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”.
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. It also applies to claimant services as a result of injuries sustained in an auto-liability claim. 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 main 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 the appropriate chapter in the main guide.
Adjuster: An Adjuster works for an insurance company, third party administrators (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 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 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, 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 (Direct or Indirect Payer): Clients include insurance carriers, TPA and other entities with contractually based authority to access OneNet for themselves or their clients. OneNet clients may be a OneNet Payer or any entity that provides administrative services to a OneNet Payer (e.g., a TPA). Direct or indirect payers may use the services of a TPA or other entity to provide administrative services, including verifying eligibility and adjudicating and issuing bill payment. References in the health care provider Agreement to “Participating Entity”, “Payer” or “Alternate Payer” also apply to OneNet clients (direct or indirect payers). OneNet, Procura, and UnitedHealthcare and its affiliates are not OneNet Payers.
OneNet Customer, Injured Worker, Insured, Claimant, Primary Participant or Participant: 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 guide. OneNet Customers, Primary Participants or Participants include the qualifying injured worker, subscriber, employee, insured, claimant policyholder or other person who, through their direct or indirect Agreement with OneNet, is eligible to access network health care providers.
Property and Casualty Benefit Plans: Workers’ Compensation Benefit Programs and Auto Liability services as defined by a federal or state entity.
Utilization Review: Utilization management or utilization review is the use of managed care techniques such as prior authorization that allow 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 usual and customary or reasonable 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.
Health care providers are physicians, health care practitioners, hospitals and facilities whose Agreement with UnitedHealthcare includes participation in the Property and Casualty Benefit Plan known as 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/or 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.
Workers’ Compensation and Auto Liability Networks, also referred to as a Property and Casualty Benefit Plan, is limited to employers and administrators contracted with Procura Management, Inc. (Procura), an Optum company.
OneNet is a network of physicians, health care practitioners, hospitals and ancillary facilities used for work- related illness and injury and/or medical services related
to an auto liability claim. It serves workers’ compensation programs and auto liability insurers administered by employers and third party administrators.
Procura Management, Inc. contracts directly or indirectly with employers, carriers and/or administrators to provide access to participating care providers at negotiated rates. Some of the advantages you may see as a participating care provider include the following: