What is a Referenced Based Pricing Plan for Medical Facilities?
Your health plan allows out of network providers, allowing you to access any provider you so choose. All payments to any provider are based off of Medicare pricing plus an incentive bonus over and above the Medicare allowable amounts. Reference Based Pricing may also be referred to as Value Based Pricing (VPB).

Can I only go to a Provider that is in network?
No.
Members enrolled in the SHA plans have the freedom to go to any provider they choose.

What should I do if scheduling or billing doesn’t recognize my membership?
Please tell your Provider that your health plan is an open access plan and that there are no reduced out-of-network reimbursements. They should collect any applicable member responsibility amount and submit a claim through the Third-Party Administrator with the information on your ID Card.
If the Provider still has questions, have them call SHA Member Services immediately at 314-594-0600. The phone number is also on the back of your ID card. Make sure you present your ID card at every visit or service .

Who should I contact for questions about my SHA memberships?
You should call member services. There is a dedicated customer service team that is ready to assist you with any questions regarding your medical coverage or plan options. Call 314-594-0600.

How will I know what my membership has paid?
After any medical service, you will receive an Explanation of Sharing (EOS) in the mail from the Third-Party Administrator. The statement that will be sent by the Third-Party Administrator is a breakdown of what medical treatments were billed and what needs were shared, along with indicating what you, the patient, is responsible for.

What is a balance bill?
A balance bill is when a provider bills a member for the difference between what the health plan allows for a medical service versus what the provider chooses to charge. In essence, it’s when the provider charges more than what the Explanation of Benefit (EOS) indicates is patient responsibility.

Example: Your hospital charges are $100 and the plan allowable at 150% of Medicare is $70.00. If the facility provider bills you the $30 difference between the charged amount and the Plan allowable, they are balance billing.

Deductibles, copays, and coinsurance are not examples of balance billing and you are still responsible for these cost sharing items.

What should I do if I receive a balance bill?
If you receive a bill from a hospital or other medical facility, you need to compare it to the EOS that you received from the Third-Party Administrator.

If you are asked to pay more money than what is shown as patient responsibility on your EOS, you need to call Shared Health Alliance Member Services at 314-594-0600. Member Services will likely need you to send the bill via email or fax.

What should I do if a facility requests payment up front?
Do not pay anything other than your member responsibility amount up front. The facility should call Shared Health Alliance Member Services at 314-594-0600.

IMPORTANT: It is important for members to open any and all mail in order to check for any balance bills. If they receive a balance bill for any medical services, it is VERY important that you call Shared Health Alliance Member Services at 314-594-0600.