One page, one explanation. Everything you need to understand OpenNetworks — from the plain-language version to the operational detail your billing team will ask about.
Direct healthcare contracting lets an employer and a provider agree on rates and terms directly, without an insurance carrier setting the price in between.
OpenNetworks is the technology platform that makes this practical at scale: providers publish their own rates and terms, purchasers (employers, TPAs, and brokers) choose which providers to include in a custom network, and OpenNetworks handles the claims processing and repricing behind the scenes — using each side's existing systems and workflows. Purchasers pay a flat fee per employee, per month. OpenNetworks is not an insurer, does not hold risk, and does not take a cut of savings.
Providers publish rates and terms based on their own market position — no one negotiates on their behalf.
Employers and TPAs choose providers and assemble a custom network suited to their population.
Members use the network; claims are captured, repriced, and routed on the agreed terms.
Purchasers and providers both have visibility into rates and claims — no asymmetry, no surprises.
Providers determine what programs, rates, and terms to offer through OpenNetworks — including payment rules, pre-authorization thresholds, and audit rights.
Purchasers browse available providers and rates when assembling a network tailored to their organization's requirements.
Selection is based on the provider's published rates and terms matched against the purchaser's specific needs.
Providers verify eligibility easily at point of service, just as they would with any standard network.
No new clearinghouse or system required — providers track claim status through processing, decisions, and appeals as usual.
Claims are repriced per the agreed contract terms and passed to the purchaser or the purchaser's TPA.
The purchaser or TPA completes adjudication per the stated contract terms and submits Form 835 to the provider and OpenNetworks.
The employer or TPA pays the provider directly; the employee pays their cost-sharing balance.
Provider network management is the ongoing work of selecting, contracting with, and monitoring the providers included in a health plan's network. On OpenNetworks, purchasers manage this directly — choosing providers from the platform and adjusting the network as their needs change, rather than accepting a fixed panel from a carrier.
Reimbursement management is the process of applying the correct payment rate and terms to each healthcare claim. OpenNetworks automates this by matching every claim to the contract terms already agreed between the purchaser and provider, so payment amounts are consistent and predictable.
Claims repricing adjusts a submitted claim to reflect the agreed contract rate rather than a provider's standard billed charge. OpenNetworks reprices claims automatically as part of the adjudication cycle, using the rates and terms set directly between purchaser and provider.
A self-funded employer selects individual providers or provider groups from OpenNetworks based on published rates and terms, assembling a network sized and shaped to their own employee population — rather than accepting a standard carrier network.