This supplement lists operational procedures and information applicable to services received by a OneNet Customer (as defined below) that are covered under a Property or Casualty Benefit Plan (as defined below) sponsored, issued or administered by a OneNet Payor (as defined below). Such services are subject to both the main guide and this supplement. This supplement controls in the event of any conflict with the main guide. For protocols, policies and procedures not referenced in this supplement, refer to the appropriate chapter in the main guide. OneNet PPO, LLC (OneNet) is a wholly owned subsidiary of UnitedHealthcare Insurance Company, a part of UnitedHealth Group, Inc. Because OneNet is a network only and not a payer, certain provisions of the main guide will apply to OneNet with some variation. This supplement identifies these principal variations.
Terms used in the supplement
Adjuster: An adjuster works for an insurance company, third-party administrator (TPA) or directly for a self-insured employer. This person coordinates with all parties on a workers’ compensation case or auto liability claim. They are responsible for, among other things, the wage replacement and return-to-work coordination as well as all management of the funding for medical services.
Clean Bill/Claim: “Bill” refers to the submitted UB or CMS1500 form. “Claim” represents the entire workers’ compensation or auto accident, including all submitted bills.
Bill/Claim Pricing or Repricing: The process of applying the OneNet contracted rates to bills, including the application of clinical edits, reimbursement policies and standard coding practices. It may include the application of state or federal workers’ compensation fee schedule rates, usual and customary or reasonable rate (UCR) or prevailing rate as defined by the state, or other government-authorized pricing methodology or schedule. The terms “claim/bill pricing” and “repricing” are used interchangeably. The process of applying contracted rates to bills from network providers includes the application of the lesser of the billed charges, contracted rate, state/federal schedule, UCR or other authorized fee schedule.
OneNet Client: An entity that has contractual authority to access the OneNet network of health care providers. OneNet Clients may include, without limitation, insurance carriers, workers’ compensation insurance carriers, auto liability insurers, risk management entities, claims management entities, TPAs and employers. A OneNet Client can access the OneNet network for itself, on behalf of another entity that is a OneNet Payer or both. A OneNet Client may or may not be the OneNet Payer for a particular OneNet Customer. A OneNet Client accessing the OneNet Network on behalf a OneNet Payer may perform some or all of the OneNet Payer’s administrative services (e.g., eligibility verification, claims adjudication and bill payment).
OneNet Customer: A person whose coverage under a Property or Casualty Benefit Plan enables them to receive treatment from OneNet participating health care providers. The term “OneNet Customer” means the same as “customer,” “member,” “participant,” “primary participant,” “injured worker,” “subscriber,” “employee,” insured” and “claimant” as used this guide.
OneNet Payer: An entity that is obligated to reimburse services covered under a Property or Casualty Benefit Plan and that has contractual authority to access the OneNet network of health care providers. References to “Participating Entity,” “Payer” or “Alternate Payer” in the health care provider Agreement and in this guide also apply to OneNet Payers. OneNet, Procura and UnitedHealthcare and its affiliates are not OneNet Payers. OneNet Payers may include, without limitation, insurance carriers, workers’ compensation insurance carriers, auto liability insurers, risk management entities and employers. A OneNet Payer’s access to the OneNet Network may be through its own contractual access to the OneNet network or through a OneNet Client’s contractual access to the OneNet network. Some or all of a OneNet Payer’s administrative services (eligibility verification, claims adjudication and bill payment) may be performed by a OneNet Client or other entity.
Property or Casualty Benefit Plan: A Benefit Plan sponsored, issued or administered by a OneNet Payer that is not a medical Benefit Plan but that includes coverage for medical services and supplies. Property and Casualty Benefit Plans include, without limitation, workers’ compensation programs and auto liability insurance.
Utilization Review: Utilization management or utilization review is the use of managed care techniques such as prior authorization that allows payers to address clinical appropriateness using evidenced-based criteria or guidelines as defined by each state. Procura may or may not provide utilization management services for their clients.
UCR/Prevailing Rate: The UCR rate (also known as prevailing rate) determined by the state or other governmental entity or a database referenced by a state or governmental agency such as FAIR Health. The database is created using rates typically charged by providers in a geographic area.
OneNet PPO product overview
OneNet is a network of physicians, health care practitioners, hospitals and ancillary facilities whose Agreements with UnitedHealthcare provide for participation in Property and Casualty Benefit Plans, including workers’ compensation programs and auto liability insurance. Entities that are obligated to reimburse medical services under Property and Casualty Benefit Plans contract directly or indirectly with Procura Management, Inc. (a UnitedHealthcare affiliate) to access OneNet providers at negotiated rates.
OneNet may include health care providers within the OneNet service area, as well as those in other areas (e.g., states adjacent to the service area or future expansion areas). Currently, the OneNet service area includes Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Pennsylvania, Tennessee (except for auto liability insurance), Virginia, Washington D.C. and West Virginia.
Advantages that providers who participate in the OneNet Property and Casualty network may see include the following:
Increased patient volume by referrals generated through published directories, workplace postings and online provider look- up tools.
Efficient and consistent payment and adjudication of bills defined by your contract terms.