OneNet PPO Supplement - 2018 UnitedHealthcare Administrative Guide

Applicability of this Supplement

OneNet PPO, LLC (OneNet) is a wholly owned subsidiary of UnitedHealthcare Insurance Company, a part of UnitedHealth Group, Incorporated. The OneNet supplement is a supplement to this UnitedHealthcare Guide, both of which OneNet health care providers must follow. This supplement may be referred to as the OneNet Physician, Health Care Practitioner, Hospital and Facility Guide or the “OneNet Guide”.

OneNet health care providers are physicians, health care practitioners, hospitals and facilities whose agreement with UnitedHealthcare includes participation in networks offered by OneNet. This may include health care providers within the OneNet service area, as well as health care providers in other areas such as states adjacent to the OneNet service area, and any future OneNet network expansion areas.

As of the published date, the OneNet service area includes Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Pennsylvania, Tennessee, Virginia, Washington DC, and West Virginia.

As of March 16, 2016, the OneNet PPO Medical Network product is no longer offered. The OneNet PPO Workers’ Compensation Network continues to operate and, as of the published date, this is the only OneNet network currently accessed. Access to the OneNet PPO Workers’ Compensation Network is limited to employers and administrators contracted with Procura Management, Inc. (Procura), an Optum Company.

This supplement lists operational procedures and information that apply to services provided to injured workers whose employer, workers’ compensation carrier, administrator or other entity has contractually based authority to access the OneNet PPO Workers’ Compensation Network for themselves or for their clients.

You are subject to both the main guide and this supplement. Because OneNet is a network only and not a payer, certain provisions of the guide will apply to OneNet with some variation. This supplement identifies these principal variations. This supplement controls if information conflicts with the main guide. For protocols, policies and procedures not referenced in this supplement, please refer to appropriate chapter in the main guide.

Terms Used in the OneNet Supplement

OneNet Client: OneNet Clients include insurance carriers, third party administrators (TPA), union health and welfarefunds, workers’ compensation administrators, workers’ compensation insurance carriers, and others. OneNet Clients may be a OneNet Payer or any entity that provides administrative services to a OneNet Payer (e.g., a TPA).

OneNet Customer: A OneNet Customer is a person authorized by OneNet PPO, LLC to access OneNet participating health care providers under the terms of their agreement. The term “OneNet Customer” means the same as “customer” or “member” in this supplement. OneNet Customers include:

  • Primary Participants: The qualifying injured worker, subscriber, employee, insured, policyholder or other person who through their direct or indirect agreement with OneNet is eligible to access network health care providers.
  • Participants: As used by OneNet and in this supplement, Participants refers to all Primary Participants and their spouses and dependents (including domestic partners, if applicable) who are authorized by OneNet to access network health care providers.

OneNet Payer: A OneNet Payer is a person or entity that has an obligation to pay for services rendered by a OneNet participating health care provider to a OneNet Customer. OneNet Payers may include insurance carriers, workers’ compensation carriers, self-funded health plans and others. OneNet Payers may use the services of a TPA or other entity to provide administrative services, including verifying eligibility and adjudicating and issuing claims payment on behalf of OneNet Payers. References in the health care provider agreement to “participating entity” or “Payer” also apply to OneNet Payers. Neither OneNet, Procura, nor UnitedHealthcare and its affiliates are OneNet Payers.

Claim Pricing or Repricing: The process of applying the OneNet contracted rates to claims submitted by participating health care providers to OneNet or to third party payers or other entities who have contractually based authority to access OneNet networks for themselves or their clients. This process includes the application of clinical edits, reimbursement policies and standard coding practices. In the case of workers’ compensation, it may include the application of state or federal fee schedule rates, or other government-authorized pricing methodology or schedule. The terms “claim pricing” and “repricing” are used interchangeably.