7. For Providers
As a medical provider, you will find that this section offers an overview of health care sharing.
7.1 Member Payments
REDEEM HealthShare members pay a monthly share amount based on the age of the oldest member in their household, their membership size, and their selected Unshareable Amount. Payments derive from Shares collected by the patient from the REDEEM member community. For timely bill processing, REDEEM HealthShare prefers that you submit bills electronically through EDI using the Payer ID listed on the member’s card.
7.2 Payment Processing
Because REDEEM HealthShare processes bills electronically, REDEEM HealthShare generally issues payment within 30–40 days after receiving a member’s bill. You will receive an Explanation of Sharing (EOS) detailing the amounts paid from Shares collected by the patient from the REDEEM member community.
7.3 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:
7.3.1 Hospitals (both inpatient and outpatient services), ambulatory surgery centers, independent facilities, and other medical and surgical services
REDEEM HealthShare determines the Permitted Sharing Levels for eligible medical care based on an average of 1) 150% of the Medicare allowable amounts for the relevant medical care and 2) 135% of the cost of medical care. Cost of Medical Care means the provider’s cost as determined through CMS cost reports, acquisition costs based on invoices or statements from the provider, industry-standard cost-to-charge ratios, a drug’s National Average Drug Acquisition Cost calculated by CMS, a drug's Average Acquisition Cost (AAC) for the state in which the facility resides, a drug’s predictive acquisition cost calculated by Glass Box Analytics, or comparable cost documentation for products or services as determined by REDEEM HealthShare in its reasonable discretion. 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.
7.3.2 Professional Services
REDEEM HealthShare determines the Permitted Sharing Levels for professional services on the chart for the specific professional service which is available upon request. Professional services refer to eligible services provided by medical professionals identified in section 3.6 Approved Sharing of Bills.
7.3.3 Dialysis Services
For dialysis services including dialysis, facility services, supplies, and medications provided during treatment, REDEEM HealthShare determines the Permitted Sharing Level using the Medicare allowable amount for the billing hospital or physician, together with clinical considerations pertinent to the patient’s treatment.
7.3.4 Provider Agreed Rates
REDEEM HealthShare determines the Permitted Sharing Level based on an agreed rate or fee with you, if applicable. These rates meet usual, customary, and reasonable standards.
7.3.5 Actual Billed Charges
If the Permitted Sharing Level exceeds the actual amount billed for the treatment, service, or supply, REDEEM HealthShare will use the billed amount when determining payment. The Permitted Sharing Level for medical care will not include charges related to unbundling, errors, unclear description, or misidentification.