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BLUE CROSS AND BLUE SHIELD OF TENNESSEE

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					BLUE CROSS AND BLUE SHIELD OF TENNESSEE
801 PINE STREET CHATTANOOGA, TN. 37402-2520 PROVIDER ELECTRONIC BILLING SYSTEM AGREEMENT #7 THIS AGREEMENT between ______________________________________(herein called "Provider") and BLUE CROSS AND BLUE SHIELD OF TENNESSEE (herein called "Plan"), shall commence on the effective date herein, and shall remain in effect until terminated. For purposes of this Agreement, it is mutually understood that the Provider Electronic Billing System, (herein called the "System"), is an information system of the Plan interfacing certain Provider and Plan data. The System will provide claims data entry by the Provider. Claims submitted through the System will be subject to audit. "Provider hereby expressly acknowledges its understanding that this agreement constitutes a contract between Provider and the Plan, that the Plan is an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the "Association") permitting the Plan to use the (Blue Cross and/or Blue Shield Service) Mark in the State of Tennessee, and that the Plan is not contracting as the agent of the Association. Provider further acknowledges and agrees that it has not entered into this agreement based upon representations by any person other than the Plan and that no person, entity, or organization other than the Plan shall be held accountable or liable to Provider for any of the Plan's obligations to Provider created under this agreement. This paragraph shall not create any additional obligations whatsoever on the part of the Plan other than those obligations created under other provisions of this agreement." 1. 2. COSTS: The Provider will have no billable cost from the Plan. PLAN RESPONSIBILITIES: The Plan will furnish the following equipment and/or services: A. B. 3. A User's Manual including file descriptions and characteristics. Periodic reports of claims entered by the Provider.

PROVIDER RESPONSIBILITIES: The Provider agrees to the following: A. B. C. To submit claims to the Plan in the specified format required by the Plan as set forth in the User's Manual. To maintain the claims data in a manner that it may be re-submitted within 30 days, if necessary. To furnish and update the Plan on additions/deletions to the information pertaining to the names and provider numbers for whom you are submitting claims (see page 4 of contract).

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Provider Electronic Billing System Agreement #7

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AUDIT CAPABILITY: The Plan has the right to audit and confirm information submitted by the Provider and have access to all documents pertaining to claims, including medical records. Any incorrect payments which are discovered will be adjusted according to the applicable Blue Cross, Blue Shield, Medicare, and/or other applicable guidelines. The Provider will establish a procedure whereby every claims submitted can be readily associated and identified with a source document, including patient authorizations and signatures. The Provider will maintain medical records in accordance with applicable State and Federal Laws and/or regulations. LIMITATION OF DAMAGES: Provider agrees that the Plan's liability for damages here under shall not exceed the total amount paid by the Provider under this Agreement. In no event shall the Plan be liable for any special or consequential damages of any nature with respect to the leasing, delivery, installation, or maintenance servicing of the equipment or failure to perform any obligation here under. The Plan is not responsible for failure to fulfill its obligation under this Agreement due to Acts of God or causes beyond its control. ENTIRE AGREEMENT: This Agreement shall constitute the entire Agreement between the Provider and the Plan for the equipment, services, and functions addressed in the Agreement. However, it is expressly agreed that any participating Provider Agreement between the Plan and the Provider shall remain in full force and effect, separate and apart from this Agreement, and that this Agreement shall not act to modify or alter the terms of that Agreement. STATUS OF CONTRACTOR: The Plan and the Provider shall be independent contractors and nothing herein shall be construed as creating a partnership or joint venture; nor shall any employee of either party be construed as employees, agents, or principles of the other party hereto. TERMINATION: Either party may terminate this Agreement by giving sixty (60) days prior written notice to the other party. The Plan may terminate this Agreement without notice if the Billing Service fails to perform as required herein. CONTROLLING LAW: This Agreement shall be governed by the Laws of the State of Tennessee and applicable Federal Laws.

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Provider Electronic Billing System Agreement #7

THIS AGREEMENT shall be effective as signed and dated below.

PROVIDER

AUTHORIZED SIGNATURE

TITLE

DATE

BLUE CROSS AND BLUE SHIELD OF TENNESSEE PLAN

AUTHORIZED SIGNATURE

TITLE

DATE

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Provider Electronic Billing System Agreement #7

Tax Number ______________________________ (As on file with Internal Revenue Service) Name __________________________________________________ (As on file with Internal Revenue Service) Please list below the Individual Providers reporting under this tax number and name. Tax Number Assigned Individual Blue (if different Provider Name Shield Provider Number from above) ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________ ____________________________ ______________________ __________________

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