Guidelines - III.A Expenses Eligible for Sharing

Right to Reject Charges. REDEEM HealthShare has the discretion to declare amounts ineligible for sharing it finds unreasonable, excessive, or duplicate charges.

To be eligible for sharing, a bill must be:

The Result of Condition, Injury, or Illness:

The bill must be for a condition, injury, or illness and have a Date of Service (DoS) after the member start date.

Bills for pre-existing conditions are also shareable under certain circumstances. The guidelines for pre-existing conditions are discussed in detail in Section III.D. In every case, bills must always have a Date of Service (DoS) after the member start date to be eligible for sharing.

Bills not related to a condition, injury, or illness—such as preventive and routine wellness visits—may only be shareable in REDEEM Enhanced (See Section III.F) or in FlexShare.

The bill must be for a physical condition being treated—not a psychological, emotional, or spiritual condition. Examples of ineligible conditions: Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, Sensory Process Disorder, Post Traumatic Stress Disorder, and cognitive developmental issues.

For Incurred Services or Qualifying Estimates:

In most instances the bill must be for actual services incurred. However, for maternity or in cases where significant savings can be achieved, the submission of bill estimates may be acceptable. Please contact Member Care for more details.

Prepayment. 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. The member can choose to see the provider of their 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 the member will directly pay the remaining balance.

The member can share any bills paid in full based off what the member paid.

Be Not Listed as Not Eligible:

The bill must not be included in the Not Eligible for Sharing category in Section III.G.

Within Submission Timeframe:

A provider or member must submit the bill to REDEEM HealthShare within 12 months of the date of service.