*Official Member Guideline

Sharing requests are submitted on a per member, per medical need basis. A medical need is the reason for which a member submits a sharing request. This includes, but is not limited to, preventive visits, maternity, an accident, or a serious medical incident. Each medical need may result in medical expenses incurred by receiving medically necessary treatment that is proven safe and effective from licensed medical professionals and facilities, such as physicians, emergency rooms, and hospital facilities. 

When a member has a medical expense to be shared, the member must submit a sharing request. Once their sharing request is open, the member must submit original, itemized bills for the medical expense within six (6) months of treatment. Bills submitted more than six (6) months after the date of service may be considered ineligible for sharing. There is no lifetime limit on the number of eligible expenses that may be shared.

See the Sharing Request Guide for more information.

Submitting a Sharing Request

Sharing requests must be submitted through the Member Portal, as soon as possible, but no later than six (6) months from the date of service. Most nonemergency eligible sharing requests, such as surgical procedures and preventive, should be submitted prior to the date of service.

Determination of a Sharing Request

Expenses related to the same medical need, whether expenses for a single incident or separate incidents, will be shared as one sharing request. Members do not need to pay another IUA for any given sharing request until they are symptom free for 12 months. After 12 months, if symptoms return a new sharing request will need to be opened and another IUA paid.

Required Documentation & Time Limit for Providing Documentation

In order to be eligible for sharing, sharing requests and each itemized bill and statement must be submitted within six (6) months of the date of service. The IUA must also be paid within six (6) months to be considered for sharing. When submitting a sharing request, members must submit any documentation received from their provider. Zion HealthShare may request additional documents that may be required throughout the sharing request process. 

Document types can include, but are not limited to, receipts, proofs of payment, itemized bills and statements. 

Original, itemized bills and statements must be submitted promptly to Zion HealthShare along with the sharing request form, opened through the Member Portal, for us to process the sharing request as soon as possible.

Please reference all applicable guidelines to determine if there are other document requirements or time limits.

Meeting the IUA 

Medical expenses are only eligible for sharing after members have met their IUA. Members must provide documentation to Zion HealthShare of all payments that may contribute toward the member’s IUA. 

The IUA must be paid within six (6) months of the date of service or bills may become ineligible for sharing. Consideration will be given for situations where the cost of treatment has not exceeded the IUA after six (6) months for certain eligible sharing requests. Members must communicate with their Member Needs team representative about a timeline for IUA payment.

Paying at the Time of Service 

Zion HealthShare is not insurance, so members should tell their provider they are an uninsured, self-pay patient if they do not have insurance through other means. That way, members can obtain self-pay discounts on services, which allows us to keep membership contributions low. Members must obtain itemized bills and receipts to request payment or reimbursement from Zion HealthShare. In some cases, prepayment may be an option. 

Contact our Medical Advocacy team before receiving nonemergency medical treatment for prompt payment at the time of service.

Requesting Discounts 

Members have options for sharing prior to, at the time of, or after medical services are rendered. For all purposes, members should present as self-pay patients and communicate costs and discounts as soon as possible to Zion HealthShare.

Insurance, Third-Party Administrators, & Government Assistance Plans

If you have other insurance, a group plan, or government assistance, or the like, those will be responsible for covering your medical expenses first. The Zion HealthShare community will only step in to share any remaining eligible medical expenses. 

If you've hired a lawyer to handle medical expenses related to a specific need or because of issues with medical services, Zion HealthShare will wait to see the outcome of your case before deciding if the community can share any leftover eligible medical expenses. 

It's important to let us know if you have any other coverage, including through a spouse, family member, employer, or government program. If you don’t disclose this information, your expenses may not be eligible for sharing.

Appeals

If a member believes that a sharing limitation was incorrectly placed or a determination of ineligible for sharing was provided on their sharing request, they may submit an appeal. Members may submit an appeal only if their membership remains active throughout the appeals process. All appeals are reviewed by a committee, which includes at least one Zion HealthShare board member, as well as trained medical professionals. All appeals results are final and may not be appealed again. 

Appeal requests must be submitted within thirty (30) days of the sharing request determination and must be submitted by the member, not the member’s providers. Zion HealthShare may request additional information from providers if needed. 

To file an appeal, send the medical evidence, a written explanation, and any other supporting documentation to the Determination Adjudicators.

Aging Out at 65

Medical incidents, services, and expenses that occur prior to the members age-out at sixtyfive (65), will have up to thirty (30) days after their membership end date to submit a sharing request. All other time limits will remain in effect including:

• itemized bills and statements must be submitted within six (6) months of the date of service, and
• the IUA must be paid within six (6) months of the initial date of service, or they become ineligible for sharing.

Medical Records Addendums 

A member’s Medical Records may be requested to assist with the determination of a sharing request. After the requested medical records have been reviewed and a determination is made, medical record addendums will not be considered unless they are combined with an official addendum from the applicable provider. The addendum must be separate and include the following:

• signature from the applicable probider,
• date,
• description of what was changed, and 
• reason for change.

Conflict of Interest 

In keeping with the Principles of Membership, and in the interest of protecting the Zion HealthShare community, medical expenses incurred by a member that obtains medical treatment from a provider with which the member has an affiliation, partnership, personal or business relationship, or the like, and receives financial gain, is ineligible for sharing.

Maximum Shareable Amount

There is no annual or lifetime maximum for any member or household membership. However, some expenses may be subject to limitations according to these Member Guidelines.