Guidelines - 3.5 Expenses Eligible for Sharing

To be eligible for sharing, a bill must be:

3.5.1. Free from unreasonable, excessive, or duplicated amounts, as 
determined in the discretion of REDEEM HealthShare.

3.5.2. Not listed as not eligible, which means the bill must not be listed in 
section 3.11 Not Eligible for Sharing.

3.5.3. Within submission time limit, which means a provider or you must 
submit the bill to REDEEM HealthShare within 12 months of the date 
of service.

3.5.4. The result of condition, injury, or illness 

• The bill must be for a condition, injury, or illness and have a 
date of service after your start date. Note: Bills for pre-existing 
eligible conditions are also eligible for sharing under certain 
circumstances. See section 3.8 Pre-existing Conditions for 
details. In every case, bills must always have a date of service 
after the Member Start Date to be eligible for sharing.

• The bill must be for treatment of physical conditions—not 
primarily psychological, emotional, or spiritual conditions. 
Examples of conditions that are not eligible for sharing: Attention 
Deficit Disorder, Attention Deficit Hyperactivity Disorder, Sensory 
Process Disorder, Post Traumatic Stress Disorder, and cognitive 
developmental issues. 

3.5.5. For services incurred or qualifying estimates or prepayments

• In most instances the bill must be for actual services incurred. 

• For maternity, you may submit bill estimates for consideration. 

• For other cases where paying upfront results in significant 
savings, contact Member Care for more details.

• When a provider requests prepayment, REDEEM HealthShare 
will make every effort to negotiate with the provider or facility 
to ensure that we obtain a rate that is consistent with our 
Permitted Sharing Level. If the provider or facility is unable to 
provide a rate that meets our Permitted Sharing Level, we will 
make every effort to find a provider or facility whose fees are 
closer to our Permitted Sharing Level. You may choose to see 
the provider of your choice, but if the rate is more than our 
Permitted Sharing Level, then REDEEM HealthShare will limit the 
prepayment and sharing to 200% of the CMS rate, and you will 
pay the remaining balance directly to the provider. Based on 
what you paid, REDEEM HealthShare will publish the eligible bills 
paid in full.