CurrentHealthPartnersPolicy N/A

HealthPartners Robin-Oak Individual Policy

This document is the Individual Policy contract between an enrollee and HealthPartners Insurance Company describing rights, obligations, coverage terms, grievance procedures, nondiscrimination, and network/provider payment rules for individual members.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Robin-Oak Individual Policy

Policy CodePolicy N/A

Change TypeAdministrative/operational — no material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from HealthPartners for certain non-emergent services; standard decisions within 14 calendar days and urgent decisions within 72 hours.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10-dayright to return policy period

14 daysinitial prior auth (standard)

72 hoursinitial prior auth (urgent)

60 daysnewborn automatic coverage

90 dayscontinuity of care duration

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.

Coverage, Enrollment, and Claims Rules

Extracted coverage-related administrative criteria

Highlights of coverage-related administrative rules present in this portion of the policy:

The Policy is guaranteed renewable except as otherwise provided herein.

When non-participating providers are used, benefit payments are determined by the policy's fee schedule, Usual and Customary Charge, or other method; members may be billed for amounts above that payment and such amounts do not apply to the Deductible or Out-of-Pocket Limit.

Enrollees have a 10-day right to return the policy for a full premium refund if returned within 10 days; claims incurred prior to cancellation remain the insured's responsibility.

HealthPartners provides language and communication assistance and follows federal civil rights laws; grievance filing options and contact information (including phone numbers and the Civil Rights Coordinator) are available to members.

Coverage and Administrative Criteria

High-level coverage statements, network requirements, continuity of care provisions, and prior authorization process.

Policy provides Network Benefits when services are delivered by participating Network Providers and Out-of-Network Benefits when delivered by Out-of-Network Providers.

A Benefits Chart is incorporated into the Policy and describes payment amounts and limits applicable to coverage.

Continuity of care: Network Benefits may continue up to 90 days when a Provider leaves the Network for qualifying conditions (serious/complex condition, institutional/inpatient care, scheduled nonelective surgery, terminal illness, pregnancy); benefits may also continue until no longer a continuing patient, and continuity benefits may be discontinued if provider was terminated for misconduct.

Prior Authorization: certain non-emergent services may require prior authorization; medical directors or designees make coverage determinations based on Medical Policies; initial determinations for standard requests within 14 calendar days (may extend 14 days); urgent requests within 72 hours; approvals and denials are communicated to providers by telephone and may be followed in writing, with denials notified to provider and hospital by telephone within one working day and followed in writing.

Administrative coverage criteria

Coverage depends on medical necessity as determined by medical directors and established Coverage Criteria Policies. Continuity of care and exceptions described below.

Continuity of Care: Allow continuation of services from terminated-network providers when member meets qualifying conditions (serious/complex condition, institutional/inpatient care, scheduled nonelective surgery, terminal illness, pregnancy) until the earlier of 90 days from contract termination or the date member is no longer a continuing patient; continuity benefits may be discontinued if the provider was terminated for misconduct.

Medical Necessity Determination: Eligible services are covered only when medically necessary; medical directors or their designees make final coverage determinations based on established Coverage Criteria Policies; prescription drug coverage determinations follow the HealthPartners Pharmacy & Therapeutics Committee requirements.

Prior Authorization Timeframes: When prior authorization is required, initial determination for standard requests within 14 calendar days (may extend an additional 14 days) provided all information reasonably needed is received; for urgent services initial determination within 72 hours provided all information reasonably needed is received; approvals notified to the Health Care Provider by telephone (may be followed in writing); denials notified to the Health Care Provider and hospital by telephone within one working day and followed in writing.

Enrollment, Termination, and Claims Criteria

Enrollment, eligibility, termination, and claims criteria reflected in the policy excerpts.

Enrollment Windows: HIPAA qualifying events: must enroll within 30 days of specified HIPAA events; ACA qualifying events: may enroll within the period starting 60 days before and ending 60 days after the qualifying event.

Newborn/Adopted Child Coverage: Newborns and newly adopted or placed-for-adoption children are automatically covered for the first 60 days; if premium is required to add the child, required premium must be paid within 60 days or the child may be added up to one year from birth/adoption by paying required premium (past due premium may accrue interest); failure to add within one year makes the child a late entrant.

Late Enrollment: If not enrolled during open enrollment or a special enrollment period, the person must wait until the next annual open enrollment period to enroll unless another special enrollment period applies.

Voluntary Termination:

Network Coding & Decision Timeframes

Network Service Rulesmixed

Network vs Out-of-Network service distinction; certain services require designated vendors/providers (e.g., durable medical equipment, specialty drugs).

Designated Provider/Facility Requirementsmixed

Services that require use of a Designated Physician, Provider or Facility to obtain Network Benefits (e.g., convenience clinics, durable medical equipment from approved vendors, specialty drugs from designated vendors).

Coverage basismixed

Coverage determinations and prior authorization decisions are made by medical directors based on established Medical Policies (Coverage Criteria Policies) and Pharmacy & Therapeutics Committee requirements for prescription drugs; initial prior authorization determinations within 14 calendar days (may extend 14 days) and 72 hours for urgent services.

inv-07: Prior Authorization decision time — 14 calendar days (standard), 72 hours (urgent).

Prior Authorization decision timeInitial determination within 14 calendar days for standard requests; may extend an additional 14 days

Urgent prior authorization decision timeInitial determination within 72 hours for urgent requests

Condition for timingTimeframe applies when all information reasonably needed to make the decision has been provided

inv-08: standard_decision_time_days — numeric key/value for standard prior auth timeframe.

Standard decision time (days)14

Possible extensionMay extend an additional 14 calendar days if needed

ApplicabilityApplies when Prior Authorization is required and all information reasonably needed has been provided

inv-09: urgent_decision_time_hours — numeric key/value for urgent prior auth timeframe.

Urgent decision time (hours)72

ApplicabilityFor Prior Authorization requests for urgent services when all information reasonably needed has been provided

Notification practiceApprovals notified by telephone and may be followed in writing; denials notified by telephone within one working day and sent in writing

Provider Requirements, Payments, and Prior Authorization

Note

Out-of-Network Payment Basis and Member Liability

NOTICE: LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED You should be aware that when you elect to utilize the services of a non-participating Provider for a covered service, benefit payments to such non-participating Provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your policy's fee schedule, Usual and Customary Charge (which is determined by comparing Charges for similar services adjusted to the geographical area where the services are performed), or other method as defined by the Policy. YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLE AND COPAYMENT AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION. Non-participating Providers may bill Enrollees for any amount up to the billed Charge after the plan has paid its portion of the bill. Participating Providers have agreed to accept discounted payment for Covered Services with no additional billing to the Enrollee other than copayment, coinsurance and deductible amounts. You may obtain further information about the participating status of professional Providers and information on out-of-pocket expenses by calling 952-883-5900 or 888-360-0622, the number on your identification card or visiting HealthPartners' website at healthpartners.com. Usual and Customary Charge is the maximum amount allowed that we consider in the calculation of payment of Charges incurred for certain Covered Services received from Out of-Network Providers. It is consistent with the range of reasonable fees charged by other Providers of a given service or item in the same geographic region. The Usual and Customary Charge is determined using one of the following options in the following order, depending on availability: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on the Medicare fee schedule; or 3) a commercially reasonable rate for such service. You may be liable for any amounts above the Usual and Customary Charge, and they do not apply to the Deductible or Out-of-Pocket Limit.

Prior Authorization

Prior Authorization and Decision Timelines

Prior Authorization for Services There is no referral requirement for services delivered by Providers within your Network. There is no referral requirement for emergency services. Your Physician may be required to obtain Prior Authorization for certain non-emergent 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 directors, or their designees, make coverage determinations of medical necessity and make final authorization for certain Covered Services. Coverage determinations are based on established Medical Policies (Coverage Criteria Policies), which are subject to periodic review and modification by the medical 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. 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. If the determination is made to approve the service, we will notify your Health Care Provider by telephone, and may send written verification. If the initial determination is made not to approve 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. 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 information regarding Complaint and Grievance Procedure in the section of this Policy titled, 'Disputes and Complaints' for a description of how to proceed.

Billing Rule

Provider payment and claim submission

CLAIMS PROVISIONS Notice of Claims. When a claim arises for services you have already received, you should notify us of the Charges incurred in writing. This written notice of claim must be given within 20 days after any Charges incurred, which are covered by this section, 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 HealthPartners Medical Claims, P.O. Box 21024, Eagan, MN 55121, with information sufficient to identify you and the service, is deemed notice. Claim Forms. After receiving notice of claim, we will furnish a claim form for filing proof of loss. If this form is not received within 15 days after notice is given, 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. Where this section provides for payments contingent upon a period of confinement, these 90 days shall begin at the end of the period for which we are liable. If you do not furnish proof within 90 days as required, benefits shall still be paid for that loss if (1) it was not reasonably possible to give proof within those 90 days, and (2) proof is 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 HealthPartners within 15 months of incurring the Charges. Any bill received after 15 months from the date of service can be denied even if it is for a covered service, unless you were unable to submit the bill because you were legally incompetent.

Billing Rule

Provider payment and claim submission (continued)

CLAIMS PROVISIONS Time of Payment of Claims. Unless otherwise provided by law, we will make payment promptly upon receipt of due written proof of loss. Benefits which are payable periodically during a period of continuing loss shall be payable on at least a monthly basis. We will notify you of our benefit determination if you have any remaining liability within 30 days of receipt of a completed claim. Payment of Claims. All or any portion of any benefits provided on account of hospital, nursing, medical, dental or surgical services may, at our option, be paid directly to the hospital or Provider providing such services, but it is not required that the services be provided by a particular hospital or Provider. At our option, all payments for claims may be made directly to the Provider of medical services, rather than to the Enrollee, for claims incurred by a child, who is covered as a dependent of an Enrollee who has legal responsibility for the dependent's medical care pursuant to a court order, provided we are informed of such order. This payment will discharge us from all further liability to the extent of the payment made. Information. When you seek coverage for goods or services under this Policy, you grant us the right to collect and review any claims, eligibility, coordination of benefits, or medical information necessary to make a proper determination of coverage under this Policy. In the event you fail to cooperate with or execute any documents necessary for our review of coverage requests, or coordination of benefits, or rights of subrogation, we reserve the right to refuse to grant coverage without receipt of necessary information. Legal Action. No legal action may be taken on claims until 60 days after the bills have been submitted, nor more than three years after due proof of loss is required to be submitted.

Key Definitions

inv-14: Individual Policy — definition of the individual policy contract.

DefinitionIndividual Policy: a legal contract between you (the enrollee) and HealthPartners Insurance Company that details the rights and obligations of both parties and the terms of coverage

ContentIncludes Benefits Chart, Terms and Conditions, grievance procedures, and other policy provisions as described in the Table of Contents

PartiesContract is between the enrollee and HealthPartners Insurance Company

inv-15: Usual and Customary Charge — definition used for out-of-network payment calculation.

DefinitionUsual and Customary Charge: the maximum amount allowed used in calculating payment for services from Out-of-Network Providers; consistent with the range of reasonable fees charged by other providers in the same geographic region

Determination hierarchyDetermined using one of the following, in order as available: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on Medicare fee schedule; 3) a commercially reasonable rate

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

inv-16: Network Provider — definition of participating licensed providers.

DefinitionNetwork Provider: any participating licensed Physician, Dentist, mental health or substance use disorder provider, other Health Care Provider, Facility or pharmacy listed in the Network directory that has an agreement with HealthPartners to provide services

AccessNetwork Providers are available to view via the 'myHealthPartners' account at healthpartners.com or by calling Member Services

Benefit requirementTo obtain Network Benefits for Covered Services you must select and receive services from Network Providers unless an exception applies

inv-17: Designated Provider/Facility — definition of designated physicians, providers, or facilities.

DefinitionDesignated Physician/Provider/Facility: a current list of Network physicians, Providers or Facilities authorized to provide certain Covered Services as described in the Policy

Required useCertain services (e.g., designated convenience clinics, Durable Medical Equipment vendors, Specialty Drug vendors) must be obtained from designated providers to receive Network Benefits

How to obtain listCall Member Services for a current list of designated providers or view the Network directory

inv-18: Authorized Representative — who may act on member's behalf and appointment requirements.

Who may actAuthorized Representative: anyone acting on the enrollee's behalf in connection with an initial claim or to file a Complaint or Grievance

Appointment requirementTo designate an authorized representative you must complete and sign the 'Appointment of Authorized Representative' form and return it to HealthPartners

ScopeSpecify on the form the extent of the authorized representative's authority; without a proper authorization we will respond directly to the enrollee

inv-19: Continuity of Care — definition of continuity of care and qualifying conditions.

DefinitionContinuity of Care: continuation of services from a provider who leaves the Network such that those services continue to be treated as Network Benefits under qualifying conditions

Qualifying conditionsIncludes serious and complex condition treatment, institutional/inpatient care, scheduled nonelective surgery (including related care), terminal illness, and pregnancy (services may continue through postpartum care if in 2nd/3rd trimester)

DurationNetwork Benefits continue until the earlier of 90 days from the Provider contract termination or the date you are no longer a continuing patient; benefits may be discontinued if provider terminated for misconduct

inv-20: Subrogation / Reimbursement — insurer's right to recover payments from third-party recoveries and member obligations.

Insurer rightRight of Reimbursement and Subrogation: HealthPartners has the right to recover the value of services it paid from third-party recoveries by reimbursement and subrogation

Member obligationsYou must promptly inform HealthPartners in writing of any potential or pending third-party claim and cooperate fully in recovery efforts; amounts recovered must be held in trust for the insurer to the extent of its claim

Scope of recoveriesApplies to recoveries from tortfeasors, underinsured/uninsured motorist coverage, medical payments coverage, umbrella coverage, or any other recovery source; rights not reduced by attorney's fees

inv-21: Coordination of Benefits / Medicare — rules coordinating benefits with other coverage and Medicare.

Coordination ruleCoordination of Benefits: when the Insured has other group coverage, benefits are reduced so total payments do not exceed 100% of Covered Services

Data exchangeHealthPartners may obtain or share necessary facts with other organizations consistent with law to determine coordination without additional consent unless prohibited by law

Medicare interactionMedicare is primary for eligible Medicare enrollees; benefits under this Policy are not intended to duplicate Medicare and HealthPartners may reduce Policy benefits by amounts payable under Medicare consistent with law

inv-22: Special Enrollment Period — HIPAA and ACA qualifying events definitions and windows.

HIPAA qualifying events window30 days to enroll following listed HIPAA qualifying events (e.g., loss of group coverage due to termination, death, divorce, loss of dependent eligibility)

ACA qualifying events window60 days to enroll for ACA qualifying events (e.g., loss of minimum essential coverage, birth/adoption, change in eligibility for premium tax credit)

Newborn/adoption noticeYou must notify HealthPartners and submit any required premium within 60 days to add a newborn or newly adopted child beyond automatic coverage period

inv-23: Newborn/Adopted Child Coverage — automatic coverage period for newborns or newly adopted children.

Automatic coverage periodNewborns and newly adopted children are automatically covered for the first 60 days after birth, adoption, or placement for adoption

Premium requirementIf premium is required to add the Child permanently, you must notify HealthPartners and send required premium within 60 days

Notification when no premiumIf no premium is required, you should still notify HealthPartners as soon as possible so the Child can be enrolled

inv-24: Two-year defense limitation — time limit after which non-fraudulent misstatements cannot void policy or deny claims.

Two-year limitationAfter two years from the Policy effective date, no misstatements (except fraudulent misstatements) made by the applicant may be used to void the Policy or deny a claim for loss incurred commencing after that two-year period

ScopeNo claim for loss commencing after two years from the effective date is reduced or denied on the ground that a disease or condition existed prior to the effective date unless excluded by name or description

ExceptionFraudulent misstatements remain actionable beyond the two-year limitation