Terms of Service Agreement

You must have completed and filed an EDI Agreement with your Medicare carrier in order to be eligible to use this service.

1. This Is a Contract Between US.

This is a contract between you and ICS Software, Ltd. (located at 3720 Oceanside Road West, Oceanside, NY 11572). We will refer to ourselves in this contract as either "ICS Software, Ltd.", "ICS", "we", "us", or "our." You are an individual person, or you are an employee or other agent of an entity on whose behalf you are accepting this contract. You must be at least 18 years old and have attained the age of majority in the province, state or country in which you live. The facts you give us must be complete and correct. You are also affirming that you have a valid EDI Agreement filed with your Medicare carrier and that you understand that we will start to process your request to use this service because we believe that you are telling us the truth. Before we issue you an account username and password, we will require a copy of a document that indicates that you are a provider in the Medicare program. We have these security measures in place so that unauthorized persons cannot access PHI. In addition, you will also sign a "business associate agreement" in accordance with HIPAA regulations.

 

This contract covers your use of this service, and does not include any other related services, software, machines, support, content and other media, papers, updates or upgrades. We refer the use of this website to retrieve Eligibility and Benefit Information for patients you treat as the "Service." This contract does not cover your use of any additional ICS Software, Ltd. services for which you choose to sign-up while this contract is in force.

 

Please note that this contract limits our liability and we do not provide warranties for the Service. The contract also limits your remedies. These terms are in Sections 10 and 11 and we urge you to read the terms carefully.

 

2. How and When You May Use the Service.

2.1 Service Usage. We provide the Service for your business use. You may not use the Service in a way that is against the law. You may not rent, lease, license, or otherwise transfer any rights to use the Service. You may not provide commercial hosting services under this Agreement. You also may not use it in a way that harms us or our affiliates, resellers, distributors, service providers, and/or suppliers (collectively, the "ICS Parties"), or any customer of an ICS Party. We may tell you about certain specific harmful uses in a code of conduct or other notice available through the Service. We have, however, no duty to do so. You will obey any codes of conduct and any other notices we provide.

 
2.2 Eligibility Rules of Behavior. As a user of this service, you are bound by rules and regulation put forth by CMS and HIPAA, as well as the terms of this contract. Violation of these rules and regulations will result in deactivation of your accounts and possible civil and/or criminal penalties. CMS may also demand that your account be deactivated as they warrant appropriate. For your benefit and information, we have posted the the rules pertaining to Eligibility as put forth by CMS here for your information and must be abided to use this service.  The rules posted here are not all inclusive and there may be additional rules and regulations you must abide by. These rules may change without notice. It is your responsibility to ensure that you know and abide by the most current rules and regulations. For the most up to date rules and regulations, please visit CMS website (http://www.cms.hhs.gov/home/medicare.asp)

[Excerpt From Medicare Claims Processing Manual, Chapter 31 - ANSI X12N Formats Other than Claims or Remittance, Section 10.3 - Eligibility Rules of Behavior. (Rev. 991, Issued: 06-23-06; Effective/Implementation Dates: 07-24-06) ]

10.3 – Eligibility Rules of Behavior

(Rev. 991, Issued: 06-23-06; Effective/Implementation Dates: 07-24-06)

The Centers for Medicare & Medicaid Services (CMS) is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. Disclosure of Medicare beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA.)

In October 2005, the CMS began offering to specific Clearinghouses and providers, the HIPAA 270/271 beneficiary eligibility transaction in a real-time environment via the CMS AT&T communication Extranet.

This document reiterates your responsibility in obtaining, disseminating, and using beneficiary’s Medicare eligibility data. It also further explains the expectations for Clearinghouses and providers using this application. Violating these Medicare Health Benefit Eligibility Inquiry Rules of Behavior and other CMS data privacy and security rules could result in revoked access and other penalties.

Providers/Suppliers

The EDI Enrollment process must be executed by each provider that submits/receives EDI either directly to or from Medicare or through a third party. Each provider that will use EDI either directly or through a billing agent or clearinghouse to exchange EDI transactions with Medicare must sign the EDI Enrollment Form and submit it to the Carrier, DMERC, or FI with whom EDI transactions will be exchanged before any transaction is conducted.

As a reminder, along with other EDI provisions, you agreed to use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access.

Acting on behalf of the beneficiary, providers/users of Medicare data are expected to use and disclose protected health information according to the CMS regulations. The HIPAA Privacy Rule mandates the protection and privacy of all health information. This rule specifically defines the authorized uses and disclosures of "individually-identifiable" health information. The privacy regulations ensures privacy protections for patients by limiting the ways that physicians, qualified non-physician practitioners, suppliers, hospitals and other provider covered entities can use a patients' personal medical information.

Authentication for HIPAA 270/271 Eligibility Data

Authenticating elements that must be granted by the inquirer prior to the release of any beneficiary-specific eligibility information include:

Beneficiary last name (must match the name on the Medicare card)

Beneficiary first name or first initial (must match the information on the Medicare card)

Assigned Medicare Claim Number (also referred to as the Health Insurance Claim Number (HICN)), including both alpha and numerical characters

Date of birth

NOTE: The Medicare beneficiary should be your first source of health insurance eligibility information. When scheduling a medical appointment for a Medicare beneficiary, remind them to bring, on the day of their appointment, all health insurance cards showing their health insurance coverage. This will not only help you determining who to bill for services rendered, but also give you the proper spelling of the beneficiary’s first and last name and identify their Medicare Claim Number as reflected on the Medicare Health Insurance card. If the beneficiary has Medicare coverage but does not have a Medicare Health Insurance card, encouraged them to contact the Social Security Administration at 1-800-772-1213 to obtain a replacement Medicare Health Insurance card. Those beneficiaries receiving benefits from the Railroad Retirement Board (RRB) can call 1-800-808-0772 to request a replacement Medicare Health Insurance card from RRB.

Authorized Purposes for Requesting Medicare Beneficiary Eligibility Information

In conjunction with the intent to provide health care services to a Medicare beneficiary, authorized purposes include to:

  • Verify eligibility for Part A or Part B of Medicare (CheckEligibilityNow.com does not show Part A Info.)
  • Determine beneficiary payment responsibility with regard to deductible/co-insurance 
  • Determine eligibility for services such as preventive services
  • Determine if Medicare is the primary or secondary payer
  • Determine if the beneficiary is in the original Medicare plan or a Part C plan (Medicare Advantage)
  • Determine proper billing

Unauthorized Purposes for Requesting Beneficiary Medicare Eligibility Information

  • To determine eligibility for Medicare
  • To acquire the beneficiary's health insurance claim number (or any other PHI)
Medicare eligibility data is only to be used for the business of Medicare; such as preparing an accurate Medicare claim or determining eligibility for specific services.

In order to obtain access to eligibility data, as a provider you will be responsible for the following:

  • Before you request Medicare beneficiary eligibility information and at all times thereafter, you will ensure sufficient security measures to associate a particular transaction with the particular employee.
  • You will cooperate with CMS or its agents in the event that CMS has a security concern with respect to any eligibility inquiry.
  • You will promptly inform CMS or one of CMS’s contractors in the event you identify misuse of "individually-identifiable" health information accessed from the CMS database.
  • Each eligibility inquiry will be limited to requests for Medicare beneficiary eligibility data with respect to a patient currently being treated or served by you, or who has contacted you about treatment or service, or for whom you have received a referral from a health care provider that has treated or served that patient.
Medicare health benefit beneficiary eligibility inquiries are monitored. Providers identified as having aberrant behavior (e.g., high inquiry error rate or high ratio of eligibility inquires to claims submitted) may be contacted to verify proper use of system, made aware of educational opportunities, or when appropriate referred for investigation of possible fraud and abuse or violation of HIPAA privacy law.

Criminal Penalties

Trading Partner Agreement Violation

42 U.S.C. 1320d-6 authorizes criminal penalties against a person who, "knowingly and in violation of this part ... (2) obtains individually identifiable health information relating to an individual; or (3) discloses individually identifiable health information to another person." Offenders shall "(1) be fined not more than $50,000, imprisoned not more than 1 year, or both; (2) if the offense is committed under false pretenses, be fined not more than $100,000, imprisoned not more than 5 years, or both; and (3) if the offense is committed with intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm, be fined not more than $250,000, imprisoned not more than 10 years, or both."

False Claim Act

Under the False Claims Act, 31 U.S.C. §§ 3729-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim.

Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HHS may impose civil money penalties on a covered entity of $100 per failure to comply with a Privacy Rule requirement. That penalty may not exceed $25,000 per year for multiple violations of the identical Privacy Rule requirement in a calendar year. A person who knowingly obtains or discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to one-year imprisonment. The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to ten years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm. Criminal sanctions will be enforced by the Department of Justice.

[Excerpt End]
 

2.3 Authorization. You may start using the Service right after the verification, documentation, and authorization process has completed and your payment has been accepted. No withdrawal right or "cooling-off" period applies to the Service, except if the law requires a "cooling off" period even when your use of a service starts right away.

 

3. You Are Responsible For Your Service Account.

You are responsible for all activity under your Service account. You may authorize other persons working directly for you or your office to use your Service account, and you are responsible for keeping confidential any password for your Service account. We may allow you to have additional member accounts associated to your Service account. We refer to these as "associated accounts." We may limit who may use any associated accounts. You must tell us right away about anyone using any of your accounts or associated accounts without your consent, or any security breach that relates to the Service.

 

4. Associated Account Users.

If you are the user of an associated account, then the holder of the Service account has full control over your associated account. This control includes the right to end the Service, close or alter your associated account at any time, and to request and receive usage information related to your associated account. Any data related to your associated account is collected and delivered to the holder of the Service account and ICS Software, Ltd. As an associated account user, this contract applies to you except for the following sections: Section 3 (You Are Responsible for Your Service Account), Section 5 (Charges and Billing); Section 13 (Your Cancellation of Service), and Section 19 (Our Notices to You; Consent Regarding Electronic Information).

 

5. Charges and Billing.

5.1 Payment. When you first sign up for the Service, you create a "Billing Account" and enter your "Payment Method." You confirm that you are authorized to use the Payment Method. You authorize us to charge you for the Service using your Payment Method. You authorize us to charge you for any additional ICS Software, Ltd. services for which you choose to sign-up while this contract is in force. You will pay Service charges in advance.

 

You can access your Billing Account at https://www.checkEligibilityNow.com/Client/. There you can make changes to your Billing Account after you have logged in.

 

5.2 Prices and Price Increases. The price for the Service excludes all taxes and phone charges, unless expressly stated otherwise. To the maximum extent permitted by law, such taxes and charges are your responsibility. Currency exchange settlements are based on your agreement with your Payment Method provider. We may change the price of the Service from time to time. We will tell you before any change. If there is a specific time length and price for your Service offer, then that price will remain in force for such time. Your use of the Service after such time, however, will be charged at the new price. If your Service is on a period basis (for example, monthly), with no specific time period, then any price change will start when we say. If you do not agree to such changes, then you must cancel and stop using the Service before the changes are in force. If you cancel your Service, then your Service ends at the end of your current service term or, if we bill your account on a period basis, at the end of the period in which you cancelled.

 

5.3 Online Statement. We will provide you with an paper billing statement. This is the only billing statement that we provide. We will only provide paper copies for the past 120 days.

 

5.4 Errors. If we make an error on your bill, we will correct it promptly after you tell us and we investigate the charge. You must tell us within 60 days after an error first appears on your bill. You release us from all liability and claims of loss resulting from any error that you do not report to us within 60 days after the error first appears on your online statement. If you do not tell us within this time, we will not be required to correct the error.

 

6. Privacy - Period!

This is probably one of the few places in the world that will discuss how this information exchanged between you and us is to be used and how it is exchanged via high speed internet connections. The data that leaves your computer is encrypted. In the unlikely event that someone “hijacks” the data in the < 1 second it takes to get from you to us, they would not be able to read or decipher the data. After we verify who is sending us data, we decrypt it and place it in the proper format to go to the Medicare database. That journey and back takes place along a “secure” connection as required by CMS. Once the information is returned to us, we place it into a format that you can read, encrypt it and send it on to you. Your computer screen shows it in human readable form. While HIPAA gives you instruction on how to handle patient information such as this, here is another version – as a general rule, we at ICS will never see the information that is moving under this service. Therefore, it’s all yours. You should not discuss the information with anyone other than the patient and others in your office who are allowed to by you. You must take the necessary precautions to safeguard this information. We will consider your use of the Service, including the content of your communications, to be private. However, to the extent permitted by law, we may be requested by CMS or their agents to give them information about you, including contents of transactions to: (1) conform to legal requirements or respond to legal process; (2) ensure your compliance with this contract; or (3) protect the rights, property, or interests of ICS Software, Ltd., its employees, its customers, persons whose identity is contained within the submission, or the public.

 

7. Software.

We may provide you with software to use with the Service. If you receive software from us, your use of that software is under the terms of the license that is presented to you for acceptance for that software. If there is no license presented to you, then we grant you the right to use the software only for the authorized use of the Service. Copyright and other intellectual property laws and treaties protect such software and content. We reserve all other rights to the software. ICS Software, Ltd. owns the title, copyright, and other intellectual property rights in such software.

 

We may automatically check your version of the software. We may automatically download upgrades to such software to your computer to update, enhance and further develop the Service. Your license will end on the date your Service ends. Your license will also end if we modify the Service in a way that no longer supports such software. Promptly after the date your Service ends, you shall uninstall such software. We may disable such software after the date the Service ends.

 

You will not disassemble, decompile, or reverse engineer any software or any machine included in the Service, except and only to the extent that the law expressly permits such activity.

 

The software is subject to United States HIPAA privacy laws and regulations. You must comply with all domestic and international export laws and regulations that apply to the software. These laws include restrictions on destinations, end users and end use.

 

8. Performance and Usage Information.

We may automatically upload performance and usage data for evaluating the Service and the software associated with the Service. Such data will not personally identify you. You may opt out of the automatic uploading of your usage data (but not performance data) as indicated in software associated with the Service.

 

9. How We May Change the Contract.

If we change this contract, then we will tell you at least 30 days before the change is in force. We will tell you of the change by e-mail or online posting. We may also use other ways that we believe will reach you. If you do not agree to such changes, then you must cancel and stop using the Service before the changes are in force. If you do not stop using the Service, then your use of the Service will continue under the changed contract.

 

10. WE MAKE NO WARRANTY.

We provide the Service "as-is," "with all faults" and "as available." The Service is designed for commercial use. The ICS Parties give no express warranties, guarantees or conditions. You may have additional consumer rights under your local laws that this contract cannot change. To the extent permitted by law, we exclude the implied warranties of merchantability, fitness for a particular purpose, workmanlike effort and non-infringement.

 

11. LIABILITY LIMITATION; YOUR EXCLUSIVE REMEDY.

You can recover from the ICS Parties only direct damages up to an amount equal to your Service fee for one month. You cannot recover any other damages, including consequential, lost profits, special, indirect or incidental damages.

 

This limitation applies to

  • any matter related to the Service,
  • any matter related to content (including code) on third party Internet sites, third party programs or third party conduct,
  • any matter related to viruses or other disabling features that affect your access to or use of the Service,
  • any matter related to incompatibility between the Service and other services, software and hardware,
  • any matter related to delays or failures you may have in initiating, conducting or completing any transmissions or transactions in connection with the Service in an accurate or timely manner, and
  • claims for breach of contract, breach of warranty, guarantee or condition, strict liability, negligence, or other tort to the extent permitted by applicable law.

It also applies even if

  • this remedy does not fully compensate you for any losses, or fails of its essential purpose; or
  • ICS Software, Ltd. knew or should have known about the possibility of the damages.

Some states do not allow the exclusion or limitation of incidental or consequential damages, so the above limitation or exclusion may not apply to you. They also may not apply to you because your province or country may not allow the exclusion or limitation of incidental, consequential or other damages.

 

12. Changes to the Service; Our Cancellation of Service.

We may change the Service or delete features at any time and for any reason. We may cancel or suspend your Service at any time. Our cancellation or suspension may be without cause and/or without notice. Upon Service cancellation, your right to use the Service stops right away. Once the Service is cancelled or suspended, any data you have stored on the Service may not be retrieved later. Our cancellation of the Service will not alter your obligation to pay all charges made to your Billing Account. If we cancel the Service in its entirety without cause, then we will refund to you, on a pro-rata basis the amount of your payment corresponding to the portion of your Service remaining right before such cancellation.

 

13. Your Cancellation of Service.

You may cancel the Service at any time, with or without cause, upon notice to us as specified in the customer support or "help" area for the Service. If you are participating in any trial period offer, you must cancel the Service by the end of the trial period to avoid incurring charges. Certain Service offers may require cancellation charges, and you will pay all such cancellation charges as specified in the materials describing such offer. Cancellation of the Service by you will not alter your obligation to pay all charges made to your Billing Account.

 

14. Choice of Law and Location for Resolving Disputes.

If this contract is with ICS Software, Ltd., then claims for breach of this contract will be subject to the laws of the State of New York, without reference to conflict of laws principles. All other claims, including claims regarding consumer protection laws, unfair competition laws, and in tort, will be subject to the laws of your state of residence in the United States.

 

If this contract is with ICS Software, Ltd., you consent to the exclusive jurisdiction and venue of state or federal courts in Nassau County, New York, USA for all disputes relating to this contract or the Service. You cannot revoke this consent.

 

15. Interpreting the Contract.

All parts of this contract apply to the maximum extent permitted by law. A court may hold that we cannot enforce a part of this contract as written. If this happens, then we will replace that part with terms that most closely match the intent of the part that we cannot enforce. The rest of this contract will not change. This is the entire contract between us regarding your use of the Service. It supersedes any prior contract or statements regarding your use of the Service. If you have confidentiality obligations related to the Service, those obligations remain in force (for example, you may have been a beta tester). The section titles in the contract do not limit the other terms of this contract.

 

16. Assignment.

We may assign this contract, in whole or in part, at any time with or without notice to you. You may not assign this contract, or any part of it, to any other party. Any attempt by you to do so is void. Instead, you may cancel your Service. The other party may then establish a Service account and enter into a contract with us.

 

17. Claim Must Be Filed Within One Month.

Any claim related to this contract or the Service must be brought within one month. The one-month period begins on the date when the claim first could be filed. If it is not filed, then that claim is permanently barred. This applies to you and your successors. It also applies to us and our successors and assigns.

 

18. Your Notices to Us.

You may notify us by e-mail or postal mail. Your notices to us must be addressed as stated in the customer support or "help" area for the Service.

 

19. Our Notices to You; Consent Regarding Electronic Information.

This contract is in electronic form. There may be other information regarding the Service that the law requires us to send you. We may send you this information in electronic form. You have the right to withdraw this consent, but if you do, we may cancel your Service. We may provide required information to you (1) via e-mail at the e-mail address you specified when you signed up for your Service, (2) by access to a ICS Software, Ltd. web site that will be designated in an e-mail notice sent to you at the time the information is available, or (3) by access to a ICS Software, Ltd. web site that will be generally designated in advance for such purpose. Notices provided to you via e-mail will be deemed given and received on the transmission date of such e-mail. If you would like a copy of this information or this contract in paper form, you may request one from us. To do so, or to withdraw your consent, go to https://www.checkEligibilityNow.com/Client/. You must make a request for a paper copy within 120 days after we first provided it to you. If you do not, we may not provide you a paper copy. We may charge a reasonable fee for providing such paper copies.

 

As long as you access and use the Service, you will have the necessary software and hardware to receive such notices. If you do not consent to receive any notices electronically, you must stop using the Service.