HealthPartners Group Certificate Coverage Update | OpenPayer
CurrentHealthPartnersPolicy N/A
Group Certificate of Coverage (HealthPartners Insurance Company)
This document is the Group Certificate evidencing health (medical and dental) coverage under a Group Policy issued by HealthPartners Insurance Company; it governs member rights, benefits (network and out-of-network), enrollment, claims, and related administrative terms for covered enrollees and their dependents.
Policy Summary
PayerHealthPartners
PolicyGroup Certificate of Coverage (HealthPartners Insurance Company)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders should obtain prior authorization when required and submit predeterminations for pediatric dental treatments expected to exceed $300.
No material clinical or coverage changes in this revision.
Network & Out-of-Networktypes of benefits described
31 daysgrace period for enrollment payment
$300pediatric dental predetermination threshold
60 daysnewborn automatic coverage
15 monthslatest claim submission
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Coverage, Enrollment, Continuation and Administrative Criteria
Coverage criteria excerpt
Summary of coverage provisions present in this excerpt:
ALL of the following
Network Benefits for services delivered by participating Network Providers (medical and dental).
Out-of-Network Benefits for services delivered by Out-of-Network Providers; eligible expense limited to usual and customary charges and member may be responsible for amounts billed above usual and customary.
Second opinions are covered for Out-of-Network Benefits when a member questions a decision about medical or dental care.
Benefits Chart is incorporated and specifies payment amounts, limits and exclusions for covered benefits.
Coverage is conditioned on timely enrollment payments with a 31-day grace period for initial premium payment after first payment (enrollment payment obligations apply).
Assignment of benefits is restricted under the Certificate (assignment/rights limitations apply).
Medical and Dental Necessity and Authorization
Eligible services require medical or dental necessity and may require prior authorization or predetermination; coverage determinations are made by medical/dental directors based on established Coverage Criteria Policies.
Services covered only when Medically Necessary or Dentally Necessary.
Coverage determinations and final authorizations for certain Covered Services are made by our medical or dental directors or their designees, based on established Coverage Criteria Policies.
When prior authorization is required (non-urgent): initial determination within 14 calendar days if all information provided; may extend an additional 14 days; claimant has up to 45 days to provide requested additional information; if information not received a determination will be made on available information.
When prior authorization is required for urgent services: initial determination within 72 hours if all information provided; if not, claimant notified within 24 hours and given 48 hours to provide information; final notification within 48 hours after receipt or end of time allowed.
Coverage and Administrative Criteria
Coverage decisions and related administrative rules
Services are covered only when Medically Necessary or Dentally Necessary; determinations made by medical or dental directors or designees using established Coverage Criteria Policies.
The plan has rights of reimbursement and subrogation to recover amounts paid from third-party recoveries; members must cooperate and hold recoveries in trust to the extent of subrogation claims and promptly notify the insurer of potential claims.
Coordination of Benefits (COB) applies when an enrollee has coverage under more than one plan; This Plan's benefits may be reduced so that combined payments do not exceed Allowable Expenses; we may obtain needed facts and seek recovery if overpaid.
Members may file complaints via Member Services and proceed to written grievances; standard grievance decided within 30 calendar days and expedited grievances for urgent services decided within 72 hours; appeals and expedited review rights are available and timelines for Independent Review are provided.
Medicare coordination
Medicare coordination and impact on benefits
Medicare may be primary or secondary depending on beneficiary status (ESRD timing, retirees age 65+, disability rules) and employer size; consult the employer to determine primary/secondary status.
We may reduce Certificate benefits by amounts payable under Medicare to the extent permitted by law; charges used to satisfy Medicare Part B deductible will be applied under this Certificate in the order received (largest charges first).
Each Insured must provide consents, releases, assignments and other documents as requested to obtain or assure Medicare reimbursement; all sums payable under Medicare for services provided pursuant to this Certificate shall be payable to and retained by us.
We will not reduce benefits where federal law requires determination without regard to Medicare benefits.
Enrollment and Special Enrollment
Enrollment, Special Enrollment, and Effective Date rules
Coverage begins on the Effective Date shown with the initial ID card; coverage is contingent on meeting the Group Policy eligibility rules and the Actively at Work requirement (coverage may be delayed if not Actively at Work unless absence is due to health status, medical condition, or disability).
You must submit written application to enroll yourself and Eligible Dependents within 31 days of first becoming eligible; newly acquired dependents must be enrolled within 31 days of acquisition for coverage to be effective under Special Enrollment Period rules.
If not enrolled within 31 days, enrollment is permitted during annual open enrollment or a Special Enrollment Period.
Special Enrollment is allowed when prior coverage existed and certain conditions are met (including exhaustion of COBRA, loss of eligibility, termination of employer contributions); enrollment request generally must be made within 30 days of the triggering event or COBRA exhaustion as specified.
Continuation of Group Coverage
Continuation of Group Coverage (COBRA-like) rules by group size
Continuation of group coverage may be available when eligibility ends due to qualifying events (termination, reduction in hours, death, divorce/legal separation, loss of dependent status, initial Medicare eligibility, employer bankruptcy for retirees).
For groups with 20 or more employees: maximum continuation periods vary by qualifying event — generally 18 months for termination/reduced hours; may extend to 29 months for disability extension and to 36 months for many other events (divorce, death, second qualifying events).
For groups with fewer than 20 employees: maximum continuation periods are generally 18 months for most qualifying events, with some variations for disability and bankruptcy-related retiree situations as specified.
Continuation coverage may terminate earlier for events such as plan termination, failure to pay premium (30 days for monthly payments), obtaining other group coverage (subject to pre-existing condition limits), loss of disability status for extended coverage, or termination provisions under this Certificate.
Continuation, extension and termination criteria
Conditions under which continuation or extension of coverage applies and events that terminate coverage.
Election requirements: election must be made within applicable election window (30 days for groups <20, 60 days for groups ≥20 as applicable) measured from termination or mailing of notice; application in writing to the Group Health Plan Sponsor is required; first monthly payment due within 45 days of election; subsequent monthly payments due at the start of each month.
Notice requirements: Enrollee or dependents must notify the Group Health Plan Sponsor within required timeframes of events such as divorce, legal separation, loss of dependent status, or a second qualifying event; notices must be in writing and include names, qualifying event or disability, and date of event.
Extension for disability: if the Group Policy terminates while an enrollee is Totally Disabled and was covered the day prior to termination, coverage may be extended until the earlier of the end of total disability, the last day of the current contract year, or the date Lifetime Maximum benefits are incurred; the Group Health Plan Sponsor may require payment for such coverage.
Replacement while confined: if the Group Policy is replaced while an enrollee is confined for covered services, coverage will be extended for services related to the confinement incurred prior to coverage end and ends at discharge or when benefits are exhausted.
Coding, Timely Filing and Predetermination Thresholds
Pre-service CPT inquiryCPT
No codes listed
Coverage determination basismixed
No codes listed
Timely claim submission rulesmixed
No codes listed
inv-11: pediatric dental predetermination dollar threshold
Recommended predetermination threshold$300 — predetermination recommended when a pediatric dental course of treatment is expected to involve charges of $300 or more.
What to include in predeterminationDescription of procedures, estimate of Dentist's charges, and appropriate x-ray filed in writing by the Dentist prior to treatment.
Initial determination timing (standard)Initial determination within 10 business days when all information reasonably needed has been provided.
Initial determination timing (urgent)Urgent predetermination: initial determination within 72 hours; claimant notified of missing info within 24 hours and given 48 hours to respond.
inv-12: Medical/dental necessity
Provider Requirements, Prior Authorization and Claims Procedures
Prior Authorization
Prior Authorization Required
There is no referral requirement for services delivered by Providers within your Network. Your Physician may be required to obtain prior authorization for certain services. Your Physician will coordinate the authorization process for any services which must first be authorized. You may call Member Services or log on to your 'my HealthPartners' account at healthpartners.com for a list of which services require prior authorization.
Our medical or dental directors, or their designees, make coverage determinations of medical and dental necessity and make final authorization for certain Covered Services. Coverage determinations are based on established Medical and Dental Policies (Coverage Criteria Policies), which are subject to periodic review and modification by the medical or dental directors.
When a prior authorization for a service is required, we will make an initial determination within 14 calendar days, so long as all information reasonably needed to make the decision has been provided. This time period may be extended for an additional 14 calendar days. If we request additional information, you have up to 45 days to provide the information requested. If the additional information is not received within 45 days, a coverage determination will be made based on the information available at the time of the review.
When a prior authorization for an urgent service is required, we will make an initial determination within 72 hours, so long as all information reasonably needed to make a decision has been provided. In the event that you have not provided all information necessary to make a decision, you will be notified of such failure within 24 hours. You will then be given 48 hours to provide the requested information. You will be notified of the benefit determination within 48 hours after the earlier of our receipt of the complete information or the end of the time granted to you to provide the specified additional information.
If the determination is made to authorize the service, we will notify your Health Care Provider by telephone, and may send written verification.
If the initial determination is made not to authorize the service, we will notify your Health Care Provider and Hospital, if appropriate, by telephone within one working day of the determination, and we will send written verification with details of the denial.
Defined Terms Used in This Certificate
inv-22: Defined terms / capitalized words
Capitalized terms definedCertain capitalized words have special meanings and are defined in the 'Definitions' section or within applicable sections of the Certificate.
Additional definitionsAdditional capitalized terms are defined in the Benefits Chart, which is incorporated into the Certificate.
Where to find definitionsSee the 'Definitions' section and the Benefits Chart for the specific meanings of capitalized words used throughout this Certificate.
inv-23: Usual and customary charge
DefinitionThe usual and customary charge is the maximum amount allowed that we consider in calculating payment for non-contracted Out-of-Network services.
Determination method (order)
Policy Summary
PayerHealthPartners
PolicyGroup Certificate of Coverage (HealthPartners Insurance Company)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders should obtain prior authorization when required and submit predeterminations for pediatric dental treatments expected to exceed $300.
Predetermination for pediatric dental: recommended when a course of treatment is expected to involve charges of $300 or more; standard predetermination decision within 10 business days if all information provided; urgent predetermination decision within 72 hours with the same notification timeline for missing information.
External independent review (IRO) is available for adverse determinations if requested within specified timeframes; IRO decisions are binding except for rescissions and have specific completion timeframes (standard and expedited).
Medicare interaction: rules identify when Medicare is primary or secondary based on ESRD, age, disability, employer size and retiree status; benefits under this Certificate are secondary when Medicare is primary and the Insured has enrolled in Medicare.
Dependent special enrollment periods apply for marriage, birth, adoption or placement for adoption with at least a 30-day period; effective date depends on event (marriage: first day of next month; birth: date of birth; adoption/placement: date of adoption/placement; court order: as specified).
Newborns and newly adopted children are automatically covered for the first 60 days; if premium is required you must notify and pay within 60 days to continue coverage; if not timely added, you may add up to one year with payment of required premium (past due premiums may accrue interest).
Medicaid/CHIP special rules (choose one)
You may request coverage within 60 days after loss of Medicaid/CHIP coverage due to loss of eligibility.
You may request coverage within 60 days after becoming eligible for Medicaid/CHIP assistance for premiums for this plan.
Election timing for groups with 20+ employees: you have 60 days to elect continuation beginning on the date coverage would terminate or when notice is mailed; first monthly payment due within 45 days of election; ongoing monthly payments due at the start of each month.
Election timing for groups with fewer than 20 employees: you have 30 days to elect continuation beginning on the date coverage would terminate or when notice is mailed; first monthly payment due within 45 days of election; ongoing monthly payments due at the start of each month.
Notices for continuation must be written, include enrollee and dependent names, qualifying event or disability, and date of event; check with employer for where to send notice; strict time limits apply; Plan will comply with federal law for active military duty call-ups.
Termination events (any of the following ends coverage)
Failure to pay required premium after the 31-day grace period may result in termination (we will send notice of termination if payment not received within the grace period).
When an Enrollee ceases to be eligible under the Group Policy, coverage terminates on the last day of the month in which eligibility ceases (unless continuation is elected).
Coverage for a dependent ends on the last day of the month in which the dependent reaches the limiting age or otherwise no longer meets Eligible Dependent definition (unless continuation is elected).
Coverage terminates when the Group Policy is terminated or the Group Health Plan Sponsor terminates participation.
Rescission for material misrepresentation: if an enrollee knowingly gives false material information, the Certificate may be rescinded with 30 days' advance notice if discovered within two years of enrollment.
Coverage conditionServices are covered only when Medically Necessary or Dentally Necessary for proper treatment of an Insured.
DecisionmakersCoverage determinations and final authorizations are made by our medical or dental directors or their designees.
Basis for determinationsDecisions are based on established Coverage Criteria Policies subject to periodic review and modification by medical/dental directors.
Exceptions for pediatric dental limitsFrequency limits, Deductibles, Copayments, Coinsurance or other maximums for certain pediatric dental services may not apply for specified medical conditions if coverage criteria are met.
inv-13: Proof of loss deadline
Proof of loss (itemized bill) deadlineSubmit itemized bill documenting date/type of service, Provider name and charges within 90 days after the date services were first received.
Exception if not reasonably possibleIf proof cannot reasonably be furnished within 90 days, it must be furnished as soon as reasonably possible but no later than one year after the end of those 90 days.
Latest submission for billsAny bills for Covered Services must be submitted to the plan within 15 months of incurring the loss; bills received after 15 months can be denied unless legally incompetent.
Notice of claim timingProvide written notice of charges within 20 days after any charges incurred, or as soon as reasonably possible.
Providers should consult Member Services or the my HealthPartners portal for services requiring prior authorization.
Initial (non-urgent) determinations: 14 calendar days; may extend an additional 14 days.
Member/Provider response window for requested additional information: up to 45 days.
Urgent determinations: 72 hours; if incomplete, notice within 24 hours and 48 hours to provide information; final notification within 48 hours after receipt or deadline.
Denial Risk
Expedited Review and Appeal Rights
If you want to request an expedited review, or have received a denial of an authorization and want to appeal that decision, you have a right to do so. If your Complaint is not resolved to your satisfaction in the internal complaint and appeal process, you may request an external review under certain circumstances. Refer to the information regarding Complaint and Grievance Procedure in the section of this Certificate titled, 'Disputes and Complaints' for a description of how to proceed.
Members and providers may request expedited review when applicable.
External review is available when internal appeals do not resolve the Complaint and conditions for external review are met.
Note
Provider Discussion on Clinical Denials
If your Complaint involves a claim for medical services that was denied based on our clinical coverage criteria, your Provider can discuss the decision with a clinician who reviewed the request for coverage. Your Provider should refer to the denial notice for information or call our Member Services department for assistance.
Providers may speak with the insurer clinician who reviewed the case to discuss clinical denials.
Refer to the denial notice or contact Member Services at 800-883-2177 for assistance.
Documentation Required
Medicare Coordination and Reimbursement
The provisions in this section apply to some, but not all, Insureds who are eligible for Medicare. They apply in situations where the federal Secondary Medicare Payer Program allows Medicare to be the primary payer of an Insured's health care claims. Consult your Employer to determine whether or not Medicare is primary in your situation.
All sums payable under Medicare for services provided pursuant to this Certificate shall be payable to and retained by us. Each Insured shall complete and submit to us such consents, releases, assignments and other documents as may be requested by us in order to obtain or assure reimbursement under Medicare for which Insureds are eligible. We also reserve the right to reduce benefits for any medical expenses covered under this Certificate by the amount of any benefits available for such expenses under Medicare. This will be done before the benefits under this Certificate are calculated.
The benefits under this Certificate are considered secondary to those under Medicare only when the Insured has actually enrolled in Medicare. The provisions of this section will apply to the maximum extent permitted by federal or state law. We will not reduce the benefits due any Insured where federal law requires that we determine our benefits for that Insured without regard to the benefits available under Medicare.
Insureds must provide consents, releases, assignments and other documents to obtain Medicare reimbursement.
HealthPartners may require assignment of Medicare payments and may reduce Certificate benefits by amounts payable under Medicare, to the extent permitted by law.
Whether Medicare is primary depends on federal Secondary Payer rules and specific employment/enrollment circumstances — consult your Employer.
Billing Rule
Claims Submission and Proof of Loss
Notice of Claims: When a claim arises for services you have already received, you should notify us of the charges incurred in writing within 20 days after any charges incurred or as soon as reasonably possible. Notice given to us by you or on behalf of you at HealthPartners Insurance Company's principal office at 8170 33rd Avenue South, P.O. Box 1289, Minneapolis, MN 55440-1289, with information sufficient to identify you and the service, is deemed notice.
Claim Forms: After receiving notice of claim, we will furnish you a claim form for filing your proof of loss. If you do not receive this form within 15 days after notice is given to us, you should submit written proof which documents the date and type of service, Provider name and itemized charges, for which a claim is made.
Proof of Loss: You must submit an itemized bill which documents the date and type of service, Provider name and charges for Covered Services. Bills must be submitted within 90 days after the date services were first received. If proof cannot reasonably be furnished within 90 days, it must be furnished as soon as reasonably possible but no later than one year after the end of those 90 days. Any bills for Covered Services must be submitted to the plan within 15 months of incurring the loss; bills received after 15 months may be denied unless prevented by legal incapacity.
Time of Payment and Payment of Claims: We will make payment promptly upon receipt of due written proof of loss. We will notify you of our benefit determination if you have any remaining liability within 30 days of receipt of a completed claim. At our option, payments may be made directly to the Hospital or Provider, and may be made directly to a Provider for claims incurred by a dependent if informed of a court order.
Written notice of claim within 20 days of charge or as soon as reasonably possible.
If claim form is not provided within 15 days of notice, submit written proof including date, service type, Provider name and itemized charges.
Itemized bills/proof of loss due within 90 days of service; exceptions allow up to one year in certain circumstances.
All bills must be submitted within 15 months of service; late submissions may be denied unless legally excused.
No legal action until 60 days after bills submitted and within three years after due proof of loss is required.
Determined using, in order of availability: (1) a percentage of the Medicare fee schedule; (2) a comparable schedule if service not on Medicare fee schedule; or (3) a commercially reasonable rate.
Member responsibilityFor services not covered under the No Surprises Act, members must pay any Charges above the usual and customary charge; such excess does not apply to Deductible or Out-of-Pocket Limit.
inv-24: Actively at Work
Core definitionActively at Work means the time an Enrollee is customarily performing all regular duties of their occupation at the usual place of employment or at a required travel location.
Vacation/holiday ruleAn Enrollee is considered actively at work during a vacation or holiday absence if they were actively at work on the last preceding regular work day.
Effective date impactAn employee must be Actively at Work on the Effective Date or coverage for the employee and dependents will be delayed until the employee returns to work, except if absence is due to health status, medical condition or disability.
inv-25: Authorized Representative
Who qualifiesAn Authorized Representative is anyone acting on your behalf in connection with an initial claim or to issue a Complaint or Grievance.
Designation requirementTo designate an Authorized Representative you must complete and sign the 'Appointment of Authorized Representative' form and return it to us; specify the extent of authority on the form.
Authorization purposeThe authorization permits us to disclose your personal health information to the Authorized Representative; without such authorization, a third party's Complaint or Grievance will be investigated and responded to you directly unless permitted by law.
Eligible Dependents scopeEligible Dependents include Spouse, Child (natural, legally adopted, placed for adoption, legal guardian, covered under qualified medical child support order), and stepchild — generally under age 26 unless a Disabled Child.
Disabled Child criteriaA Disabled Child is incapable of self-sustaining employment due to intellectual, mental or physical disability, chiefly dependent on the Enrollee, with disability onset prior to limiting age; Enrollee must request coverage with written proof and approval within 31 days.
Student/active duty exceptionAge-26 limit does not apply to a Child called to federal active duty in National Guard or reserve while attending college full time; medically necessary leaves may extend student coverage with required documentation.
inv-27: Facility / Provider / Physician
FacilityA Facility is a licensed medical center, clinic, Hospital, Skilled Nursing Care Facility or Outpatient care facility lawfully providing medical or dental services within licensing limits.
Provider (Health Care Provider)A Provider is any licensed non-physician (excluding naturopathic providers) lawfully performing a medical or dental service within the scope of their license who renders direct patient care.
PhysicianA Physician is a licensed medical doctor (MD) or doctor of osteopathy (DO) lawfully performing medical or surgical care within governmental licensing privileges and limitations.
inv-28: Waiting Period
DefinitionWaiting Period is the period that must pass before a potential Insured is eligible, under the Group Health Plan Sponsor's eligibility requirements, for coverage under this Certificate.
Relation to EnrollmentThe Enrollment Date may be the first day of coverage or the first day of the Waiting Period, if earlier (see Enrollment Date definition).
inv-29: Adverse Determination
DefinitionAdverse Determination is a denial, reduction, termination of, or failure to provide or make payment for a benefit for listed reasons, and includes a rescission of coverage.
Examples includedIncludes denials based on utilization review or determinations that a benefit is investigational or experimental; rescissions are included but not those retroactive due to nonpayment of premiums.
inv-30: Complaint
DefinitionComplaint is an expression of dissatisfaction by you or your Authorized Representative pertaining to services or benefits provided during enrollment or application for enrollment.
How submittedComplaints may be issued by you or your Authorized Representative; contact Member Services as described in the Certificate for assistance.
inv-31: Experimental Treatment Determination
DefinitionExperimental Treatment Determination is a determination that a proposed treatment has been reviewed and, based on provided information, determined to be experimental, with payment denied.
EffectSuch a determination results in denial of payment for the proposed treatment under the terms of this Plan.
inv-32: Grievance
DefinitionGrievance is a written statement of dissatisfaction by a complainant about provision of services, claims practices or benefit administration during enrollment or application for enrollment on this Plan.
FormalityA Grievance is formal and written, distinguishing it from an initial Complaint or informal inquiry.
inv-33: Plan
Plan definitionPlan is any arrangement that provides benefits or services for medical or dental care, including group insurance or coverage under a governmental plan (with certain exclusions such as state Medicaid plans).
Separate plansEach Certificate or other arrangement for coverage under (1) group insurance or (2) governmental coverage is considered a separate plan; multi-part arrangements may be separate for COB purposes.
inv-34: This Plan
This Plan defined'This Plan' is the part of this Certificate that provides benefits for health care expenses.
Context for useUsed throughout the Certificate when referring specifically to benefits and provisions under this Certificate rather than other plans.
inv-35: Primary Plan/Secondary Plan
Primary vs SecondaryPrimary Plan pays benefits before other plans; Secondary Plan's benefits are determined after other plans and may be reduced by the other plan's benefits.
Multiple plansWhen more than two plans apply, This Plan may be primary to some plans and secondary to others depending on order of benefit determination rules.
inv-36: Allowable Expense
Allowable ExpenseAn Allowable Expense is a necessary, reasonable and customary health care expense covered at least in part by one or more plans covering the person for whom the claim is made.
Services form valueWhen a plan provides benefits as services, the reasonable cash value of each service is considered both an Allowable Expense and a benefit paid.
Non-allowable reductionsAmounts reduced under a Primary Plan because an Insured did not comply with plan provisions are not considered Allowable Expenses (examples: failure to precertify, not obtaining second opinions).
inv-37: Effective Date
Effective DateCoverage begins on the date shown with your initial identification card (Effective Date); coverage is contingent on meeting Group Policy eligibility rules.
Actively at Work conditionEmployee must be Actively at Work on the Effective Date or coverage will be delayed until return to work, except where absence is due to health status, medical condition or disability.
Enrollment timing relationEnrollment application and premium requirements must be met as specified for coverage to be effective on the Effective Date.
inv-38: Actively at Work (definitions section)
Actively at Work may delay coverageAn employee must be Actively at Work on the Effective Date or coverage for employee and dependents will be delayed until the employee returns to work.
Health-related exceptionCoverage effective date shall not be delayed if the employee is not Actively at Work on the Effective Date due to the employee's health status, medical condition, or disability.
inv-39: Total disability
Total disability definitionTotally Disabled for employed Enrollee means inability to perform occupation duties within first two years; thereafter inability to engage in any paid employment for which reasonably qualified.
Extension implicationIf the Group Policy terminates while you are Totally Disabled and you were covered the day prior, coverage may be extended until total disability ends, end of contract year, or when lifetime maximum incurred.
inv-40: Confinement
Confinement definitionConfinement means being confined in an institution for medical care or treatment; coverage extended for services related to confinement when Group Policy is replaced.
Extension conditionCoverage extended only for services related to the confinement and incurred prior to coverage end; ends at discharge or when benefits are exhausted.