controlling as to the matters resolved herein.
Section 4. This Resolution shall be construed and enforced in accordance with the
laws of the State of Texas and the United States of America.
Section 5. If any provision of this Resolution or the application thereof to any person
or circumstance shall be held to be invalid, the remainder of this Resolution and the application
of such provision to other persons and circumstances shall nevertheless be valid, and the City
Council hereby declares that this Resolution would have been enacted without such invalid
provision.
Section 6. It is officially found, determined, and declared that the meeting at which
this Resolution is adopted was open to the public and public notice of the time, place, and subject
matter of the public business to be considered at such meeting, including this Resolution, was
given, all as required by Chapter 551, Texas Government Code, as amended.
Section 7. This Resolution shall be in force and effect from and after its final
passage, and it is so resolved.
Resolution 10-R-34.doc
PASSED AND ADOPTED, this 6th day of July, 2010.
CITY OF SCH TZ, TEXAS
Mayor
ATTEST:
\ r~..
-- -,,1
r
>ty Secretary
(CITY SEAL)
Resolution 10-R-34.doc
EXHIBIT A
LICENSE AGREEMENT
Resolution 10-R-34.doc A-1
For internal use only:
SR: Brian Franceschi
Site #:
L~~E~SE AGldEEME~41"
Gateway EDI, LLC
50t ;V Broadway, 3'~ Floor
St. Louis, MO 63102
(800)969-3666
THIS LICENSE AGREEMENT (the "Agreement"} is made and entered into as of the dale signed, between GATEWAY
EDI, LLC, a Delaware Corporation, and ~ of Schertz Texas 1400 Schertz Pkwy Bldn 7 Schertz TX 78154 (for use by the Cify's
EMS Deoartment)(hereinafter °CLIENT"}, concerning the use by CLIENT of GATEWAY EDI's Electronic Data Interchange (EDI}
system (the "System"}.
Financial Agreement.
{a) Effective as of the date of this Agreement, GATEWAY EDI will support FTP or Website processing
of healthcare transactions between the CLIENT and governmental agenaes, insurance carriers and other companies by
either electronic or paper means.
(b) All CLIENT information and data processed by the CLIENT through FTP or the Website shall be
kept confidential and shall not be disclosed to anyone outside of GATEWAY EDI other than io the extent necessary for
GATEWAY EDI to process and submit healthcare transactions for the CLIENT. In addition, except as required by law
,CLIENT will not divulge the contents, terms or conditions of this Agreement to any third party without the express written
consent of GATEWAY EDL
(c) CLIENT will pay GATEWAY EDI an initial setup fee of $200 to cover the cost of setting up the
CLIENT in the System. This initial setup fee will be due and payable on the date this Agreement is signed. This initial
setup fee is non-refundable. Thereafter, CLIENT will pay an additional setup #ee of $50 for each new provider employed
or retained by CLIENT after the initial setup is completed.
(d) CLIENT will pay GATEWAY EDI the agreed pricing listed on APPENDIX A for unlimited (defined as
zero electronic claims to unlimited electronic claims) use of the System to process healthcare transactions. The prices in
this Agreement are guaranteed for a period of one (1) year from the date this Agreement. Thereafter, GATEWAY EDI
reserves the right to modify the price payable under this Agreement upon thirty (30j day written notice to the CLIENT.
(e) GATEWAY EDI will invoice CLIENT for its services on the first day of each month for the selected
EDI transactions for the current month and any activity fees for the previous month. CLIENT will pay GATEWAY EDI for
ifs services within fifteen {15) days of the invoice date. If CLIENT fails to submit payment to GATEWAY EDi within the
time set forth in this Section, CLIENT will be responsible for paying, in addition to the invoice amount, a 1.5% per month
late charge for each month or any portion thereof, such payment is late, with a minimum fee $5.00. Failure to make
payment within 120 days will result in CLIENT's account being turned over to a collection agency at which point CLIENT
will also be responsible for any and all charges associated with collections on CLIENT's account. In addition to the
foregoing, GATEWAY EDI shall be entitled to suspend or terminate the performance of its services under this Agreement
during any period in which invoices are past due, without incurring any liability to CLIENT. GATEWAY EDI's services are
a subscription service, and as such Client will pay claims transaction fees. regardless of the volume of claims sent.
(f) In addition to the other amounts invoiced by GATEWAY EDi and payable by CLIENT under this
Agreement, GATEWAY EDI will invoice CLIENT for an annual renewal fee of $200 upon the renewal of this Agreement.
Such invoice shall be payable by CLIENT within fifteen (15) days of the invoice date.
2. GATEWAY EDI Training. Training on claims transmission and data management reports will be provided by
GATEWAY EDI to CLIENT via telephone.
3. Hours of Operation.
(a) GATEWAY EDI's System will be available, except when technical problems intervene, for
submission of claims, extracting remittances, reports, updates, etc., twenty-four (24} hours a day. GATEWAY EDI's
System may be down Sunday mornings for maintenance.
(b) Electronic claims are processed daily until 2:00 pm Central Time. All claims received after 2:00
pm Central Standard Time will be processed on the next business day. Claims reports will be available by 10:00 am
Please fax back all gages of the completed license agreement to 394-802-6822 atfn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway EDI, LLC
501 N Broadway, 3'~ Floor
St. Louis, MO 63102,
(800)969-3666
Central Standard Time for all prior day submissions. Remits received from payers are processed and available m~ithin
twenty-four (24}hours of receipt.
(c} GATEWAY EDI's customer service department is available for support Monday through Friday,
7:00 a.m. to 6:00 pm Central Time, excluding holidays, After-hours support will be provided on abest-effort basis,
normally within four (4}business hours of the call.
4. Term.
{a} The term of this Agreement shall begin on the date set forth above and continue for a period of one
(1) year. This Agreement shall automatically renew for successive one (1) year terms. This Agreement can be
terminated by either party for any reason by giving the other party shirty (30) days advanced written notice. CLIENT will
continue to be billed for GATEWAY EDI's services until the end of such thirty (30) day period. Said notice must include
CLIENT's reasons for terminating the Agreement, which may be with or without cause.
{b} CLIENT is responsible for notifying GATEWAY EDI of any providers which require termination from
the System. CLIENT will continue to be billed for such providers until such time that CLIENT provides such notice, and
any amounts paid for these providers are considered non-refundable.
5. HIPAA Compliance.
{a) GATEWAY EDI agrees that if will comply with the requirements of the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), the HIPAA Privacy Standards (45
CFR 164.500 et seq.} {the "Privacy Standards"}, the HIPAA Security Standards {45 CFR 164.302 et seq.) {the "Security
Standards"}, and the Health Technology for Economic and Clinical Health Act of 2009 (the "HITECH Act") and the
regulations promulgated thereunder {the "HITECH Regulations°) applicable io Business Associates, including obligations
set forth below. All capitalized terms in this Section 5 that are not otherwise defined in Section 5 shall have the meanings
provided under HlPAA, the Privacy Standards, the Security Standards, the HITECH Act and the HITECH Regulations.
{i) GATEWAY EDI agrees that it will not use or disclose any Protected Health Information
("PHI") which GATEWAY EDI receives or obtains from CLIENT or reviews or creates for CLIENT {"CLIENT
PH!"), other fhan to perform the services it has agreed io perform under this Agreement ("Services"), as
otherwise expressly permitted by the terms of this Agreement or as required or permitted by law; provided,
however, that GATEWAY EDI may use and disclose CLIENT PHI: (i) to manage and administer its business;
(ii) to perform data aggregation services for CLIENT (and other clients); and (iii) to create de-identified
information, subject to the requirements of the Privacy Standards regarding the de-identification of information.
GATEWAY EDl agrees to comply with any and all restrictions on the use of CLIENT PHI requested by a
patient of CLIENT, agreed to by CLIENT and communicated by CLIENT to GATEWAY EDI; provided,
however, that in the event that GATEWAY EDI is unable or unwilling to comply with any such restriction,
GATEWAY E01 shall notify CLIENT of such fact, in writing, and, upon CLIENT'S receipt of such notice,
GATEWAY EDI shall be relieved of any and ail further obligation to perform Services for CLIENT in connection
wish such patient, provided that GATEWAY EDI return to CLIENT or destroy any and all CLIENT PHl in
GATEWAY EDI's possession or control regarding such patient.
(ii) GATEWAY ED! shall implement appropriate safeguards to prevent the use or disclosure
of CLIENT PHI for purposes other fhan as set forth in this Agreement. GATEWAY EDI also shall implement
administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality,
integrity and availability of the Electronic Protected Health Information ("EPHI"), that it creates, receives,
maintains or transmits on behalf of CLIENT ("CLIENT EPHI") as required under the Security Standards.
GATEWAY EDt will provide CLIENT with such information concerning such safeguards as CLIENT may from
time to time request.
(iii} In fulfillment of its obligations under 45 CFR 164.528 and Section 13405 of the HITECH
Act, GATEWAY EDI will maintain a record of all disclosures of CLIENT PHI for which such a record is required
under 45 CFR 164.528 and Section 13405 of the HITECH Act and will provide the following information
regarding any such disclosure to CLIENT or to the person whose PHI was disclosed {"Affected Person"), upon
the request of CLIENT:
(A) The date of such disclosure;
Please fax back all pages of the completed license agreement to 314-802-6822 attn: Brian Franceschi.
For internal use only: Gateway EDI, LLC
SR: Brian Franceschi 501 N Broadway, 3`d Floor
Site #: St. Louis, MO 63102
(800)469-3666
(B} The name and, if known, the address of the recipient of such CLIENT PHI;
(C} A copy of the request for disclosure, if any, accompanied by any necessary
consents or authorizations;
(D) A brief description of the CLIENT PHI disclosed; and
(E) A statement that would reasonably inform the Affected Person of the purpose
of the disclosure.
(iv) Except as provided otherwise in 45 CFR 164.412, GATEWAY EDI agrees to report to
CLIENT any known or suspected Breach of Unsecured Protected Health Information, Security Incident, or use
or disclosure of Protected Health Information not provided for by this Agreement, within a reasonable period of
time after discovery by GATEWAY EDI. Such report shall be in writing and shall be sent to CLIENT at the
address listed below. Unless specifically known, GATEWAY EDI will be deemed to have discovered the
known or suspected Breach or other violation in accordance wish the timeline set forth in 45 CFR 164.410.
Such notification shall also include the identification of each individual whose PHI has been, or is reasonably
believed by GATEWAY EDI to have been, wrongfully accessed, acquired, used, or disclosed. GATEWAY EDI
shall also provide CLlEN7 with any other available information that the CLIENT is required to include in .its
notification to the individual under 45 CFR 164.404(c).
(v} GATEWAY EDI agrees to require ifs employees, agents and independent contractors
("Workforce"} to adhere to the. restrictions and conditions regarding CLIENT PHI and CLIENT EPHI contained
in this Section 5, including, without limitation, the following:
(A) GATEWAY EDI agrees not to disclose CLIENT PHI to any member of its
Workforce, unless GATEWAY EDI has advised such person of GATEWAY EDI's obligations under
this Section 5 and the consequences of a violation of these obligations. GATEWAY EDI agrees to
take disciplinary action against any member of its Workforce that uses or discloses CLIENT PHI in
violation of this Section 5.
(B) Except as otherwise permitted under Phis Agreement, GATEWAY EDI will not
disclose CLIENT PHI to any third party without first obtaining the written approval of CLIENT.
Further, GATEWAY EDI will not disclose CLIENT PHI to any third party without first obtaining the
written agreement of such third party to be bound by the requirements of this Section 5 for the
express benefit of GATEWAY EDI and CLIENT.. Finally, GATEWAY EDI will not disclose CLIENT
EPHI to any third party without flrs# obtaining written agreement of such third party io implement
reasonable and appropriate administrative, physical and technical safeguards to protect the
confidentiality, integrity and availability of CLIENT EPHI.
(C) Any use of CLIENT PHI by GATEWAY EDI's Workforce ar disclosure of CLIENT
PHI to GATEWAY EDI's Workforce or to third parties must be limited to the minimum amount of
CLIENT PHI necessary to achieve the purpose for such use or disclosure.
(vi) GATEWAY EDI agrees to notify CLIENT immediately in the event GATEWAY ED{
receives a request from a person identified in any CLIENT PHI ("Subject"), or such person's legal
representative ("Lego! Representative"j, to review any records in GATEWAY EDf's possession or control
regarding the Subject ("Subject PHI'S, In fulfillment of its obligations under 45 CFR 164.524 and Section
13405 of the HITECH Act, GATEWAY EDI agrees to make available to CLIENT, or at the request of CLIENT,
to a Subject or such Subject's Legal Representative, for their review, any Subject PHI in GATEWAY EDI's
possession or control.
(vii) GATEWAY EDI agrees to notify CLIENT immediately in the event GATEWAY EDI
receives a request from a Subject to amend or otherwise modify any Subject PHI in GATEWAY EDI's
possession or control that GATEWAY EDl maintains in a Designated Record Set. In fulfillment of its
obligations under 45 CFR 164.526, GATEWAY EDI agrees that, at the request of CLIENT, it wilt make any
amendments to Subject PHI that it maintains in a Designated Record Set that the CLIENT directs or
authorizes pursuant to 45 CFR 164.526.
Please fax back all pages of the completed license agreement to 314802-6822 attn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway BDI, LLC
501 Zd Broadway, 3`d Floor
St. Louis, MO 63102
{800}969-3b66
{viii) GATEWAY EDI agrees to make its policies, books and records relating to the use and
disclosure of CLIENT PHI available to the Secretary of the U.S. Department of Health and Human Services or
his or her designee #or the purpose of determining whether CLIENT is in compliance with the requirements of
the Privacy Standards.
{ix) GATEWAY EDI agrees to return to CLIENT or otherwise destroy all CLIENT PHI in its
possession or control in accordance with established medical records doctrine or upon termination of this
Agreement. if such return or destrucfion of records is not feasible, GATEWAY EDI shall continue to extend
the protections of this Section to such CLIENT PHI and limit any #urlher use of CLIENT PHI to those purposes
that make the return or destruction of CLIENT PHI infeasible.
(b) CLIENT agrees that, in connection with the performance of the Services by GATEWAY EDI,
CLIENT shall:
(i) CLIENT shall provide each of its patients with a Notice of Privacy Practices {"Privacy
Notice"). The Privacy Notice shall identify the potential uses and disclosures of a patient's PHI that CLIENT
may make, including, without limitation, the use of such PHI for billing and collection activities and disclosure
of such PNI to a health care clearinghouse in connection with such billing and collection activities. CLIENT
shat) use its good #aith efforts to have each patient acknowledge, in writing, its receipt and review of the
Privacy Notice.
(ii) CLIENT shall notify GATEWAY EDI immediately of any restrictions on fhe use of any
CLIENT PHI requested by a patient of CLIENT and agreed to by CLIENT. CLIENT shall provide GATEWAY
EDf with sufficient information regarding any such restriction to enable GATEWAY EDI to determine whether it
is able or willing to comply with such restriction.
{iii) CLIENT shall notify GATEWAY EDl immediately in the event CLIENT desires
GATEWAY EDI to disclose any Subject PHI in GATEWAY EDI's possession or control to the Subject or the
Subject's Legal Representative. .
{iv) CLIENT shall notify GATEWAY EDI immediately in the event CLIENT desires
GATEWAY EDI to amend or otherwise modify any Subjecl PHI in GATEWAY EDI's possession or control.
(c) In the event of a material breach by either party (°Breaching Party") of any of its obligations under
this Section 5, the other party ("Non-Breaching Pafty") may terminate this Agreement immediately, provided that the Non-
Breaching Party has first notified the Breaching Party, in writing, of such breach and that the Breaching Party has not
.cured such breach within thirty (30) days after its receipt of such notice.
NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED IN THIS AGREEMENT, THE RIGHT OF THE
NON-BREACHING PARTY TO TERMINATE THIS AGREEMENT PURSUANT TO THIS SECTION 5 SHALL BE THE
NON-BREACHING PARTY'S SOLE AND EXCLUSIVE REMEDY IN THE EVENT OF THE BREACHING PARTY'S
BREACH OF ITS OBLIGATIONS UNDER THIS SECTION 5 AND tN NO EVENT SHALL THE BREACHING PARTY BE
LIABLE TO THE NON-BREACHING PARTY FOR DAMAGES OF ANY KIND, INCLUDING, WITHOUT LIMITATION,
COMPENSATORY DAMAGES, INCIDENTAL DAMAGES, CONSEQUENTIAL DAMAGES OR PUNITIVE DAMAGES,
ALLEGED TO HAVE RESULTED FROM SUCH BREACH.
6. Force Maieure. Neither the CLIENT nor GATEWAY EDI shall be responsible far failure to fulfill its obligations
under this Agreement due to causes beyond its reasonable control.
7. Governing Law. This Agreement will be governed by the laws of the state of Missouri, Dispute arising
hereunder not resolved by the parties shall be litigated in a court situated in St. Louis County, Missouri.
8. DISCLAIMERS AND LIMITATIONS OF LIABILITY. EXCEPT AS OTHERWISE SET FORTH HEREIN,
THERE ARE NO WARRANTIES, WHETHER EXPRESS OR IMPLIED, INCLUDING, WITHOUT LIMITATION, ANY IMPLIED
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL GATEWAY EDI
BE LIABLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, OR EXEMPLARY DAMAGES, LOST PROFITS, OR
CLAIMS BY THIRD PARTIES, EVEN IF GATEWAY EDI HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. IN
ANY EVENT, GATEWAY EDI SHALL NOT BE LIABLE FOR ANY LOSS OR DAMAGE EXCEEDING ALL AMOUNTS PAID BY
CLIENT TO GATEWAY ED4 HEREUNDER.
Please fax back all pages of the completed license agreement to 314-802-8822 attn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway EDI, LLC
SOI N Broadway, 3`~ Floor
St. Louis, MO 63102
(800}9b9-366b
9. Acknowledgments. CLIENT is responsible for the completeness and accuracy of all information and data
generated through the QEDI processing system and CLIENT acknowledges that GATEWAY EDI has had no input with respect to
such information and data. Accordingly, to the extent permitted by law, CLIENT agrees to indemnify and hold GATEWAY EDl and
its officers, employees and agents harmless from and against any liability, Eoss, damage, claim or expense (including attorneys' fees}
arising out of the services provided by GATEWAY EDI hereunder, except to the extent any of the foregoing result directly from
GATEWAY EDI's gross negligence or willful misconduct.
10. Notice. Any notice required or permitted to be given under this Agreement shall be sufficient if in writing and
shall be deemed given when personally delivered or two (2} days after deposited in the United States-mail, certified mail, return
receipt requested, and addressed to the appropriate party at the address listed below,
11. No Third Partv Beneficiaries. There are no intended third party beneficiaries to this Agreement. Without in
any way limiting the foregoing, it is the parties' intent that nothing contained in this Agreement give rise to any right or cause of
action, contractual or othenxise, in or on behalf of any person whose PHI or EPHI Is used or disclosed pursuant to this Agreement or
any person who qualifies as a personal represenfative of such person.
12. Binding Effect, This Agreement shall be binding upon and inure to the benefit of fhe parties hereto as well as
their respec#ive heirs, assigns, and successors in interest.
13. Entire Agreement. This Agreement constitutes the entire agreement between the parties relative to the subject
matter.
14. Modiftcation. No amendment or additions to this Agreement shall be binding unless in writing and signed by
both parties.
15. Guarantee. GATEWAY EDI guarantees that we will be able to reduce CLIENT's rejection rate within 90 days.
If CLIENT is not 100% satisfied with GATEWAY EDl's customer service OR ability to lower CLIENT'S rejection rate after 90 days,
Gateway EDl will issue a refund for services provided" and GATEWAY EDI will pay for CLIENT to switch to another clearinghouse.'*
IN WITNESS WHEREOF, the parties have executed this Agreement on the date first set forth above.
GATEWAY EDI
GATEWAY EDI, LLC
~
,.
Printed: Brian Franceschi
Title: Regional Account Executive
Date: June 14, 2010
Address; 501 N Broadway, 3'd Floor
St. Louis, Missouri 63102
CLIENT .
Citv of Schertzi Texas
i
Printed: /~ ®~/ ~ ~ ~ ~/~G.t_.-
71t1e: C . ~ J` .~ ,~~ r .
Date: ~ ~ ,.-- ~ d
Address: 1400 Schertz Pkwy Bldn 7
Schertz, TX 78154
Please initial next to services desired on
Appendix A (next page}.
'Refund excludes all applicable postage costs,
'* GATEWAY EDI will pay CLIENT's initial set-up fee with another clearinghouse, not to exceed $500.
Please fax back alt pages of the completed license agreement to 314.862-8822 attn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway EDT, LLC
501 N Broadway, 3"~ Floor
St. Louis, MO 63102
(800}969-3666
~N~~~uix ~ ~c ~~~~~r~.~y EDI ! ~ce;~s~,.~.~paa~A~,t
Please iNiTIAL next to the desired services below:
~~G Electronic claims: The CLIENT will pay GATEWAY for the use of GATEWAY EDI's clearinghouse to submit
electronic claims to payers on the °Approved Payer List" based upon the following fee schedule:
$117 monthly minimum for up to 300 claims, $.39 per claim thereafter
Also included in the above fees, are the following services:
Individual Claims-status Inquiry: The CLIENT, using GATEWAY EDI's lntemet CSI, wilt be able to check the status of
any claim submitted to GATEWAY EDI; and
Unlimited individual Eligibility Inquiry for Participating Payers {Non-participating payers will be charged at $0.25 per inquiry}
~i Paper claims: The CLIENT will electronically send claims to GATEWAY EDI to be printed and forwarded to payers at
a fee of $0.561claim. Paper claims are filed for any insurer's claims received by GATEWAY EDI that are not on the "Approved
Payer list," or for claims received for payers to which the provider Etas not yet been approved to send electronic claims.
~1 All Payer Eligibility - up to 400 Eligibility inquiries and $.05 each inquiry thereafter for participating and non-
participa#ingyayers for $20 per month.
Recall Letters: The CLIENT will electronically send recall letters to GATEWAY EDI to be printed and forwarded to
patiernts at a fee of $0.59lietter.
Q~ Electronic Remittance Advice: GATEWAY EDI will electronically send to the CLIENT "ERA" files received from
payers {when available). The CLIENT agrees to pay GATEWAY EDI $251200 claims/month for this service.
aEt Click `n Print Secondary Claims: Provided the CLIENT is currently using GATEWAY EDt's Electronic
Remittance Advice service, Gateway EDI will make ERA information available through the website and CLIENT can put a
checkmark next to patients requiring secondary documentation. By choosing to print those check marked patients, a separate
page wil[ print for each patient with fhe ERA payment information as well as a header containing check information for a fee,of
$0.25/click.
~1 COB pass through to paper: Provided the CLIENT is currently using GATEWAY EDI's Electronic Remittance
Advice service and CLIENT can send the secondary payer information, Gateway EDI will create secondary claims when
necessary, print and mail the secondary claims to the secondary carriers for a fee of $0.75 per claim.
I am interested in receiving more information regarding Gateway EDI's Credit Card Services from TransFirst.
Please fax back all pages of the completed license agreement to 314-802-5822 attn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway EDI, LLC
SOE N Broadway, 3`d Floor
St. Louis, MO 63102
(800)969-3666
ACH AUTHORIZATION FORM
WE OFFER FREE ACH {AUTOMATED CLEARINGHOUSE} SERVICE TO HELP EASE SOME OF YOUR STRESS...
Here's how it works...
With Automatic Payment from Gateway EDI LLC your monthly invoices will be paid from your bank account.
You will continue to receive your Gateway EDI invoices but instead of writing a check, simply deduct the
amount from your bank account. Your bank statement will reflect your payments as a separate transaction,
so you'll always have a record. The Automatic Payment system will take care of transferring the correct
payment amount directly from your bank to your Gateway EDl account. There are no late fees. or lost
checks and your payments are made precisely on an agreed upon date. To activate the Automatic Payment
program, complete this blank form and we will take care of the rest.
Automatic Payment (ACH) Activation Form
all of the foElowing information and FAX or mail along with a votdea cnecK.
I authorize the financial institution named to charge my
(name of bank your office uses}
Checking or Share Draft Account Savings Account (not passbook}
Name of Bank Account Holder
Bank Account Number
A8A/Routing Number
And remit payment for my Gateway EDI, LLC invoices to:
Gateway EDI, LLC, Midwest BankCentre, ACN account
Monthly to begin mmlyy (Payment to be taken out the 20th of each month}
One time transaction of 200 on ,
date
Authorized Signature
tinted Signature
._~ ....a .,,.... ~s~+o.,~ont ~eiill chnw f.P,On01
Note: A test WIII TJe penOrmeQ oeiV~c at,uvauv~i ,~ ~..,,"t.'....... ~..~ ,'-.
Please don't be alarmed!
FAX this form with a copy of your voided check to:
(314)802-6822
OR
Mail this form with your voided check to:
Gateway EDI, LLC -Sales Rept.
501 N Broadway, 3`d Floor
Saint Louis, MO 63102
For assistance, please call (800}969-3666 and ask for Sales.
Please fax back all pages of the completed license agreement to 314-802-6822 attn: Brian Franceschi.
For internal use only:
SR: Brian Franceschi
Site #:
Gateway EDI, LLC
501 N Broadway, 3`d Floor
St. Louis, MO 63102
(300)969-3666
Gateway EDf, LLC Credit Card Authorization Form
We accept MasterCard and Visa as a payment option for your Set-up Fee(s). To have
your credit card charged for your Set-up Fee, we MUST have the following signed
statement on file. Accounts will be charged within 7 business days of receipt.
PLEASE PRINT
Site. Name City of Schertz, Texas
Name as is appears on the Credit Card
Street Address where statement is received
City, State where statement is received
Zip Code where statement is received
Telephone # {including area code}
Fax # (including area code)
Set-up Fee Amount 2~0
Credit Card Type (Please circle): VISA MasterCard AMEX
V/MC Card #: - - - Exp Date: / V-Cade
(3 digits on card back)
AMEX Card # - - Exp Date: / V-Code
(4 digits on card front)
1 authorize Gateway EDI, LLC to charge the credit card listed about for the initial Set-up
Fee for my account.
CARD HOLDER SIGNATURE
Name (signed)
Name (printed) Date
PERSON COMPLETING THIS FORM
Name (signed)
Name {printed)
Please fax back all pages of the completed license agreement to 314-802-6822 attn: Brian Franceschi.