Resolving Disputes - OneNet PPO Supplement, 2018 UnitedHealthcare Administrative Guide

If you have a concern or complaint about a OneNet Client, please use your best efforts to resolve the issue directly with the client.

If the issue is not resolved to your satisfaction, please follow the resolution processes outlined in Resolving Disputes - Concern or Complaint section of the UnitedHealthcare guide.

Compensation

Follow UnitedHealthcare’s protocols on compensation for care provided to OneNet Participants with the following exceptions:

  • In regards for charging members for non-covered services when you know services may not be covered, the injured worker’s written consent needs to have a statement that the payer determined services are not compensable for workers’ compensation and the injured worker agrees to be responsible for them.
  • For health benefit plans, the participant’s health benefit plan determines coverage. For workers’ compensation, the workers’ compensation carrier or administrator determines compensability.
  • The online Claim Estimator available on UHCprovider.com cannot be used to estimate claims. OneNet claims cannot be submitted for real time processing through UHCprovider.com.
  • For Hospital Audit Services, OneNet or OneNet Clients may conduct their own audits of hospital claims. They may follow their own procedures, subject to mutual agreement of the OneNet Client and the audited facility. These procedures vary from those of UnitedHealthcare’s Hospital Audit Service Department. OneNet Payers must pay the claims first before requesting an audit.
  • OneNet or Procura may request copies of medical records to comply with audits required by external accreditation agencies, the state, OneNet Clients, or for cause. OneNet Clients may conduct independent hospital or facility claims audits and may also request copies of medical records as part of the process of ensuring quality care. You must provide medical records when requested by OneNet or OneNet Clients at no cost to OneNet, the OneNet Client, or the Participant. UnitedHealthcare’s Hospital Bill Audit Protocol does not apply to such audits or requests for medical records.