Authorization and Designation of Representative

1. The practice (the "Provider")

2. The representative

Authorised individuals ("US Operators"): the individuals Rivius lists in the Provider's dashboard from time to time, each of whom works for Rivius, has completed the identity verification the federal IDR portal requires, and is physically located in the United States when using the portal. Rivius keeps that list current in the dashboard and notifies the Provider of any change.

3. What the Provider authorises

The Provider appoints Rivius, acting through its US Operators and staff, as its representative and authorises it to act on the Provider's behalf, for the claims covered by the Client Service Agreement between them, to:

Federal IDR process (45 CFR 149.510 and the parallel rules at 29 CFR 2590.716-8 and 26 CFR 54.9816-8):

• (a) send and receive open negotiation notices and responses, and negotiate with health plans, health insurance issuers and their representatives during open negotiation;
• (b) submit notices of IDR initiation and responses, including batched disputes, through the federal IDR portal (the IDR Gateway) or any other channel the Departments require;
• (c) select, agree to or object to a certified IDR entity, including objecting on conflict-of-interest grounds;
• (d) prepare and submit offers and supporting information, answer requests for information from certified IDR entities and the Departments, and request extensions where the rules allow. The Provider controls the amount of every offer: it approves each offer, or the rules for offers, under the Client Service Agreement;
• (e) agree to an out-of-network rate or withdraw a dispute, but only within the settlement limits the Provider has set under the Client Service Agreement, or with the Provider's written approval;
• (f) receive all notices, communications, eligibility decisions and payment determinations about those disputes;
• (g) make, on the Provider's behalf, the attestation of authority required on each notice, stating that Rivius has authority to act for the Provider; and
• (h) handle payment of administrative and certified IDR entity fees as set out in the Client Service Agreement. In its attestations, Rivius states that the Provider is the party obligated to pay the federal IDR administrative fee and incurs the debt for non-payment (91 FR 33984-85).

Award follow-up and complaints:

• (i) communicate with health plans, issuers and their administrators about payment of amounts determined or agreed in the Federal IDR process; and
• (j) prepare and submit complaints, on the Provider's behalf, to the Centers for Medicare & Medicaid Services (including through the No Surprises Help Desk), the U.S. Department of Labor, the Office of Personnel Management and state insurance regulators.

Commercial claim corrections and appeals:

• (k) submit corrected claims, reconsideration requests and provider appeals to commercial health plans and issuers, and communicate with them about those claims, including through their provider portals using credentials the Provider issues to Rivius.

4. Limits

Rivius is not authorised to:

• receive, deposit, endorse or redirect any payment to the Provider; all payments go directly to the Provider;
• change the Provider's enrollment, bank, remittance or electronic funds transfer details with any payer;
• sign contracts, network agreements or settlements for the Provider outside the limits in section 3(e);
• start any lawsuit or court or arbitration proceeding outside the Federal IDR process, or act as the Provider's lawyer;
• act on claims paid by Medicare, Medicaid or other government health programs; or
• file an appeal on behalf of a patient (a member appeal) without the patient's written authorisation where the plan or law requires it.

Rivius will act only through individuals it has verified, and will not let anyone use the federal IDR portal for the Provider from outside the United States.

5. Payer and agency forms

Some health plans, issuers and agencies require their own representative or authorisation form. The Provider will sign those forms when Rivius asks, and this Authorization is not a substitute for them where they are required.

6. Reliance

The Departments of Health and Human Services, Labor and the Treasury, the Office of Personnel Management, certified IDR entities, health plans, issuers and state regulators may rely on a copy of this Authorization, including an electronic copy, until they receive notice that it has been revoked.

7. Term and revocation

• This Authorization takes effect when the Provider signs it and continues until the Provider revokes it or the Client Service Agreement ends.
• After the Client Service Agreement ends, it continues only for disputes and appeals that Rivius filed before the end date (the "Filed Matters" under that agreement), and ends completely when the last of them closes.
• The Provider may revoke this Authorization at any time by notice in its dashboard or by email to support@riviushealth.com. Revocation does not undo actions Rivius took before receiving it. On revocation Rivius will stop acting, update or withdraw its designation as representative on open matters as the portal allows, and hand the matters over to the Provider.

8. Provider statements

By signing, the Provider confirms that:

• the claims covered are its own and are billed under its TIN;
• no other person or organisation holds an exclusive right or power of attorney to act for it in the Federal IDR process for those claims, or those claims have been excluded in its Rivius account; and
• the person signing has authority to sign for the Provider.

9. Signature

Accepted by Rivius: Rivius Health, by its authorised officer, on the date the Provider signs.

10. How this Authorization is signed and kept

The Provider signs this Authorization online at sign-up, after the Client Service Agreement and the Business Associate Agreement, by typing their full name and title. Rivius emails a PDF copy, keeps the signature record for at least 6 years, and holds a signed PDF for the Provider so that it can be produced to a certified IDR entity, a payer or CMS on request.