How are my bills reviewed?

All sharing will be secondary to Medicare. Eligible medical bills are eligible for sharing with no Co-Share amount, based on the difference between the Medicare-allowable charges and the actual amounts paid by Medicare. Sharing is subject to the Member’s Primary Responsibility Amount (PRA) and other limitations and exclusions set out in the Guidelines. The Member must submit a copy of the Medicare Summary Notice (MSN) and the CMS 1500, or UB and IB form.

Pre-Existing Medical Condition limitations do not apply to GraceWell Members.

Not eligible for sharing:

• Treatment for Members that is not Medicare-eligible
• Treatment for Members who are not enrolled in Medicare Parts A & B
• Prescription costs if the Member does not have Medicare Part D

Medicare Advantage plans and/or Medicare Part C do not qualify for GraceWell.

Eligibility for sharing cannot be determined until after medical services are received and bills are submitted for sharing.

Bills must be received by GraceWell within 12 months from the date of service to be considered for sharing.

Bills are to be submitted by the provider following standard healthcare industry submission and coding guidelines. This is necessary for bills to be considered for sharing.

If a Member needs to submit a bill for processing, it must be submitted electronically using the Bill Submission tool located in the Member Center. Members are responsible for gathering and providing all required information, as only complete submissions will be accepted for review and processing. Any costs incurred in obtaining necessary records or documentation are the responsibility of the Member.