“Permitted Sharing Level(s)” means charges for Medical Care, which is Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that the fees charged, therefore are within all applicable limitations and restrictions established -in the Impact Health Sharing Guidelines (the “Guidelines”) including, but not limited to, the following:
• Hospitals (both inpatient and outpatient services), Ambulatory Surgery Centers, and Independent Facilities: The Permitted Sharing Level for Medical Care established by the Guidelines shall be based upon the average of 150% of the Medicare Allowable Amount for the Medical Care included in the Guidelines and 135% of the Cost of the Medical Care included in the Guidelines; provided, however, that any such Permitted Sharing Level based on the Cost of the Medical Care included in the Guidelines shall be limited to an amount not to exceed 175% of the Medicare Allowable Amount or the amount of Usual, Customary and Reasonable Fees for the Medical Care included in the Guidelines.
• Professional Services. The Permitted Sharing Levels for Professional Services shall be determined based upon the chart for the professional service identified. This chart is available upon request.
o Dialysis Services. The Permitted Sharing Level for dialysis services (which shall include dialysis, facility services, supplies and medications provided during treatment) shall be determined by review of the Medicare Allowable Amount for the billing Hospital or Physician in light of clinical considerations pertinent to the patient being treated.
- Medical Care Provided Under Direct Contract. The Permitted Sharing Levels for Medical Care provided by Directly Contracted Hospitals or Physicians will be the rates or fees established under the applicable contract; provided, however, that the amounts of such rates and fees shall be presumed to be Usual, Customary and Reasonable only to the extent that they do not include otherwise Improper Balances, which charges shall be outside of the Permitted Sharing Levels.
In the event that the Permitted Sharing Level exceeds the actual charge billed for the treatment, service or supply in question, sharing and payments to providers will be based on the actual billed charge. The Permitted Sharing Level for Medical Care will not include charges related to Unbundling, Errors, Unclear Description or Misidentification.
Eligible needs will be approved for sharing when medically necessary. Medically Necessary, which is defined as health care
services that are clinically appropriate in terms of type, frequency, extent, site and duration for the diagnosis or treatment of the member’s sickness or injury, and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis or treatment of that member’s sickness or injury. The Medically Necessary setting and level of service is that which, considering the member’s medical symptoms and conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically Necessary must be no more costly than alternative interventions, including no intervention and are at least as likely to produce equivalent therapeutic or diagnostic results without adversely affecting the member’s medical condition.
• It must not be maintenance therapy or maintenance treatment;
• Its purpose must be to restore health;
• It must not be primarily custodial in nature;
• It must not be a listed item or treatment not allowed for reimbursement by CMS (Medicare); and
• REDEEM reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria
for determination of Medical Necessity and/or eligibility of a Need.
• The mere fact that the service is furnished, prescribed or approved by a Physician does not mean that it is “Medically Necessary.”
• The determination of whether a service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical Association and REDEEM’s own medical advisors.
Off-label Drug use is considered Medically Necessary when all of the following conditions are met:
• The Drug is approved by the FDA;
• The prescribed Drug use is supported by one of the following standard reference sources:
o DRUGDEX;
o The American Hospital Formulary Service Drug Information;
o Medicare approved Compendia; or
o Scientific evidence is supported in well- designed clinical trials published in peer-reviewed medical journals, which demonstrate that the Drug is safe and effective for the specific condition; and
o The Drug is Medically Necessary to treat the specific condition, including life-threatening conditions or chronic and seriously debilitating conditions.
Provider Appeals
A Provider has 180 days from the date a bill was processed to appeal a bill sharing decision. After completion of the initial review, if the Provider still disagrees with the bill sharing decision, the Provider then has 60 days from the date of the original decision to request a second appeal.
Prepayment
When pre-payment is requested, REDEEM will make every effort to negotiate with the provider/facility to ensure that we obtain a rate that is consistent with our permitted sharing level. If the provider/facility is unable to provide a rate that meets our permitted sharing level, REDEEM will make every effort to find a provider/facility whose fees are closer to our permitted sharing level. The member can choose to see the provider of their choosing, but if the rate is more than our permitted sharing level, then prepayment and sharing will be limited to 200% of the CMS rate, and the member will be responsible for the remaining balance.
Any bills paid in full by the member will be shared based off what was paid.