Provider Portal Information
Bill Status
  • DOS
    - Date Of Service
  • Created Date
    - The date we received the medical expense
  • Processed Date
    - The date we processed the medical expense
  • Charged Amount
    - The total amount billed
Member Eligibility
  • Expiration Date
    - The day the member is no longer effective.
  • AUA
    - Annual Unshared Amount.
    The amount of medical expense eligible for sharing must exceed an annual accumulative amount assigned for each single, couple or family membership. The annual amount shall be calculated upon each member’s Enrollment Activation Date until his or her next annual renewal date or program level change. All eligible medical expenses that exceed the applicable AUA shall then be subject to the program limits per incident selected by the member.
  • Wellness

    Liberty HealthShare encourages our members to see their Primary Care Physician or provider yearly to maintain their health and well-being. After the first two months of membership, an annual preventative wellness visit and related lab work for which there are no medical symptoms or diagnosis in advance are eligible for sharing, up to a maximum of $400 of the fair and reasonable charges as determined by Liberty HealthShare and not subject to the AUA nor subject to guideline limitations for medical expenses $200 or less.
    • a. Well baby visits including immunizations are eligible for sharing within the first 13 months after birth and not subject to the AUA or the two-month waiting period.
    • b. Any new condition based on symptoms discussed during a preventative wellness visit and any additional diagnostics or labs that are ordered to determine treatment may be shareable according to Sharing Guidelines and are subject to the AUA.
  • Screenings

    a. The following preventative screenings are not subject to the AUA:
    i. Screening pap smears are eligible for sharing once every year.
    ii. Screening mammograms, PSA tests, and Cologuard® are eligible for sharing once every two years up to and including age 49.
    iii. Screening mammograms, PSA tests, and Cologuard® are eligible for sharing once every year for members 50 years of age and older.
    b. The following screenings are eligible for sharing and are subject to the AUA:
    i. Screening colonoscopies and bone density screenings
    ii. Ultrasound/MRI/Thermogram screening conducted in lieu of a screening mammogram
    iii. All diagnostic screenings
  • Sharing Program

    Medical Expenses Eligible for sharing Unshared Amount Per Visit Maximum Sharing Limit
    Primary Care Physicians $25 $750/year
    Specialist Physicians $40 $750/year
    Urgent Care $50 $500/year
    Hospital Stays* - $1250/day
    In-/Outpatient Surgeon Fees* - $1250/day
    Emergency Room $500 $1000/year
    CT Scans $200 $1250/day
    MRI Scans $200 $1250/day
Wellness Visits and Screenings
  • Wellness

    Liberty HealthShare encourages our members to see their Primary Care Physician or provider yearly to maintain their health and well-being. After the first two months of membership, an annual preventative wellness visit and related lab work for which there are no medical symptoms or diagnosis in advance are eligible for sharing, up to a maximum of $400 of the fair and reasonable charges as determined by Liberty HealthShare and not subject to the AUA nor subject to guideline limitations for medical expenses $200 or less.
    • a. Well baby visits including immunizations are eligible for sharing within the first 13 months after birth and not subject to the AUA or the two-month waiting period.
    • b. Any new condition based on symptoms discussed during a preventative wellness visit and any additional diagnostics or labs that are ordered to determine treatment may be shareable according to Sharing Guidelines and are subject to the AUA.
  • Screenings

    a. The following preventative screenings are not subject to the AUA:
    i. Screening pap smears are eligible for sharing once every year.
    ii. Screening mammograms, PSA tests, and Cologuard® are eligible for sharing once every two years up to and including age 49.
    iii. Screening mammograms, PSA tests, and Cologuard® are eligible for sharing once every year for members 50 years of age and older.
    b. The following screenings are eligible for sharing and are subject to the AUA:
    i. Screening colonoscopies and bone density screenings
    ii. Ultrasound/MRI/Thermogram screening conducted in lieu of a screening mammogram
    iii. All diagnostic screenings
    c. Liberty Select Program Exception: Preventative screenings are eligible for sharing and included in the $400 maximum per membership year for wellness visit, related lab work and screenings and not subject to the AUA.
To submit a prenotification on behalf of a member, please enter the required information in the form below

Prenotification is NOT required for the following services:

  • CT Scans
  • Outpatient Office Visits
  • EKG
  • Emergency Department Visits
  • Routine Laboratory Testing
  • Wellness & Flu Vaccines
  • Screening & Diagnostic Mammograms
  • Ultrasounds
  • Plain X-Rays
  • Initial Evaluation by Therapists
  • Skin Biopsies
  • Ancillary Therapies
  • Chiropractic Care
  • Acupuncture
  • Screening & Diagnostic Colonoscopies
  • Complementary or Alternative Medical (CAM) Management
Tests where prenotification is not required are not necessarily eligible for sharing, based on the Sharing Guidelines

Prenotification Instructions: Please fill out the form below and attach all clinical information pertaining to this prenotification request.
Clinical Information May Include: Current and previous physician notes, medical records, imaging, lab results, hospital admission information, treatment plans, ICD-10 codes, CPT codes, etc.
Maternity Prenotification: Please attach physician notes that include date of conception.

To be considered for medical cost sharing, the member MUST notify Liberty HealthShare IN ADVANCE by contacting the prenotification department for any services, procedures, and diagnostics listed below, except in the case of true emergencies. The Sharing Member, their physician, or their representative should contact the prenotification department as soon as the need for admission or services is recognized, and at least seven days prior to admission whenever possible.

Review time begins when ALL required medical records, treatment plans or other requested supportive documentation has been received.

If this is an urgent request, please call Liberty HealthShare at 855-585-4237, option 4.


Member Information

Female Male
Requesting Provider Information


Service Provider or Facility Information (Hospital, Surgery Center, etc.)


Prenotification Details


If applicable, please include ICD-10/CPT codes and their descriptions.


Attachments

Please attach documentation with a clear onset date of signs and symptoms (medical records, treatment plans, etc.)
A 36-month pre-existing condition clinical review applies to members < 1 year.


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