CurrentHealthPartnersPolicy N/A

Authorization for Balloon Sinuplasty

This document provides the authorization form and instructions for requesting prior authorization of balloon sinuplasty procedures for HealthPartners members; it affects ordering providers, procedural providers, facilities, and requesters submitting authorization requests.

Policy Summary

PayerHealthPartners

PolicyAuthorization for Balloon Sinuplasty

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed forms to (952)853-8713 and submit clinical documentation to support the authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax (952)853-8713fax number to submit completed forms

UM phone (952)883-6333Utilization Management contact

member, requester, ordering provider, procedural provider, facility, procedureform sections

CT scan post medical treatmentexample required clinical documentation

Medical Necessity and Coverage Criteria

Medical necessity documentation

Clinical documentation required to support medical necessity:

ALL of the following

One or more imaging/supporting studies
- CT Scan post medical treatment
Medical treatment (details of medical treatment)
Duration of symptoms
Primary diagnosis code

Policy Summary

PayerHealthPartners

PolicyAuthorization for Balloon Sinuplasty

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed forms to (952)853-8713 and submit clinical documentation to support the authorization request.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission Instructions and Required Information

Prior Authorization

Submission and contact instructions

Fax completed forms to (952)853-8713. Call Utilization Management (UM) at (952)883-6333 with questions. Submit clinical documentation to support your request. Sign in at healthpartners.com/provider and use the Authorizations and referrals link to check the status of your authorization request.

Documentation Required

Required clinical and coding information

Include only procedure codes requiring authorization and provide primary and secondary diagnosis codes, procedure code(s) with units, proposed date (or TBD), urgency justification if applicable, and supporting clinical documentation (e.g., CT scan post medical treatment, details of medical treatment, duration of symptoms).

Only include codes requiring authorization; other codes will not be addressed
Provide primary and secondary diagnosis codes
List procedure code(s) and unit(s)
Provide proposed date of procedure or indicate TBD
If urgency claimed, provide clinical reason (not scheduling issues)
Attach clinical documentation: CT scan post medical treatment, medical treatment details, duration of symptoms

Provider and Facility Information Requirements

Facility site for procedure

Required facility detailsFacility name, street address, city, state, zip

Billing identifiersBilling tax ID (claim may be rejected if incorrect)

Provider identifiersFacility NPI

Contact methodsFax (for outcome notification) and phone (confidential voicemail required)

Provider information

Ordering provider required fieldsProvider first name, Provider last name, Specialty, NPI, Clinic name, Clinic street address, Clinic city, Clinic state, Clinic zip, Clinic tax ID (claim may be rejected if incorrect), Email, Phone, Fax

Procedural provider required fieldsProvider first name, Provider last name, Specialty, NPI, Clinic name, Clinic street address, Clinic city, Clinic state, Clinic zip, Clinic tax ID (claim may be rejected if incorrect), Email, Phone, Fax

Tax ID importanceClinic/procedural clinic tax ID must be accurate — incorrect tax ID may result in claim rejection

OpenPayer

Authorization for Balloon Sinuplasty

Medical Necessity and Coverage Criteria

Procedure Codes and Units

Submission Instructions and Required Information

Provider and Facility Information Requirements