VI. For Providers
REDEEM HealthShare processes bills electronically, with payments typically made to the provider within 30-40 days of receiving the member's bill. Payments are made from Shares collected by the patient from the REDEEM member community.
A. Member Payments
Members pay a monthly Share Amount based on age, membership size, and selected Unshareable Amount (AUA). Monthly Shares sent by the REDEEM community to the patient are used to pay the patient's medical bills. We recommend providers submit bills electronically through EDI using the Payer ID on the patient's member card for quick processing.
B. Payment Processing
Most bills are processed within 30 days, with electronic payments sent to the provider, less any amounts the member will pay directly (AUA or Co-Share). The provider receives an Explanation of Sharing (EoS) detailing the amounts paid from Shares collected by the patient from the REDEEM member community.
C. Permitted Sharing Levels
“Permitted Sharing Levels” means charges for medical care, which is medically necessary for the care and treatment of illness or injury, but only to the extent that the fees charged therefore are within all applicable limitations and restrictions established by the REDEEM HealthShare Sharing Guidelines including, but not limited to, the following:
Hospitals (both inpatient and outpatient services), Ambulatory Surgery Centers, Independent Facilities, and Other Medical & Surgical Services. The Permitted Sharing Level for medical care established by the Guidelines shall be based upon the average of 150% of the Medicare Allowable Amount for the medical care included in the Guidelines and 135% of the cost of the medical care included in the Guidelines; provided, however, that any such Permitted Sharing Level based on the cost of the medical care included in the Guidelines shall be limited to an amount not to exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees for the medical care included in the Guidelines.
Professional Services. The Permitted Sharing Levels for professional services shall be determined based upon the chart for the professional service identified. This chart is available upon request. Professional services refer to shareable services provided by medical professionals identified in Section III.B.
Dialysis Services. The Permitted Sharing Level for dialysis services (which shall include dialysis, facility services, supplies, and medications provided during treatment) shall be determined by review of the Medicare Allowable Amount for the billing hospital or physician in light of clinical considerations pertinent to the patient being treated.
Medical Care Provided Under Direct Contract. The Permitted Sharing Levels for medical care provided by directly contracted hospitals or physicians will be the rates or fees established under the applicable contract; provided, however, that the amounts of such rates and fees shall be presumed to be Usual, Customary and Reasonable only to the extent that they do not include otherwise improper balances, which charges shall be outside of the Permitted Sharing Levels.
If the Permitted Sharing Level exceeds the actual charge billed for the treatment, service, or supply in question, sharing and payments to providers will be based on the actual billed charge. The Permitted Sharing Level for medical care will not include charges related to unbundling, errors, unclear description, or misidentification.
