Unit Price QTY Client Initials Clearinghouse Fee Per provider/month Real‐Time Insurance Eligibility Check (Unlimited Use) Per provider/month $25 Claim Scrubber (Powered by Alpha II) Per provider/month $35 Patient Statement Submission Per statement fee (1st pg) $0.69 Monthly minimum of $20 applies Each additional page $0.19 Appointment Reminder Service (Powered by AlertSolutions) Per minute (phone) $0.14 Per text Per email $0.14 $0.07
Scanner with Insurance Card & Driver’s License OCR Integration Per scanner $1,095/device (SnapShell IDR w/.Net OCR Powered by Card Scanning Solutions Inc.) Additional charges:
Electronic Signature Pad with Integration Per signature pad $395/device
(SignatureGem Backlit LCD 1X5 Powered by Topaz Systems Inc ) Additional charges: Value-Added and Third-Party Products & Services
$65
Agreement Addendum
Unlimited Electronic Claims, Paper Claims, ERAs and Secondary Claims from Participating Payers One‐time set‐up fee of $95 applies; Monthly minimum fee of $25 applies; Text option available only as an add‐on to customers who have selected phone reminder option Optical Character Recognition (OCR) for extracting discrete data elements from scanned Drivers License, IDs and Insurance Cards and populating them directly into fields available on Demographics and Insurance page. (**NOTE: All OCR devices are warranted by manufacturer for a maximum of 12 months from date of purchase. ) Initial setup fee of $95/ scanner/workstation $45 shipping/handling $95/scanner annual maintenance & support fee **NOTE: Devices returned other than for defect will be refunded, subject to a 35% restocking fee. (SignatureGem Backlit LCD 1X5 Powered by Topaz Systems Inc.) Additional charges:Welch Allyn Vitals Device Integration Per device/computer $1,295/device
Lab/Imaging Integration Request activation Request activation Additional charges: Annual maintenance fee of $195/device f. Vitals Signs Monitor 300 Series – All models (part numbers beginning with 53) Initial setup fee of $95/ pad/workstation $45 shipping/handling $95/pad annual maintenance & support fee **NOTE: Devices returned other than for defect will be refunded, subject to a 35% restocking fee. Electronically send lab orders and receive results with the ability to interface with over 50 labs across the country, including LabCorp and Quest Diagnostics; Auto‐delivery reduces need for faxing, scanning and uploading attachments Radiology Interfacing Electronic LCD signature pad to capture patients' signature on custom forms; eliminates the need to print and scan the forms back into the system (**NOTE: All signature pad devices are warranted by manufacturer for a maximum of 12 months from date of purchase. ) a. Connex® Integrated Wall System (also referred to as CIWS) – All models (part numbers beginning with 84 or 85) b. Connex® Vital Signs Monitor (also referred to as CVSM or Connex® VSM) All models (part numbers beginning with 63, 64, & 65) c. Connex® ProBP™ 3400 – All models (part numbers beginning with 34) d. Spot Vital Signs® Lxi – All models (part numbers beginning with 45) e. Spot Vital Signs® – All models (part numbers beginning with 42) – requires use of Infrared cable adapter (part number 4200‐170USB) VER FEB 2015 Page 1
Unit Price QTY Client Initials Included with EMR InSync Direct Individual Account $10 Per fax line/month $10 Additional charges: ‐5 cents/each add'tl page Electronic Fax – Outbound (Powered by Interfax) Per page $0.08 Premium Medication Management Package (NewCrop) Per provider/month $25 0
Patient hand-outs in 18 languages and comprehensive doctor’s drug reference from Lexi-Comp Allergy, Drug and Pregnancy interaction review from First Databank
Comprehensive managed care formularies from MediMedia, including Medicare Part D and Medicaid RxHub: managed care interface for all-doctor drug history and electronic mail-order
Data Migration/Conversion1 Per practice No charge Per practice $3,000 (Powered by Secure Exchange Solutions) Individual provider personal email account (or per practice organizational account for non‐EMR customers) using the DIRECT protocol for securely sharing healthcare information between referring providers Electronic Fax – Inbound (Powered by Interfax) Up to 500 inbound pages included per fax line a.Import of patient demographic, provider and insurance payer data from the ABILITY clearinghouse for an existing ABILITY customer b. Import/export of basic patient demographic, insurance master, provider, and referring provider data from C‐CDA, .xlsx or pipe (|) delimited .csv format Per email address/ month
Value-Added and Third-Party Products & Services (CONT)
InSync Direct Organization Account (Powered by Secure Exchange Practice email account using the DIRECT protocol for securely sharing healthcare information between referring providers; Required for Meaningful Use Stage 2 (one per practice) Per practice/ month ‐One‐time setup fee of $95 applies Per practice Ask for quote Medical Transcription Per 65 character line $0.11 Airfare additional2 $1,250/day
Training Fee (Remote) 10‐hour minimum $95/hour
10‐hour minimum $180/hour 1 All Data Migration/Conversion services are provided as a convenience for our customers. InSyncHCS assumes no liability with regards to the accuracy, integrity or validity of migrated or extracted data. 2 Onsite Training and services are subject to billing of airfare at actual cost. c. Import/export of clinical data, including any of: patient visits, medical history, treatment history, lab results, insurance records and other documents ***NOTE: Any import/export of data in format other than .xlsx, pipe (|) delimited, or C‐CDA will incur additional charges for data formatting. Training Fee (Onsite) General Consulting Services (Remote) Includes any IT related services required/requested by clients for maintenance and administration of onsite application servers. VER FEB 2015 Page 2
Software & Services Term Sheet
Value‐Added Services Agreement forms
Payment Terms & Method of Payment
Credit Application (if applicable)
Technical Specifications Document
Hardware/Server Specifications Document (if hosted by practice)
Business Associate Agreement
Terms & Conditions
Terms & Conditions Addendum
Training & Implementation Staff Contact Information & Schedule
The following items (where applicable) have been confirmed with/received & returned to InSyncHCS:
***PLEASE FAX COMPLETED FORM TO: 732.200.3379 Customer Legal Name: Address: City, State, Zip: Phone: Fax: Email Contact Name: Address: City, State, Zip: Phone: 877.246.8484 Fax: 732.200.3379 Sales Person: Effective Date: Date: By: Name: Title: Title: By: Name: InSync Healthcare Solutions LLC 10 Lanidex Plaza West Parsippany, NJ 07054 VER FEB 2015 Page 3
