Jan 1, 2020
  • Applicable to all states except NC

Applicable to all states e...
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Bills Process - 2020 UnitedHealthcare Administrative Guide

Bill Submission

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 carrier or administrator 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, please call the injured workers’ employer, workers’ compensation carrier, auto liability insurer or TPA for instructions on how to submit a bill.

Complete Bill Requirements

Your bills may not be processed if you omit:

  • Items identified under the Claims and Encounter Data Submissions section of the UnitedHealthcare Guide
  • Taxonomy code 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.

Bill Review Procedures

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

Tips to Expedite Bill Processing:

  • 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 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 Bills

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

Payment for covered services is the least of:

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

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

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

Bills Subject to Bill Edits

For bills that are 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 in bill reconciliation by having priced bills match the originally submitted bills.

Allocation of Global Pricing to the Bill Line Level 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 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.

Example of Global Pricing Distributed Across Lines Example of Global Pricing Distributed Across Lines

Whenever such allocations occur, OneNet clients are instructed that 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.

Bill Inquiries

OneNet can verify our receipt, the OneNet contracted pricing and the date returned to our client. We cannot verify payment status nor any 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 injured worker’s employer, workers’ compensation carrier, auto liability insurer or TPA.

The fastest way to to locate a OneNet PPO pricing sheet is to access UHCprovider.com > Link > 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 employer, carrier, insurer or administrator 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, please call 877-461-3750.

Bill Payment

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 care provider. We send the priced bill 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 may not 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 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 utilize.

OneNet clients are required to adjudicate and pay clean bills within 30 days of bill pricing, or within applicable state or federal guidelines. If the OneNet workers’ compensation or auto liability client fails to adjudicate and pay a bill within this time period, the care provider may, at their discretion, request the least of the full charges, or in the case of workers compensation, the applicable state or federal maximums that apply. In these instances, the OneNet payer will pay the bill 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 bill payment. Exceptions to the right to request full billed charges for failing to offer timely payment is as follows:

  • OneNet, Procura or the payer will notify the care provider after receipt of the bill, but before the expiration of the bill payment’s time limit, if the bill is denied, missing required information, is deficient in some way or being held to determine auto or workers’ compensation compensability.

The OneNet client 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 contract/benefit plan,
  • Services found to be non-payable

Submit bills with non-payable services to the injured worker or claimant’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 claimant directly.

Non-Covered Services and other Participant Protocols

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:
    • Notify the participant at the time of service that the charge may not be compensable under their workers’ compensation/auto injury or illness.
    • Injured worker or claimant agrees at the time of service to be responsible for the charge.
    • You have written consent from the patient to perform the service.
    • Bill is submitted to the workers’ compensation/ auto and health insurance, and the service is not compensable.
  • The 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 or OneNet clients may conduct their own audits of hospital bills. 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 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 bill 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.

Bill Appeals (Post Service)

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

Email direct pricing appeals for Procura bills to proppo@procura-inc.com, or call 877-461-3750. Questions about a state rate allowance should be directed to the client identified on the EOR. Submit bill pricing appeals within 12 months of the bill process date, or within applicable state and federal time frames.

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, include 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 payer, please contact Procura at proppo@procura-inc.com or call 877-461-3750.

Overpayments

Direct all questions or refunds of overpayments to the applicable payer using the phone number listed on the 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.

Please include appropriate documentation that outlines the overpayment, including the patient’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 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.

Bill Pricing Adjustments of $5.00 or Less

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 $5.00 or less is not adjusted.

Appeals, Grievances or Complaints

OneNet injured workers and claimants direct appeals or grievances to their payer or administrator. 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 care provider, the payer or administrator refers the information to UnitedHealthcare and OneNet. If you, as the care provider, are disputing the state or services deemed not part of the workers’ compensation/auto illness or injury, please contact the client at the number identified on the EOR. For all network-related concerns, please contact Procura at 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.

Online Services

Care providers can view pricing sheets by using the UHCprovider.com > Link > 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, you may not use many of the web tools on UHCprovider.com.

Some unavailable tools include:

  • Eligibility or benefits
  • View patient personal health records
  • Submit advance notifications
  • View your OneNet fee schedule
  • Claim Estimator
  • Claim submission
  • Reprint EOBs
  • Electronic Payments and Statements
  • 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.