CurrentHealthPartnersPolicy N/A

HealthPartners Atlas Individual Policy

Governs the rights, obligations, benefits, renewal, and grievance procedures for enrollees under the HealthPartners Atlas Individual Policy; applies to individual enrollees and their enrolled dependents.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Atlas Individual Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for certain non‑emergent services; initial non‑urgent decisions are made within 14 calendar days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysPrior auth (non‑urgent)

72 hoursPrior auth urgent/expedited

AnnualPolicy renewal

90 daysContinuity of care period

30 daysGrievance decision timeframe

Coverage Principles and Administrative Rules

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Summary Coverage Criteria

High-level coverage stance and where details live:

Policy provides Network Benefits for services by participating Network Providers and also provides Out-of-Network Benefits for services by Out-of-Network Providers; specific payment amounts, limits and exclusions are described in the attached Benefits Chart.

Benefits Chart is incorporated into and made a part of this Policy and describes amounts of payments and limits for coverage provided under this Policy; refer to the Benefits Chart for the amount of coverage applicable to a particular benefit.

When non‑participating providers are used, benefit payments are not based on billed charges but on the policy fee schedule or usual and customary charge; the enrollee may be liable for amounts above that calculation.

Second opinions from another provider are covered if the enrollee questions a medical decision.

Medical Necessity and Coverage Determination

Eligible services are covered only when medically necessary; determinations and authorizations follow established medical policies and timelines:

Service is covered only when medically necessary for the proper treatment of an Insured.

Coverage determinations of medical necessity, restrictions on access and appropriateness of treatment are made by medical directors or their designees based on established Coverage Criteria (Medical Policies).

Coverage determinations for prescription drugs are based on requirements established by the HealthPartners Pharmacy and Therapeutics Committee and are subject to periodic review and modification.

Certain non‑emergent services may require Prior Authorization; a list of services requiring Prior Authorization is available on the member portal (myHealthPartners).

When Prior Authorization is required, initial non‑urgent determinations will be made within 14 calendar days after receipt of all information reasonably needed to make the decision; this period may be extended an additional 14 calendar days.

When Prior Authorization for an urgent service is required, initial determinations will be made within 72 hours after receipt of all information reasonably needed to make the decision.

Administrative coverage and process criteria

Processes, timelines, and member rights for complaints, grievances, independent external review, and claims submission.

Complaints: Members may call Member Services (888-360-0622) to submit a complaint; Member Services will investigate and notify the member or authorized representative of the outcome.

Standard Grievance

You or your Authorized Representative must file a written request for review within three years of the adverse decision and include comments, documents, records and other information relating to the grievance.
We will acknowledge receipt within five business days and provide access to relevant documents at no charge upon request.
You may appear in person or by teleconference before the grievance committee; you will be notified of the meeting at least seven days in advance.

Coding, Drug Governance, and Decision Timeframes

Prescription drug coverage governancemixed

Coverage determinations for Prescription Drugs are based on Pharmacy and Therapeutics Committee requirements.

Prior Authorization decision time (non-urgent)

Initial decision timeframe (non-urgent)14 calendar days from receipt of all reasonably needed information (may be extended an additional 14 calendar days)

Urgent/expedited decision timeframe72 hours from receipt of all reasonably needed information for urgent services

Provider notification for approvalsIf approved, HealthPartners notifies the Health Care Provider by telephone and may send written verification

Provider notification for denialsIf denied, HealthPartners notifies the Health Care Provider and hospital by telephone within one working day and sends written verification with denial details

Where to find list of services requiring Prior AuthorizationmyHealthPartners account at healthpartners.com or call Member Services

Provider Responsibilities and Appeal Actions

Note

Second Opinion Coverage

If a member questions a decision about medical care, HealthPartners covers a second opinion from another Provider when requested. Members may seek a second opinion from an appropriate network Provider; refer members to their myHealthPartners account or Member Services for available options and any program details.

Second opinions are covered when requested by the enrollee.
Members can access information and submit requests via myHealthPartners or by contacting Member Services.

Prior Authorization

Prior Authorization and Determination Timelines

Certain non-emergency services require Prior Authorization. Providers should check the list of services requiring Prior Authorization on healthpartners.com or the member's myHealthPartners account. HealthPartners' medical directors or their designees make medical necessity and authorization determinations based on established Medical Policies (Coverage Criteria Policies).

No referral is required for in-network or emergency services, but Prior Authorization may still be required for specific non-emergent services.
Initial Prior Authorization determinations are made within 14 calendar days after all information reasonably needed is provided. This may be extended by an additional 14 calendar days when necessary.
For urgent services requiring Prior Authorization, initial determinations are made within 72 hours after all information reasonably needed is provided.
If approved, the Provider will be notified by telephone and may receive written verification. If denied, the Provider and hospital (if appropriate) will be notified by telephone within one working day and will receive written confirmation with denial details.

Denial Risk

Provider Discussion for Denied Claims

When a clinical coverage determination results in a denial, the member's Provider may discuss the decision with the clinician who reviewed the request. The Provider should follow instructions on the denial notice or contact Member Services for assistance in obtaining a clinician-to-clinician discussion.

Provider-to-clinician discussion is available for denials based on clinical coverage criteria.
Refer to the denial notice or contact Member Services for next steps and contact information.

Note

Expedited Grievance for Urgent Services

Members and their Authorized Representatives may file a grievance if not satisfied with a complaint resolution or an adverse decision. For urgently-needed services where standard grievance timeframes could cause adverse health effects, an expedited grievance may be requested verbally or in writing by the member or the member's Provider.

Standard grievance: written request must be filed within three years of the adverse decision. HealthPartners will acknowledge receipt within five business days and issue a decision within 30 calendar days of receipt.
Expedited grievance: may be requested for urgently-needed services verbally (call Member Services) or in writing. HealthPartners will review as expeditiously as possible and notify the outcome within 72 hours.
An urgent internal and external review may occur simultaneously when applicable.

Defined Terms

Defined Terms (general)Certain capitalized words have special meanings and are defined in 'Definitions' or within applicable sections; additional capitalized terms are defined in the Benefits Chart.

'This Policy'Refers to the Individual Policy (the Enrollee's evidence of coverage) issued by HealthPartners Insurance Company and incorporates the Benefits Chart, amendments, and enrollment form as the whole agreement.

Interpretation of gendered languageUse of any gender-specific terms refers to sex assigned at birth.

Where definitions appearDefinitions are located in the 'Definitions' section and within applicable sections and the Benefits Chart.

Usual and Customary Charge

Usual and Customary Charge (definition)The maximum amount allowed considered in payment calculation for certain Out-of-Network services; consistent with reasonable fees charged by similar providers in the same geographic area.

Method of determinationDetermined in order of availability: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if not on Medicare; or 3) a commercially reasonable rate.

Member liabilityMembers may be liable for amounts above the Usual and Customary Charge; such amounts do not apply to the Deductible or Out-of-Pocket Limit.

Network Provider

Network Provider (definition)A participating licensed physician, dentist, mental health/substance use disorder or other health care provider, facility, or pharmacy listed in the Network directory that has an agreement with HealthPartners to provide services.

Network directory and accessNetwork Providers are viewable free of charge via myHealthPartners account; Member Services can assist locating in-network providers.

Designated Physicians/Providers/FacilitiesCertain services require use of designated physicians, providers, or facilities (listed via Member Services or website) to receive Network Benefits.

Continuity of Care

Continuity of Care entitlementWhen a Provider leaves the Network, members may continue to receive services considered Network Benefits until the earlier of 90 days from contract termination or until the member is no longer a continuing patient, subject to qualifying conditions.

Qualifying conditionsIncludes ongoing treatment for a serious complex condition, scheduled nonelective surgery (including related care), ongoing institutional/inpatient care, terminal illness as defined by Social Security Act section 1861(dd)(3)(A), and pregnancy (services may continue through postpartum care if in second or third trimester).

Exclusions/termination of benefitContinuity benefits may be discontinued if the Provider is terminated for misconduct; additional continuation may apply if material provided included a non-participating Provider until plan year end.

Authorized Representative

Authorized Representative (definition)A person acting on a member's behalf for claims, complaints, or grievances after completion of the Appointment of Authorized Representative form.

How to designateComplete, sign and return HealthPartners' 'Appointment of Authorized Representative' form (available on myHealthPartners or upon request) specifying the extent of authority.

Limits without authorizationIf a third party issues a complaint or grievance and HealthPartners does not have the authorization form, HealthPartners will investigate and respond directly to the member.

IRO (Independent Review Organization)

Independent Review Organization (IRO)An external reviewer that conducts independent review of an Adverse Determination when requested by the enrollee or representative as part of the external review process.

Notice and participationUpon receipt of a request, the IRO must provide immediate notice of the review to the complainant and HealthPartners; both parties have opportunity to present information to the reviewer.

Timeline for determinationThe IRO will notify the enrollee and HealthPartners of its determination within 45 calendar days (or within 72 hours if the independent review is expedited) of receipt of all needed information.

Subrogation / Reimbursement

Subrogation / Reimbursement (scope)HealthPartners has the right to reimbursement and subrogation from any third-party recovery (including tortfeasors, uninsured/underinsured motorist, medical payments, umbrella coverage, or other sources) for payments made to treat injury or illness caused by another party.

Member obligationsMembers must promptly inform HealthPartners in writing of any potential or pending third-party claim and cooperate fully; recovered amounts must be held in trust for HealthPartners to the extent of its subrogation claims.

Enforcement and limitationsHealthPartners may pursue claims in the member's name or its own name; rights may be subject to state law and are not reduced by the member's attorney fees or costs of collection; disputes over 'made whole' status may be resolved judicially.