ࡱ> '` bjbj{P{P 8p::48T@ ƍƍƍƍCϕH+------$@hPQQƍƍƍƍ++ƍz @Ez/dϞ\$0TQQXT$>B<B  Today s Date: FORMTEXT      Please Check One:  FORMCHECKBOX  Self Funded  FORMCHECKBOX  Indemnity  FORMCHECKBOX  Union Health Fund  FORMCHECKBOX  Workers Comp  FORMCHECKBOX  Consumer Driven Health PlanGroup InformationGroup Name: Exactly as to appear on card FORMTEXT      Group Number: Subject to OneNet approval FORMTEXT      Group Effective Date: Should be the 1st or 15th of month FORMTEXT      Group Address: Include City, State & Zip Code FORMTEXT      County: FORMTEXT      Group Phone:  FORMTEXT      Subsidiary: If yes, attach list of subgroups with addresses.  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCoalition: FORMCHECKBOX  Yes  FORMCHECKBOX  NoGroup contact through Payer only? 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FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Utilization Management Only FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Dental-Discount FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Dental-PPO FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      All Claims (PPO and Non-PPO) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      MultiPlan Network FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      MultiPlan Travel Network FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      WC Network (includes MAPSI, without MAPSI UM) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Other:  FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      OneNet PPO / MAPSI PackagesOneNet PPO Network and CARE U.M. FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      OneNet PPO and MAPSI Networks (includes MAPSI U.M.) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      OneNet PPO and MAPSI Networks only (without MAPSI U.M.) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      OneNet PPO Network, CARE U.M. & MAPSI (includes MAPSI U.M.) FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT      OneNet PPO Network, CARE U.M., MAPSI (without MAPSI U.M.) 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"4"6"8"B"D"F"T"V"j"l"n"x"z"|"ŹŗxgxSg=gx+jhF{oh'O5CJUaJmHnHu&j1~hF{oh'O5CJUaJ jhF{oh'O5CJUaJhF{oh'O5CJaJ%jh'O5CJUaJmHnHu&j}hF{oh'O5CJUaJjh'O5CJUaJh Csh'O5CJaJh'O5CJaJh'Oh-h'O56CJaJhuCJ aJ h7-;CJ aJ h8yQCJ aJ h CsCJ aJ !!"F"T"|""#}mmmmmm$& #$/Ifgd'Okd)}$$Ifl,,  t 6  0,44 lap yt:|"""""""""""""#######*#,#.#8#:#<#>#ٿ٭٩nZnDn+jhF{oh'O5CJUaJmHnHu&j׀hF{oh'O5CJUaJ jhF{oh'O5CJUaJhF{oh'O5CJaJh'O5CJaJh Csh'O5CJaJh'O5CJaJh'O#jhSh'OCJUaJh'OCJaJ#j~hSh'OCJUaJhSh'OCJaJjhSh'OCJUaJhSh'O6CJaJ####.$& #$/Ifgd'Okd$$Ifl4r 8%,@ dl&T t 6 0,44 lapyt:##<#>#$& #$/Ifgd'O>#@#n##.$& #$/Ifgd'OkdM$$Ifl4r 8%, @  dl&T t 6 0,44 lapyt:>#@#n#p#################$岦{h\MB@BUhSh'OCJaJjhSh'OCJUaJhSh'O6CJaJ%jh'O5CJUaJmHnHu&jhF{oh'O5CJUaJh'O5CJaJjh'O5CJUaJhF{oh'O5CJaJh Csh'O5CJaJ%jh'O5CJUaJmHnHu&jhF{oh'O5CJUaJjh'O5CJUaJh'O5CJaJh'O####P$& #$/Ifgd'OHECKBOX  Payer  FORMCHECKBOX  GrpEmail: FORMTEXT      Accounting Contact: FORMTEXT      Phone: FORMTEXT      Contact works for:  FORMCHECKBOX  Payer  FORMCHECKBOX  GrpEmail: FORMTEXT      Contracting Contact: FORMTEXT      Phone: FORMTEXT      Contact works for:  FORMCHECKBOX  Payer  FORMCHECKBOX  GrpEmail: FORMTEXT      Contracts for Self-Funded Groups Sent: FORMCHECKBOX  Directly to Group  FORMCHECKBOX  To Payer OnlySend Contracts To:Name: FORMTEXT      Phone: FORMTEXT      Address: FORMTEXT      Email: FORMTEXT      Who do members call for benefits?Name: FORMTEXT      Phone: FORMTEXT      Who do members call for eligibility?Name: FORMTEXT      Phone: FORMTEXT      Utilization Management InformationDoes OneNet Provide U.M Services FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, please skip to question 61. Is pre-certification mandatory? FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. Is a second opinion required? FORMCHECKBOX  Yes  FORMCHECKBOX  No3. Is outpatient pre-certification required? FORMCHECKBOX  Yes  FORMCHECKBOX  No4. U.M Grid:  FORMCHECKBOX  Group Level  FORMCHECKBOX  Payer Level U.M. Grid Attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No U.M. grid required if U.M. services yes, and must be attached5. Who should electronic U.M. reports be sent to?Name: FORMTEXT      Email: FORMTEXT      If not electronic, address: FORMTEXT      6. If OneNet does not perform U.M., please provide the following: Name of UM Company: FORMTEXT      Phone of UM Company: FORMTEXT      7. Is Large Case Management (LCM) notification required?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. If OneNet does not perform LCM, please provide contact for LCM cases: Name: FORMTEXT      Phone: FORMTEXT      Email: FORMTEXT      9. Does OneNet provide U.M. services for Behavioral Health? (applies to groups with MAPSI only)  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, please move on to question 11 10. MAPSI (Behavioral Health) out patient pre-certification required?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Behavioral Health U.M. CompanyName: FORMTEXT      Phone: FORMTEXT      Additional Notes:  FORMTEXT       FOR COMPLETION BY ONENET PPO ACCOUNT MANGEMENTSales Rep: FORMTEXT      Sales ID: FORMTEXT      Please Use Assignment Table to Determine Sales RepPayer Number: FORMTEXT      ALLMAP Number: FORMTEXT      EDI ClaimsDirect:  FORMCHECKBOX  Participating Providers Only?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoClearinghouse: FORMCHECKBOX  Par and Non Par Providers?  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