Workers' Compensation Claims Process - OneNet PPO Supplement, 2018 UnitedHealthcare Administrative Guide

Claims Submission

All workers’ compensation claims should be sent directly to the applicable employer, worker’s compensation insurance carrier or administrator. Do not submit workers’ compensation claims directly to OneNet or Procura, except for pricing appeals.

When submitting workers’ compensation claims, it is important to submit complete claims and to accurately code all diagnoses and services in accordance with national coding guidelines.

Additional information may be required for particular types of services, or based on particular circumstances or state requirements.

Claims must be submitted within the time-frame identified in your contract and in accordance with any applicable laws. Failure to submit claims correctly will result in the rejection and return of claims. You will receive a notice from the workers’ compensation carrier or administrator in the event your claims are being withheld from claim pricing and payment while compensability is being determined.

If you have questions about submitting claims to us, please call the employer or workers’ compensation carrier or administrator.

Complete Claims Requirements

Your workers’ compensation claims may not be processedif you omit any of the following items.

Additional requirements for the CMS 1450 form:

  • Items identified under the Additional Information Needed for a Complete UB-04 (or CMS-1450) Form section the UnitedHealthcare guide.
  • When billing late charges, indicate bill type 115 or 117 (inpatient), or 135 or 137 (outpatient), in form locator 4 of the CMS-1450/UB-04.
  • Bill all outpatient surgeries with the appropriate revenue and CPT codes if reimbursed according to ambulatory surgery groupings.

Submit all claims for professional services or facility services on a CMS 1500 or CMS-1450/UB-04 claim form or their electronic equivalents (when submitting workers’ compensation claims electronically) and include all standard code sets that apply.

Claim Review Procedures

Our workers’ compensation claim review procedures identifies coding errors and coding irregularities. This helps provide better consistency during our claims pricing.

Tips to Expedite Claim Processing:

  • Submit claims on a red CMS 1500 or a CMS-1450/UB-04 form, using 11 or 12 point font size and black laser jet ink.
  • Do not use a highlighter on the claim form or any attachments.
  • Line up forms to print in the appropriate boxes.
  • Submit claims on original forms, not photocopies.
  • Complete all required fields on standard claim forms.
  • Make sure attachments are complete and legible.
  • Make sure information such as the care provider’s name, telephone number, NPI, and other information is accurate.
  • Remember to sign and date all necessary forms; an electronic signature is acceptable.

Pricing of OneNet PPO Workers’ Compensation Claims

OneNet workers’ compensation claims pricing includes claim completeness and accuracy review, and application of claim pricing per your contracted rate.

Payment for covered services is the least of:

  • The OneNet PPO Workers’ Compensation payment rate per your agreement
  • Your billed charges
  • The state’s workers’ compensation fee schedule
  • The federal workers’ compensation fee schedule

Or,

  • Other state, federal, or government authorized fee schedule

Application of this reimbursement comparison is generally at the claim line (service code) level, unless state or federal regulations applicable to the job-related injury specify comparisons must be done at claim-level aggregate values.

Workers’ Compensation Claims Subject to Claim Edits

For workers’ compensation 837P and CMS 1500 (formerly HCFA-1500) claims subject to code edits or line bundling and unbundling, the claim pricing resulting from these edits is allocated back to the original submitted claim lines and codes. Priced claims do not display the lines or codes added or deleted by these claim edits. This is intended to assist physicians and OneNet’s workers’ compensation clients in claims reconciliation by having priced claims match originally submitted claims.

Allocation of Global Pricing to the Claim Line Level

Certain claims are subject to global pricing, including case rates, flat rates and per diems, as examples. In these cases, a fixed percentage of the overall global rate may be allocated to the applicable lines of the claim.

Example of Global Pricing Distributed Across Lines

Health care provider has billed lines totaling $100 that are subject to a state fee maximum of $90 and a contracted global rate of $80. A portion of the global rate is allocated to each line as a percentage of the state fee charges. 

Line Number 

Line 1

Line 2

Line 3

Total 

Billled Charges 

$50.00

$30.00

$20.00

$100.00 

State Fee 

$45.00

$27.00

$18.00

$90.00 

Allowed Amount 

$40.00

$24.00

$16.00

$80.00 

Whenever such allocations occur, OneNet Clients are instructed that individual lines where global pricing has been distributed cannot be processed separately. This means if the payer finds a service line to be noncompensable, and a portion of a global rate has been allocated to that line, that portion must still be considered when determining payment. Remark codes on the pricing sheet show when we cannot process individual lines of a claim-level rate separately.

Claim Inquiries

We can only verify the receipt, pricing and mail date of a claim from participating care providers. Make other claims inquires directly to the applicable employer, workers’ compensation insurance carrier or administrator.

The fastest way to check for a claim pricing sheet for a Participant accessing the OneNet PPO Workers’ Compensation Network through Procura is through UHCprovider.com/claims > Check Claim Status > Go to OneNet PPO Pricing Status Tool.

Pricing sheets show the allowed amount of your claims after the application of OneNet claim pricing. They do not show the final claim adjudication by the payer. They may include charges identified as non-payable, ineligible or the member’s responsibility. The EOB or remit shows these charges.

If you do not have Internet access, or if you cannot find the claim information for the Procura client you need on our website, please call 877-461-3750.

Workers’ Compensation Claim Payment

OneNet and Procura do not pay claims and do not have an obligation to pay for services rendered by a OneNet provider to an injured worker authorized to access the OneNet PPO Workers’ Compensation Network. The priced claim is sent to the appropriate payer for adjudication and payment determination. You are required to accept the OneNet contracted amount as payment in full for covered services.

For compensable workers’ compensation related services, the injured worker cannot be billed and there are no copayments, deductibles, or coinsurances. Balance billing is prohibited for all services covered by a workers’ compensation benefit plan.

A health care provider may not bill participants for non-professional services including charges for overhead, administration fees, malpractice surcharges, membership fees, fees for referrals, or fees for completing claim forms or submitting additional information. If OneNet rejects or denies a claim because a health care provider failed to follow policies and procedures, the participant may not be billed.

OneNet Clients are required to adjudicate and pay clean claims within 30 days of claim pricing, or within applicable state or federal guidelines. If the OneNet Client fails to adjudicate and pay a claim within this time period, the care provider may, at their discretion, request the least of the full charges, or applicable state or federal maximums applying to workers’ compensation. In these instances, the OneNet Payer will pay the claim as it was priced by OneNet.

After receiving payment, the care provider must notify the OneNet Payer that payment of full charges or applicable state or federal maximums are requested due to late claim payment.

Exceptions to the right to request full billed charges for failing to offer timely payment is as follows:

  • When OneNet notifies the care provider after receipt of the claim but prior to the expiration of the applicable claim payment time limit that the claim is denied, missing required information or is deficient in some way.
  • When a OneNet Client notifies the care provider after receipt of the claim but prior to the expiration of the applicable claim payment time limit that the claim is denied, deficient or being held to determine workers’ compensation compensability.

The OneNet Client must send you an EOB or remittance advice indicating that the OneNet PPO Network was reimbursement amounts for services. The EOB shows:

  • The billed charges for services
  • The OneNet contracted amount
  • The reimbursement amount
  • The amount adjusted based on the contract/benefit plan
  • Services found to be non-payable

Submit claims with non-payable services to the injured worker’s health plan. Do not assume that UnitedHealthcare is the worker’s health insurer. You can get this information by calling their employer or from the worker directly.

Claims Appeals (Post Service)

OneNet claim appeals cannot be submitted for reconsideration using the Claim Reconsideration tool on UHCprovider.com/claims.

Email direct pricing appeals for Procura claims to proppo@procura-inc.com, or call 877-461-3750.

Claim pricing appeals must be submitted within 12 months of the date of the EOB, or within applicable state and federal time frames. Follow the procedure below for payment appeals on OneNet PPO Workers’ Compensation claims:

Payment Appeal Procedures

Email your payment appeals to Procura at proppo@procura-inc.com.

When resubmitting information, include all applicable documentation, including any additional information requested, with a copy of the claim and EOB.

Overpayments

Direct all questions or refunds of overpayments to the applicable OneNet payer at the phone number listed on the injured worker’s EOB or remittance advice.

If you find a claim where you were overpaid or if we inform you of an overpaid claim that you do not dispute, you must send the overpayment within 30 calendar days (or as required by law or your agreement) from the date of your identification or our request.

Please include appropriate documentation that outlines the overpayment, including the participant’s name, ID number, date of service, and amount paid. If possible, please also include a copy of the EOB that corresponds with the payment.

If you disagree with a request for an overpayment refund, notify the OneNet Payer in writing as to why you do not believe overpayment occurred and why you dispute the refund.

If the OneNet Payer still believes a refund should be provided, the OneNet Payer forwards the information to OneNet for further review. OneNet works with you and the OneNet Payer to resolve the issue.

Claim Pricing Adjustments of $5.00 or Less

We strive to accurately re-price all claims, and make adjustments when an incorrectly priced claim results in significant underpayment or overpayment for services.

Claim pricing that results in either an overpayment or underpayment of $5.00 or less is not adjusted.