CurrentHealthPartnersPolicy N/A

Group Certificate / Certificate of Coverage

This document is a Group Certificate of Coverage from HealthPartners Insurance Company describing rights, responsibilities, benefit payment rules, grievance procedures, nondiscrimination and enrollment/identification procedures for enrollees under a Wisconsin small employer plan.

Policy Summary

PayerHealthPartners

PolicyGroup Certificate / Certificate of Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionCall Member Services for estimates of eligible expense and CPT code information prior to a procedure.

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

U&COut-of-network payment basis described

31 daysGrace period for enrollment payment

90-dayContinuity-of-care transition period

14 daysStandard prior auth timeline

$300Pediatric dental predetermination threshold

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Newborn automatic coverage

Coverage, Enrollment, Continuation, and Claims Rules

ERISA Rights and Plan Information

For group health plans subject to ERISA, federal law requires this Statement of ERISA Rights and specific plan information. This section summarizes participants' rights, fiduciary duties, appeal and claim procedures, and where to obtain plan documents and assistance.

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Statement of ERISA Rights

This Statement of ERISA Rights applies to group health plans that are subject to ERISA. Your Group Health Plan Sponsor can tell you whether your plan is subject to ERISA.
As a participant in this Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). These rights are in addition to any rights you may also have under state law.

Receive Information about Your Plan and Benefits

Examine, without charge, at the plan administrator's office and at other specified locations, all documents governing the plan, including insurance contracts and collective bargaining agreements, and where applicable, copies of the latest annual report (Form 5500).
Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan (insurance contracts, collective bargaining agreements, latest Form 5500, and updated summary plan description). The administrator may make a reasonable charge for the copies.
Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage (COBRA)

You and your dependents may be entitled to continue health care coverage if there is a loss of coverage under the plan as a result of a qualifying event. You may have to pay for such coverage. See the section titled 'Continuation of Group Coverage' for rules governing your COBRA continuation coverage rights.

Prudent Actions by Plan Fiduciaries

Fiduciaries who operate the plan must act prudently and in the interest of plan participants and beneficiaries. No one may discriminate against you to prevent you from obtaining a benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefit is denied or ignored in whole or in part, you have the right to know why, obtain copies of non-privileged documents relating to the decision, and appeal any denial within certain time schedules.
If you request copies of plan documents or the latest annual report and do not receive them within 30 days, you may file suit in Federal court. The court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive them, unless the failure was for reasons beyond the administrator's control.
If you disagree with the plan's decision regarding rights (including qualified domestic relations orders or medical child support orders), you may seek assistance from the U.S. Department of Labor or file suit in Federal court. The court will decide who should pay court costs and legal fees.

Assistance with Your Questions

If you have questions about the plan, contact the plan administrator (your employer). For questions about this statement or your ERISA rights, contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.
You may obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

Specific Information About the Plan

The federal government requires the following plan information be furnished: Name of the Plan, Address of the Plan, IRS Employer Identification Number, Plan Identification Number, Plan Year/Plan Fiscal Year end, Plan Administrator, Agent for Service of Legal Process, Named Fiduciary, Funding, Network Providers, Contributions, Employment Waiting Period, Eligible Classes, and Contact for Continuation of Coverage Notices. Refer to your employer's plan documents for the specific entries for many of these items.
For this Certificate's benefits: HealthPartners Insurance Company is the Agent for Service of Legal Process and the Named Fiduciary. The Plan Administrator and other plan-specific details are provided in your employer's plan documents. This Certificate is fully insured under applicable law and network providers are the HealthPartners Network.

How to Enforce and Appeal

If a claim is denied, you have the right to appeal under the plan's claims and appeals procedures. You have the right to obtain reasons for denial and copies of non-privileged documents relevant to the decision. Specific timeframes and steps for filing appeals are set out in the claims provisions of this Certificate.

Document Availability and Charges

You may examine plan governing documents and obtain copies upon written request. The plan administrator may charge a reasonable fee for copies. Contact your plan administrator or employer for details on how to request documents.

Coding, Payment Basis, and Key Deadlines

Pre-authorization coding inquirymixed

CPT (ask provider)

Members are instructed to ask their provider for the CPT code to get an estimate from Member Services.

Timelines and administrative rules (no specific billing codes provided in this excerpt)mixed

No codes listed

Coverage basismixed

No codes listed

Not specified in this segmentmixed

No codes listed

Usual and Customary determination order

Determination order1) percentage of the Medicare fee schedule; 2) a comparable schedule if service not on Medicare fee schedule; 3) a commercially reasonable rate — used in this order depending on availability

PurposeDefines the Usual and Customary Charge as the maximum amount considered for payment for Out‑of‑Network services

Member liabilityMember may be liable for amounts above the Usual and Customary Charge, which do not apply to the deductible or out‑of‑pocket limit

Pediatric dental predetermination threshold

Predetermination threshold$300 (recommended when expected dental Charges for a pediatric course of treatment are $300 or more)

Provider & Member Actions — Prior Authorization, Claims, and Recovery

Note

Pre-procedure member/provider inquiry

Members or providers may call Member Services (number on ID card) to request the eligible expense allowed based on the Usual and Customary charge and to obtain an estimate; providers should give the Current Procedural Terminology (CPT) code and estimated charge when contacting Member Services.

Ask the Provider for the CPT code and estimated charge before calling Member Services.
Member Services will provide the eligible expense allowed based on Usual and Customary charges.

Prior Authorization

Prior Authorization process and timelines

When Prior Authorization is required for non-emergent services, the physician coordinates the authorization; initial determinations are made by medical or dental directors (or designees) within 14 calendar days after all information is provided for standard requests, or within 72 hours for urgent requests, with authorization notices sent to the provider by phone and written verification for denials.

Physician must coordinate and submit all information needed for authorization.

Defined Terms Used in This Certificate

Capitalized terms

Defined capitalized termsCertain capitalized words have special meanings defined in the Definitions section or in the Benefits Chart

Interpretation noteUses of gender‑specific terms refer to sex assigned at birth (policy language guidance)

Usual and Customary Charge

DefinitionUsual and Customary Charge is the maximum amount allowed considered for payment for Out‑of‑Network services

Determination methodDetermined by comparing charges for similar services adjusted to the geographic area and using: 1) Medicare fee schedule percentage; 2) comparable schedule; or 3) commercially reasonable rate

Member cost impactUsual and Customary may be less than billed charge; members may owe the difference for services not covered by the No Surprises Act

Policy Summary

PayerHealthPartners

PolicyGroup Certificate / Certificate of Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionCall Member Services for estimates of eligible expense and CPT code information prior to a procedure.

SourceLink

On This Page

Required documentationDescription of procedures, estimate of Dentist's Charges, and appropriate X‑ray should be filed by the Dentist in writing

Decision timelinesInitial determination within 10 business days (routine) or within 72 hours (urgent) after all reasonably needed information provided

Medical/dental necessity requirement

Coverage conditionEligible services are covered only when Medically Necessary or Dentally Necessary for the proper treatment of an Insured

Decision authorityMedical or dental directors, or their designees, make coverage determinations and final authorizations for certain Covered Services

Basis for determinationsCoverage determinations are based on established Coverage Criteria Policies subject to periodic review

Continuation duration thresholds

Standard maximum continuation18 months for termination or reduction in hours (typical qualifying events)

Disability extensionMay be extended to 29 months for a disabled person (notify sponsor within 60 days)

Second qualifying event / other eventsMay extend to 36 months for certain events (e.g., second qualifying event, death, divorce) depending on group size and event

Claims submission deadlines

Notice of claimWritten notice of claim must be given within 20 days after any Charges incurred

Claim form / proof if form not receivedIf claim form not received within 15 days after notice, submit written proof documenting date/type of service, provider name, and itemized charges

Itemized bills deadlineItemized bills must be submitted within 90 days after date services were first received (plan submission for Covered Services within 15 months)

Standard initial determination: within 14 calendar days after all information received (may extend 14 days).

Urgent initial determination: within 72 hours after all information received.

If authorized, provider will be notified by telephone; denials are notified by phone within one working day and followed by written verification.

Prior Authorization

Pediatric dental predetermination

For pediatric dental courses of treatment expected to total $300 or more, dentists are recommended to submit a written predetermination (procedures, estimate of charges, and appropriate X‑rays); routine predetermination decisions are made within 10 business days and urgent predeterminations within 72 hours, and approvals/denials are communicated to the dental provider.

Submit a course of treatment description, estimate of the Dentist's charges, and relevant X‑rays in writing when charges are $300 or more.
Routine predetermination initial determination: within 10 business days after all information received.
Urgent predetermination initial determination: within 72 hours after all information received.
Predetermination approvals notified by telephone; denials notified by phone within one working day and followed by written verification.

Documentation Required

Provider discussion and authorization

If a claim or predetermination is denied based on clinical coverage criteria, the provider may discuss the decision with the clinician who reviewed the request; final authorization decisions for certain covered services are made by the medical or dental directors or their designees.

Provider should refer to the denial notice or call Member Services for contact information to discuss the clinical review.
Final authorization for certain services is made by medical/dental directors or designees based on established Coverage Criteria Policies.

Documentation Required

Coordination of Benefits and Right of Recovery

The Plan may seek recovery or payment from other payers and has a right of recovery if payments were made by another plan that should have been paid by this Plan; providers and enrollees must cooperate in billing no‑fault and workers' compensation insurers.

HealthPartners may pay the other organization and treat that amount as if it were a benefit under this Plan.
Right of recovery exists if HealthPartners' payments exceed the amount that should have been paid under COB rules.
You must cooperate with the program to bill allowable no‑fault and workers' compensation claims to the appropriate insurers.

Documentation Required

Medicare Coordination (provider-facing)

Medicare coordination follows federal Secondary Medicare Payer rules; benefits under this Certificate are not intended to duplicate Medicare and HealthPartners may require consents, releases, assignments and may reduce Certificate benefits by amounts payable under Medicare.

Consult the Employer to determine whether Medicare is primary in a given situation.
Insureds must complete and submit consents, releases, assignments and other documents as requested to obtain Medicare reimbursement.
HealthPartners may reduce Certificate benefits by amounts available under Medicare before calculating Plan benefits.

Documentation Required

Claims submission and proof of loss (provider instructions)

Submit written notice of claim within 20 days of incurred charges; if a claim form is not received within 15 days after notice, submit written proof documenting date/type of service, provider name, and itemized charges; itemized bills must be submitted within 90 days (or as soon as reasonably possible, but no later than one year, with plan submission for covered services within 15 months) or benefits may be denied.

Notice of claim: written notice within 20 days of any covered charges.
If claim form not furnished within 15 days of notice, submit written proof with date/type of service, provider name and itemized charges.
Itemized bills (proof of loss) due within 90 days after service; plan must receive bills for covered services within 15 months or they can be denied except in limited circumstances.

Billing Rule

Payment to providers option

HealthPartners may, at its option, pay all or part of benefits directly to the provider or hospital; for dependents covered under a court order, payments may be made directly to the provider if HealthPartners is informed of the order.

Payments may be sent directly to the facility or provider rather than to the enrollee.
For dependent claims covered by a court order, notify HealthPartners so payments can be made directly to the provider.

Actively at Work

MeaningActively at Work is the time period when an Enrollee is customarily performing all regular duties of their occupation at their usual place of employment

Temporary absencesAn Enrollee is considered actively at work if absent solely for vacation or holiday provided they were actively at work on the last regular work day

Effect on Effective DateAn employee must be Actively at Work on the Effective Date or coverage will be delayed until the date the employee returns to work (with certain exceptions for health status)

Authorized Representative

Who may actAuthorized Representative is anyone acting on your behalf in connection with an initial claim or to issue a Complaint or Grievance

Designation processYou must complete and sign the Appointment of Authorized Representative form and return it to HealthPartners to designate an Authorized Representative

PHI disclosureThe authorization permits HealthPartners to disclose your personal health information to the Authorized Representative per applicable law

Eligible Dependents

Included personsEligible Dependents include a spouse and children (natural, adopted, placed for adoption, legal guardianship, qualified medical child support orders, and stepchildren)

Age limitDependent children generally eligible up to age 26, with specific exceptions (e.g., certain military call‑ups or student status) described in the Definitions

Disabled child rulesA Disabled Child may continue coverage beyond limiting age if approved in writing and periodic reviews apply

Provider / Physician

Provider (Health Care Provider)Any licensed non‑physician (excluding naturopathic providers) lawfully performing medical or dental services within scope of license who renders direct patient care

PhysicianA licensed medical doctor or doctor of osteopathy lawfully performing covered medical or surgical care within licensing limits

Scope noteProviders render services in accordance with applicable governmental licensing privileges and limitations

Confidentiality / PHI use

ComplianceHealthPartners complies with state and federal laws governing confidentiality and use of protected health information (including HIPAA)

Permitted usesPHI may be used for claims processing, subrogation, quality assessment, accreditation, credentialing, case management, utilization management, disease management, premium rating, employer reporting (when certified), auditing, legal services, and other operations as permitted by law

Provider releaseWe may use PHI when your Provider releases health information to us according to state law

Enrollment Date / Insured / Provider

Enrollment DateThe first day of coverage under this Certificate or the first day of the Waiting Period, if earlier

Insured / EnrolleeAn Enrollee (Insured) is a person eligible through the Group Health Plan Sponsor whose application is accepted for coverage under this Certificate

Provider definition noteGroup Health Plan Sponsor is the purchaser of group medical coverage that covers the Enrollee and Eligible Dependents

Physician

DefinitionPhysician means a licensed medical doctor or doctor of osteopathy lawfully performing a medical service in accordance with licensing privileges and limitations

ScopePhysicians render medical or surgical care as covered in this Certificate

Relation to Health Care ServicePhysician is one category within 'Health Care Service' which includes procedures, supplies, and DME

Adverse Determination

DefinitionAdverse Determination is a denial, reduction, termination, failure to pay, or rescission of coverage or benefit payment

IncludesDeterminations based on utilization review, investigational/experimental treatment findings, and rescissions of coverage

ConsequencesAn adverse determination may be appealed through the internal Complaint/Grievance process and, in some cases, external review

Coordination of Benefits

PurposeCoordination of Benefits (COB) governs payment when an Enrollee has coverage under more than one plan to avoid duplicative payment

Order of benefit determinationOrder‑of‑benefit determination rules decide whether this Plan pays before or after another plan; this Plan's benefits may be reduced when another plan determines benefits first

Member obligationsEnrollee must provide facts and authorizations needed to coordinate benefits; failure to provide may delay or deny claims

Effective Date

Effective DateCoverage begins on the date shown on the information that accompanies your initial identification card and is contingent on eligibility rules

Effect of Active WorkEmployee must be Actively at Work on the Effective Date or coverage will be delayed until they return to work, except where delay is due to health status/condition/disability per policy

Identification materialsThe Effective Date is reflected on ID card and accompanying enrollment information

Special Enrollment Period

Triggers for special enrollmentLoss of other coverage, marriage, birth, adoption or placement for adoption, exhaustion of COBRA, or eligibility for Medicaid/CHIP assistance can trigger a Special Enrollment Period

Timing for dependent special enrollmentDependent special enrollment period is not less than 30 days and begins on the later of coverage availability or the marriage/birth/adoption date

Medicaid/CHIP timingYou or your dependent may enroll within 60 days after termination of Medicaid/CHIP coverage or within 60 days after becoming eligible for assistance under such programs

Totally Disabled

Definition (Totally Disabled)Totally Disabled describes inability to engage in duties of occupation (initial two years) and thereafter inability to engage in any employment for which one is reasonably qualified

Extension of coverage on policy terminationIf Group Policy terminates while you are Totally Disabled and you were covered immediately prior, coverage under this Certificate will be extended until earliest of: disability ends, last day of current contract year, or when lifetime maximum benefit is reached

Payment responsibilityGroup Health Plan Sponsor may require the Enrollee to pay all or part of the premium to continue coverage during such extension

Continuation of Group Coverage

Right to elect continuationYou have 30 days to elect continuation of group coverage; the 30‑day period begins on the date coverage would otherwise terminate or the date written notice is mailed, whichever is later

Election mechanicsYou must apply in writing to your Group Health Plan Sponsor (not HealthPartners) and pay the first monthly payment within 45 days of election; thereafter payments due at start of each month

Notice requirementsYou or your dependents must notify the Group Health Plan Sponsor within 30 days of divorce, legal separation, change in dependent status, or second qualifying event