Bill process, OneNet PPO/Workers Compensation Supplement - 2022 UnitedHealthcare Administrative Guide

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All bills, whether submitted electronically or by paper, should be sent directly to the applicable employer, worker’s compensation carrier, auto liability insurer or third-party administrator (TPA). Do not submit bills directly to OneNet or Procura, except for pricing appeals.

When submitting a bill, it is important to submit complete bills 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.

Clean bills must be submitted within the time frame identified in your contract, or within 12 months of the date services are provided, and in accordance with any applicable laws. Failure to submit bills correctly will result in the rejection and return of bills. You will receive a notice from the applicable claimant or injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA in the event your bills are being withheld from bill pricing and payment while compensability is being determined.

If you have questions about submitting claims to us, call the claimant or injured workers’ employer, workers’ compensation carrier, auto liability insurer or TPA for instructions on how to submit a bill.

Your bills may not be processed if you omit:

 Additional requirements:

  • Items identified under the Additional information needed for a complete UB-04/CMS-1450 Form section of 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 bills for professional services or facility services on a CMS 1500 or UB-04 claim form or their electronic equivalents and include all standard code sets that apply.

Our bill review procedures identify coding errors and coding irregularities. This helps provide better consistency during our claims pricing.

  • Submit bills on a red CMS 1500 or a 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 bills on original forms, not photocopies.
  • Complete all required fields on standard forms.
  • Make sure attachments are complete and legible.
  • Make sure information such as the health 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.

OneNet pricing includes bill completeness, accuracy review and pricing, per your contracted rate.

Payment for covered services related to a workers’ compensation injury is the least of the following:

  • The Property & Casualty Benefit Plan payment rate per your Agreement
  • Your eligible billed charges
  • The state’s workers’ compensation fee schedule
  • The federal workers’ compensation fee schedule
  • UCR or prevailing rate as determined by the state
  • 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.

Payment for covered services of an auto liability bill is the least of the following:

  • The Property & Casualty Benefit Plan Auto Liability payment rate per your agreement
  • Your eligible billed charges
  • UCR or prevailing rate as determined by the state
  • Any state, federal or mandated rates applicable to auto

For bills subject to code edits or line bundling and unbundling, the bill pricing resulting from these edits is allocated back to the original submitted bill lines and codes (refer to the OneNet pricing sheet). Priced bills do not display the lines or codes added or deleted by these bill edits. This is intended to assist physicians and OneNet’s clients and payers in bill reconciliation by having priced bills match the originally submitted bills.

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

Example of global pricing distributed across lines

A 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.

OneNet PPO billing table

These allocations occur because individual lines where global pricing has been distributed may not be processed separately. This means if the payer finds a service line to be non-compensable, 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 bill-level rate separately.

OneNet can verify our receipt, the OneNet contracted pricing and the date returned to our client. We cannot verify payment status or questions related to anything outside of the network contract.

Bill inquires related to the status of payments and non-OneNet related pricing should be directed to the applicable claimant or injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA.

The fastest way to locate a OneNet PPO pricing sheet is to access the UnitedHealthcare Provider Portal at uhcprovider.com > Sign In > Claims & Payments > UnitedHealthcare OneNet PPO pricing. Pricing sheets show the allowed amount of your bills after the application of OneNet bill pricing. They do not show the final bill adjudication by the payer, which could include pricing for charges that the payer identifies as non-payable, ineligible or the patient’s responsibility. The EOB or remit created by the applicable claimant or injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA will identify charges deemed not payable for workers’ compensation or auto liability.

If you do not have internet access, or if you cannot find the information for the Procura client you need on our website, call 1-877-461-3750.

OneNet and Procura do not pay bills and do not have an obligation to pay for services rendered to an injured worker or claimant authorized to access a OneNet PPO Network provider. We send the priced bill to the appropriate client or 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 may not be billed. 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 bill forms or submitting additional information. If OneNet rejects or denies a bill because a health care provider failed to follow policies and procedures, the patient may not be billed.

For compensable auto claims, the claimant may have deductibles according to their policy. The claimant is responsible for those deductibles. An auto liability policy may also contain limited benefits. Once those benefits are exhausted, the claimant is responsible for all remaining charges or the services can be billed through their health insurance carrier if there are additional benefits for the claimant to use.

OneNet payers are required to adjudicate and pay clean bills within 30 days of bill pricing, or within applicable state or federal guidelines. If the OneNet payer fails to adjudicate and pay a bill within this time period, the health care provider may, at their discretion, request the least of the full charges. In the case of workers compensation, the applicable state or federal maximums will still apply. In these instances, the OneNet payer will pay the bill as it was priced by OneNet. After receiving payment, the health care provider must notify the OneNet payer that payment of full charges or applicable state or federal maximums are requested due to late bill payment. A health care provider cannot request full billed charges for failing to offer timely payment if OneNet, Procura or the client or payer notifies the health care provider after receipt of the bill but before the expiration of the bill payment’s time limit that the bill is denied, is missing required information, is deficient in some way or is being held to determine auto or workers’ compensation compensability.

The claimant or injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA must send you an EOB or remittance advice indicating that the OneNet PPO Network was accessed and the reimbursement amount for those services. The EOB shows: 

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

Submit bills with services not payable under the Property or Casualty Benefit Plan to the injured worker or claimant’s health plan. Do not assume that UnitedHealthcare is the claimant or worker’s health insurer. You can get this information by calling their employer or from the claimant or injured worker directly.

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

  • Workers’ compensation and auto liability lines of business - When you perform a service that may not be covered under the workers’ compensation/auto claim or the patient’s health insurance, you may balance bill the injured worker or claimant only if the following conditions are met:
    • You notified the injured worker or claimant at the time of service that the charge may not be compensable under their workers’ compensation/auto injury or illness.
    • The injured worker or claimant agrees at the time of service to be responsible for the charge.
    • You obtained written consent from the patient to perform the service.
    • You have submitted the bill to both the workers’ compensation/auto employer, carrier, insurer or TPA and the claimant or injured worker’s health insurance, and the service is not compensable under either the workers’ compensation/auto coverage or the injured worker or claimant’s health insurance.
  • The claimant or injured workers’ employer, workers’ compensation carrier, auto liability insurer or TPA determines compensability.
  • You cannot use the online Claim Estimator on uhcprovider.com to estimate bills.
  • You cannot submit OneNet bills for real-time processing on uhcprovider.com.

For hospital audit services, OneNet and OneNet clients or payers may conduct their own audits of hospital bills. They may follow their own procedures, subject to mutual agreement of the OneNet client or payer and the audited facility. These procedures vary from those of UnitedHealthcare’s Hospital Audit Service Department. OneNet or Procura may request copies of medical records to comply with audits required by external accreditation agencies, the state, OneNet clients or payers or for cause. OneNet clients and payers may conduct independent hospital or facility bill audits and request copies of medical records to help ensure quality care. You must provide medical records when requested by OneNet or OneNet clients or payers at no cost to OneNet, the OneNet client or payer, or the participant. UnitedHealthcare’s hospital bill audit protocol does not apply to such audits or requests for medical records.

Email direct pricing appeals for Procura bills to proppo@procura-inc.com, or call 1-877-461-3750. Questions about a state rate allowance should be directed to the claimant or injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA identified on the EOR.

Any bill pricing appeals must be submitted within 12 months of the bill process date, or within the time frame prescribed by applicable law or your Agreement.

Follow the procedure below for payment appeals related to OneNet PPO:

  • Email your payment appeals to Procura at: proppo@procura-inc.com.
  • When resubmitting information, attach all applicable documentation, including any additional information requested.
  • Include the UB/HCFA bill and EOB.

If you have any concerns about the appeal process or specific concerns about a Procura/OneNet client or payer, contact Procura at proppo@procura-inc.com or call 1-877-461-3750.

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

If you find a bill where you were overpaid or if we inform you of an overpaid bill 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.

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

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

If the payer still believes a refund should be provided, the payer forwards the information to Procura and OneNet for further review. Procura and OneNet will work with you and the payer to resolve the issue.

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

Bill pricing resulting in either an overpayment or underpayment of $5 or less is not adjusted.

OneNet injured workers and claimants direct appeals or grievances to their employer, workers’ compensation carrier, auto liability insurer or TPA. They do not use the Appeals and Grievance Form used by UnitedHealthcare members. You are required to support the payer’s appeals process by providing records as requested and complying with final determinations. In the case of complaints or grievances related to a participating health care provider, the employer, workers’ compensation carrier, auto liability insurer or TPA refers the information to UnitedHealthcare and OneNet. If you are disputing the state or services deemed not part of the workers’ compensation/auto illness or injury, contact the employer, workers’ compensation carrier, auto liability insurer or TPA at the number identified on the EOR. For all network-related concerns, call Procura at 1-877-461-3750. Some states have formal dispute resolution or appeals processes. You must submit your appeal to Procura before using these appeals processes for both workers’ compensation and auto bills.

Health care professionals can view pricing sheets in the UnitedHealthcare Provider Portal at uhcprovider.com > Sign In > Claims & Payments > UnitedHealthcare OneNet PPO Pricing. Pricing sheets show the allowed amount of your bill after the application of OneNet pricing. Pricing sheets do not show the final bill adjudication by the payer. It may include billed charges and pricing for charges that are not payable as identified on the EOB or remittance advice.

Because workers’ compensation and auto liability information is not stored on any UnitedHealthcare member system, many of the online solutions on uhcprovider.com are unavailable for OneNet claims.

Some unavailable tools include the following:

  • Eligibility or benefits
  • View patient personal health records
  • Submit advance notifications
  • View your OneNet fee schedule
  • Claim Estimator
  • Claim submission
  • Reprint EOBs
  • Optum Pay
  • Authorizations and referral information, submission and status

Similar limitations exist for other UnitedHealthcare systems designed to use or verify benefits and eligibility information, such as the United Voice Portal.