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 to a provider derive 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 Annual Unshareable Amount (AUA). The REDEEM community sends monthly Shares to the patient to pay their medical bills. For quick processing, REDEEM HealthShare prefers that providers submit bills electronically through EDI using the Payer ID on the patient’s Member Card.
B. Payment Processing
REDEEM HealthShare processes most bills within 30 days, with electronic payments sent to the provider, minus 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
REDEEM HealthShare defines Permitted Sharing Levels as charges for medically necessary care, for the care and treatment of illness or injury, but only to the extent that the fees charged 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 and Surgical Services. The Permitted Sharing Level for medical care, established by the Guidelines, is based upon an average of 150% of the Medicare allowable amounts for the medical care and 135% of the cost of medical care (included in the Guidelines). However, REDEEM HealthShare bases any such Permitted Sharing Level on the cost of the medical care included in the Guidelines. The limited amount must not exceed 175% of the Medicare allowable amounts or the usual, customary, and reasonable fees for the medical care included in the Guidelines.
- Professional Services. REDEEM HealthShare determines the Permitted Sharing Levels for professional services on 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.REDEEM HealthShare determines the Permitted Sharing Level for dialysis services including dialysis, facility services, supplies, and medications provided during treatment by review of the Medicare allowable amount for the billing hospital or physician considering clinical considerations pertinent to the patient receiving treatment.
- The allowed sharing amount for medical care from hospitals or physicians will be based on an agreed rate or fee directly with REDEEM HealthShare or through a service provider, if applicable. These rates meet Usual, Customary, and Reasonable standards and they must exclude any improper balance charge, which are not allowed for sharing.
- 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.