Providers
Reach new markets
and new members on your terms
OpenNetworks is a technology platform facilitating transparent, predictable, and simple business arrangements between healthcare providers and purchasers such as employers and third-party administrators. OpenNetworks is not another health plan. It’s not a narrow network. It gives you new control over your business.
The Provider Platform
How OpenNetworks is different
How the OpenNetworks Platform Works
1
Providers set their rates and terms based on market demand
2
Providers are available as an option for purchasers to include in custom networks they create based on their specific requirements
3
Providers are selected for each custom network based on their rates and terms
4
Employees access healthcare services using their OpenNetworks ID cards. Providers can easily verify eligibility.
5
Providers submit claims in 837 format and can track the claim status throughout the adjudication process: processing steps, decisions, and appeals
6
OpenNetworks performs claim editing and repricing and passes information along to purchaser or purchaser’s TPA
7
Purchaser or TPA conducts final adjudication according to stated contract terms and submits form 835 to provider and OpenNetworks
8
Employer or TPA pays provider; employee pays cost-sharing balance
How the OpenNetworks Platform Works
1
Providers set their rates and terms based on market demand
2
Providers are available as an option for purchasers to include in custom networks they create based on their specific requirements
3
Providers are selected for each custom network based on their rates and terms
4
Employees access healthcare services using their OpenNetworks ID cards. Providers can easily verify eligibility.
5
Providers submit claims in 837 format and can track the claim status throughout the adjudication process: processing steps, decisions, and appeals
6
OpenNetworks performs claim editing and repricing and passes information along to purchaser or purchaser’s TPA
7
Purchaser or TPA conducts final adjudication according to stated contract terms and submits form 835 to provider and OpenNetworks
8
Employer or TPA pays provider; employee pays cost-sharing balance
How the OpenNetworks Platform Works
1
Providers set their rates and terms based on market demand
2
Providers are available as an option for purchasers to include in custom networks they create based on their specific requirements
3
Providers are selected for each custom network based on their rates and terms
4
Employees access healthcare services using their OpenNetworks ID cards. Providers can easily verify eligibility.
5
Providers submit claims in 837 format and can track the claim status throughout the adjudication process: processing steps, decisions, and appeals
6
OpenNetworks performs claim editing and repricing and passes information along to purchaser or purchaser’s TPA
7
Purchaser or TPA conducts final adjudication according to stated contract terms and submits form 835 to provider and OpenNetworks
8
Employer or TPA pays provider; employee pays cost-sharing balance
Frequently asked questions from healthcare providers
OpenNetworks is an open platform bringing together purchasers seeking transparently-priced healthcare services and healthcare providers willing to deliver those services based on clearly defined terms. Purchasers, including employers with self-funded health plans or aggregate purchasers such as health plans, select and curate custom provider networks from the providers participating on the platform, based on these standardized terms. Purchasers are charged flat, per-employee fees for platform access.
OpenNetworks is a technology platform facilitating transparent, predictable, and simple business arrangements between healthcare providers and purchasers such as employers and third-party administrators. OpenNetworks is not an insurance plan or a third-party administrator (TPA). OpenNetworks does not take on insurance risk.
OpenNetworks charges per employee per month (PEPM) with no hidden fees and no percent-of-savings charges.
OpenNetworks works differently in three key ways:
- It’s transparent. OpenNetworks facilitates business arrangements with fee schedules tied to transparent business rules such as claims editing, utilization management, and audit rights. In addition, providers and purchasers have access to benchmarked pricing data in their local markets, and visibility into claims as they are being processed and paid. OpenNetworks generates revenue through per-employee fees for participating employers, not through other services fees or complicated percent-of-savings arrangements.
- It’s predictable. OpenNetworks makes money through per-employee per-month (PEPM) access fees, not by sharing a portion of “total spend,” “shared cost savings,” or additional service fees which can significantly drive up costs. And, OpenNetworks operates through a cooperative business model. Providers who meet volume thresholds participate in profit sharing.
- It’s simple. It is open to all providers who easily join OpenNetworks: there are no competitive exclusions, gag clauses, or requirements to work with new intermediaries. Providers and purchasers keep their existing business processes, and the OpenNetworks technology makes sure that claims get processed.
No, OpenNetworks is not one fixed network. It is a national platform enabling healthcare providers to deliver unique value propositions based on rates tied to detailed business terms. Self-funded employers can configure customized networks to suit their specific needs. OpenNetworks acts as the “pipes” through which the purchasers and providers agree on their contract terms process claims for the members.
Do you share our belief that healthcare needs more transparency and much less complexity? We’re here to partner with you.
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