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Guidelines - III.B Approved Sharing of Bills

To be eligible for sharing, a provider must submit their billing via 1) the Electronic Data Interchange (EDI) on the REDEEM Member Card, 2) a Center for Medicare and Medicaid Services card (CMS) 1500, or 3) a Uniform Billing (UB) and Integrated Billing (IB) form. Bills submitted by the provider must follow standard healthcare industry submission and coding guidelines to meet sharing consideration.

Many medical providers are willing to submit their bills electronically directly via the Member Card EDI number. However, if a member must manually submit a bill for processing, the member must submit the bill using the online submission portal in the Member Center. Members should ask their provider for a Superbill, which is a common and comprehensive healthcare industry billing documentation format.

Member submitted bills must include the following itemized details:

  • Name of patient
  • Diagnosis and International Classification of Diseases (ICD-10) codes
  • Procedure and Current Procedural Terminology (CPT) codes
  • Provider’s TAX ID
  • Provider’s National Provider Identifier (NPI)
  • Provider’s billing address
  • Facility service and physical address
  • Date of service
  • Charged amounts

When submitting a medical bill for processing, the member is responsible for obtaining all information needed for processing per the prompts in the online submission portal.

The services or items in the bills must be within the scope of licensing and ordered or provided by a:

  • Medical Doctor (M.D.)
  • Doctor of Osteopathy (D.O.)
  • Naturopathic Doctor (N.D.)
  • Nurse Practitioner (N.P. or A.P.R.N.)
  • Physician Assistant (P.A.)
  • Doctor of Podiatric Medicine (D.P.M.)
  • Dentist (D.D.S. or D.M.D.)
  • Midwife (if certified)
  • Ophthalmologist
  • Optometrist
  • Optician
  • Chiropractor

These tests and treatments must occur at one of the following:

  • Hospital
  • Surgery center
  • Surgery Ambulatory center
  • Clinic
  • Doctor’s office
  • Diagnostic facility
  • Independent Facilities
  • Residential setting (for home births, hospice care and pre-approved home health)
  • Skilled Nursing and Rehabilitation Facility