Guidelines - 7 For Providers
2026-07-01
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.