CurrentHealthPartnersPolicy N/A

HealthPartners Robin-Oak Individual Policy

This document is the Individual Policy — a legal contract between an enrollee and HealthPartners Insurance Company describing coverage terms, member rights and responsibilities, network use, grievance procedures, and administrative provisions for individual enrollees and their dependents.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Robin-Oak Individual Policy

Policy CodePolicy N/A

Change TypeNo material changes / informational update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit predetermination for pediatric dental treatment expected to exceed $300 and submit claims with itemized bills and proof of loss within 90 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysinitial prior auth timeframe

72 hoursurgent prior auth timeframe

1-800-883-2177language help phone

952-967-7540network info phones

$300predetermination threshold

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.

proof of loss window

Coverage, Eligibility, and Administrative Rules

Administrative and Member Rights Criteria

Key administrative and enrollee-facing provisions and obligations included in this excerpt:

Enrollee must ensure enrollment form information is correct; omissions or misstatements may cause claim denial and must be reported to the insurer within 10 days.

Enrollee has a 10-day right to return the Policy for a full premium refund; claims incurred before cancellation remain the enrollee's responsibility.

A 10-day grace period applies for premium payments after the first premium; coverage continues during the grace period and may terminate retroactively if payment is not received within the grace period.

The Individual Policy, Benefits Chart, any amendments and the enrollment form constitute the entire agreement between the Enrollee and HealthPartners Insurance Company.

Insureds on Medicare retain specified protections including rights regarding disenrollment and clear descriptions of nursing home and home care benefits.

We follow applicable federal civil rights and nondiscrimination requirements and provide language and communication assistance; contact details are provided in the Policy.

No agent may change or waive Policy terms; only the insurer may approve changes to the Policy and any legal changes required by law become effective according to law.

Network and Out-of-Network Benefits; Designated Providers

Coverage includes Network Benefits when services are provided by participating Network Providers and limited Out-of-Network Benefits as described in the Policy and Benefits Chart. Certain services require designated providers or vendors to obtain Network coverage.

Network Benefits are provided when medical and dental services are delivered by participating Network Providers; to obtain Network Benefits you must select and receive services from Network Providers unless an exception applies.

Out-of-Network Benefits are available for services delivered by Out-of-Network Providers but benefit payments for non-participating Providers are determined by the Policy's fee schedule, Usual and Customary Charge or other method; Enrollees may be billed for amounts above plan payment.

Certain services require use of a Designated Physician, Provider, Facility or vendor to receive Network Benefits (examples: contracted convenience clinics, approved vendors for durable medical equipment, designated vendors for specialty drugs); call Member Services for current lists and prior authorization requirements.

Participating Providers have agreed to accept discounted payment for Covered Services with no additional billing to the Enrollee beyond copayments, coinsurance and deductible amounts; Out-of-Network Usual and Customary Charges do not apply to Deductible or Out-of-Pocket Limit unless specified.

Continuity of Care Eligibility

Continuity of Care protections allow continuation of network benefits in specific circumstances when a provider leaves the network.

Network Benefits may continue for up to the earlier of 90 days from the Provider contract termination date or until you are no longer a continuing patient with that Provider, unless otherwise noted.

Conditions that qualify for continuity of care

You are undergoing a course of treatment for a serious and complex condition.
You are undergoing a course of institutional or inpatient care.
You are scheduled to undergo nonelective surgery (including related care from such Provider or Facility).
You were determined to be terminally ill and are receiving treatment for such illness.

Pediatric Dental Predetermination Criteria

Predetermination and notification requirements for pediatric dental courses of treatment expected to exceed the specified charge threshold.

If a course of dental treatment for a child is expected to involve Charges of $300 or more, the Dentist is recommended to submit a written predetermination including procedure descriptions, an estimate of the Dentist's Charges and an appropriate x-ray prior to treatment.

A 'course of treatment' is a planned program of one or more services or supplies for a diagnosed dental condition and begins on the date the Dentist first renders a service to correct or treat that condition.

Initial predetermination decisions must be made within 10 business days when all reasonably needed information is provided; for urgent predeterminations the initial decision must be made within 72 hours.

If approved, the Dentist will be notified by telephone and may receive written verification; denials are telephoned within one working day and followed by written verification detailing the denial.

Medical/Dental Necessity and Coverage Determination

Coverage is limited to services that are medically or dentally necessary and determined by medical/dental directors using established Coverage Criteria Policies.

Eligible services are covered only when medically or dentally necessary for the proper treatment of an Insured.

Medical or dental directors, or their designees, make coverage determinations of medical or dental necessity, restrictions on access and appropriateness of treatment, and make final authorization for certain Covered Services.

Coverage determinations are based on established Coverage Criteria Policies that are subject to periodic review and modification by the medical or dental directors; Prescription Drug determinations follow HealthPartners Pharmacy and Therapeutics Committee requirements.

Exceptions for pediatric dental service limits

Frequency limits, deductibles, copayments or coinsurance, or other maximums or limits for certain covered pediatric dental services may not apply if you meet specific coverage criteria set by our dental directors.

Termination and claims criteria

Administrative rules governing policy changes, termination, and claims handling for enrollees and dependents.

Termination of coverage for the Enrollee constitutes automatic termination of coverage for all enrolled dependents unless otherwise specified.

Voluntary termination: Enrollee may terminate the Policy at any time by written notice; coverage ends on the date specified if 14 days advance written notice is given, otherwise coverage ends 14 days after the request. The Policy cannot be retroactively cancelled.

Involuntary termination grounds and notice periods

We may terminate coverage if we no longer offer individual market coverage (180 days notice).
We may terminate a particular plan or product (90 days notice), in which case you may select a different plan or product.

Procedure Codes, Thresholds, and Submission Windows

Procedure codingmixed

No explicit CPT/HCPCS/ICD-10 codes listed in this excerpt.

Pediatric dental predetermination threshold

Recommended predetermination threshold$300 — predetermination recommended when a pediatric dental course of treatment is expected to involve Charges of $300 or more.

Definition of course of treatmentA planned program of one or more services or supplies (may be by one or more Dentists); commences on the date a Dentist first renders a service to correct or treat the diagnosed dental condition.

Predetermination decision timeframesInitial determination within 10 business days (72 hours for urgent predeterminations) when all reasonably needed information is provided.

Proof of loss and bill submission timelines

Proof of loss timeframeItemized bills and proof of loss must be submitted within 90 days after the date services were first received; exceptions allow up to one year if it was not reasonably possible to submit within 90 days.

Provider Requirements, Authorizations, and Billing Rules

Billing Rule

Out-of-Network Payment Rule

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 952-967-7540 or 866-232-1166, 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.

Key Terms and Roles

HealthPartners Insurance Company identity

Insurer nameHealthPartners Insurance Company (issues and underwrites the Individual Policy).

Pronoun mappingWhen used in this Policy, 'we', 'us' or 'our' refer to HealthPartners Insurance Company.

Relationship to HealthPartners, Inc.HealthPartners, Inc. provides network access and administrative services for HealthPartners Insurance Company.

Entire Contract

Documents comprising the Entire ContractThis Policy, the Benefits Chart, any amendments and the enrollment form constitute the whole agreement between HealthPartners Insurance Company and the Enrollee.

Effect on prior policiesThis Policy replaces an Enrollee's prior Policy with HealthPartners Insurance Company as of the effective date of this Policy.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Robin-Oak Individual Policy

Policy CodePolicy N/A

Change TypeNo material changes / informational update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit predetermination for pediatric dental treatment expected to exceed $300 and submit claims with itemized bills and proof of loss within 90 days.

SourceLink

On This Page

You are pregnant and undergoing a course of treatment for the pregnancy; if in second or third trimester, services may continue through completion of postpartum care for you and the newborn.

Continuity of care benefits may be discontinued if the Provider is terminated from the Network for misconduct; if a non-participating Provider was identified in the material provided to you, services from that Provider may be covered until the end of the current plan year.

Predetermination approvals are valid for services performed within 90 days of approval; services after 90 days require submission of a new course of treatment for review.

We may terminate if you move outside the service area (31 days notice).

Dependent reaches limiting age: coverage for that dependent terminates the last day of the Calendar Year in which the dependent reaches the limiting age; rescissions require 30 days notice where applicable.

If any other enrolled dependent no longer meets eligibility, coverage for that dependent terminates the last day of the month in which eligibility ceases; rescissions require 30 days notice where applicable.

Termination for cause: premium due first of month with a 10-day grace period; if no payment received within the grace period coverage terminates retroactive to the paid-through date. Misstatements (except fraud) cannot be used to void the Policy or deny claims after two years from the issue date for losses commencing after that period.

Claims notice and proof: Notify insurer in writing within 20 days of Charges incurred or as soon as reasonably possible. Claim forms will be furnished; if not received within 15 days, submit written proof. Itemized bills and proof of loss must be submitted within 90 days (or up to one year if not reasonably possible); all bills must be submitted within 15 months of service.

Payment and information: We will make payment promptly upon receipt of due written proof of loss; periodic benefits paid at least monthly; we may pay Providers directly and reserve the right to collect necessary information and refuse coverage if the enrollee fails to cooperate.

Legal action and defenses: No legal action until 60 days after bills submitted; actions must be brought within three years after due proof is required. After two years from the Policy effective date, misstatements (except fraud) cannot be used to void the Policy or deny claims for losses commencing after that two-year period.

Notice of claimYou must give written notice of Charges within 20 days after any Charges incurred, or as soon as reasonably possible.

Final bill submission deadlineAny bills for Covered Services must be submitted to HealthPartners within 15 months of incurring the Charges; bills received after 15 months may be denied unless legally incompetent.

Prior Authorization

Prior Authorization Required

There is no referral requirement for services delivered by Providers within your Network or for emergency services. For certain non-emergent services, Prior Authorization (PA) is required. Your Physician coordinates the authorization process. Medical or dental directors, or their designees, make coverage determinations of medical and dental necessity and issue final authorizations based on established Coverage Criteria Policies.

Initial PA decision for standard services: within 14 calendar days if all required information is provided; may extend one additional 14-day period.
Initial PA decision for urgent services: within 72 hours if all required information is provided.
If approved: Provider notified by telephone and may receive written verification.
If denied initially: Provider (and hospital if appropriate) notified by telephone within one working day and written verification sent with denial details.
Right to request expedited review and to appeal denials; external review available under certain circumstances.

Documentation Required

Pediatric Dental Predetermination

If a pediatric dental course of treatment will involve charges of $300 or more, Dentists are recommended to submit a predetermination in writing prior to treatment. A 'course of treatment' begins on the date the Dentist first renders a service to correct or treat the diagnosed dental condition. Predetermination requests are reviewed and decided by dental directors or their designees.

Recommended threshold for predetermination: >= $300 in expected dental charges.
Initial predetermination decision for standard pediatric dental services: within 10 business days if all required information is provided.
Initial predetermination decision for urgent pediatric dental services: within 72 hours if all required information is provided.
If approved: Dentist notified by telephone and may receive written verification.
If denied initially: Dentist notified by telephone within one working day and written verification sent with denial details.
Predetermination approvals apply to services performed within 90 days of approval; additional services after 90 days require a new predetermination.

Note

Coverage Determination and Authorization

Our medical or dental directors, or their designees, have authority to make coverage determinations of medical or dental necessity, determine restrictions on access and appropriateness of treatment, and make final authorizations for certain Covered Services. Coverage determinations are based on established Coverage Criteria Policies and, for prescription drugs, on requirements from the HealthPartners Pharmacy and Therapeutics Committee. These policies are subject to periodic review and modification by the respective directors.

Directors/designees make final authorization decisions for services requiring review.
Coverage determinations consider medical/dental necessity, frequency limits, and applicability of deductibles, copayments, coinsurance, or other limits; some pediatric dental limits may be waived if coverage criteria are met.
Coverage decisions follow established Coverage Criteria Policies and Pharmacy & Therapeutics requirements for drugs.

Documentation Required

Claims Submission and Timing

Providers and Enrollees must submit timely notice and documentation for claims. Specific timelines and requirements are set for notice of claim, claim forms, proof of loss, and bill submission. Failure to provide required documentation within stated timeframes may lead to denial, except in limited circumstances where late submission was not reasonably possible.

Notice of claim: Written notice to HealthPartners within 20 days after Charges are incurred, or as soon as reasonably possible. Send to HealthPartners Medical Claims, P.O. Box 21024, Eagan, MN 55121 with information sufficient to identify the Enrollee and service.
Claim forms: After notice, HealthPartners will furnish claim forms. If not received within 15 days, submit written proof documenting date/type of service, Provider name and itemized Charges.
Proof of loss / Itemized bills: Submit itemized bill documenting date/type of service, Provider name and Charges within 90 days after date services were first received. If not reasonably possible, proof must be furnished as soon as reasonably possible but no later than one year after the end of the 90-day period.
Final bill submission: Any bills for Covered Services must be submitted within 15 months of the date of service. Bills received after 15 months can be denied unless prevented by legal incapacity.
Time of payment: We will make payment promptly upon receipt of due written proof of loss. We will notify you of benefit determination if you have remaining liability within 30 days of receipt of a completed claim.
Legal action: No legal action on claims until 60 days after bills submitted, nor more than three years after due proof of loss is required to be submitted.

ScopeCovers the Enrollee and enrolled dependents named on the enrollment form.

Individual Policy ('this Policy')

Definition labelIndividual Policy ('this Policy') — the Enrollee's evidence of coverage issued by HealthPartners Insurance Company.

IncludesThe Policy covers the Enrollee and any enrolled dependents named on the enrollment form.

Replacement effectReplaces any prior policy as of this Policy's effective date.

Network Provider

DefinitionNetwork Provider — Health Care Providers, Facilities and pharmacies contracted to provide services for your plan (listed in the Network directory).

Network requirementsTo obtain Network Benefits you must select and receive services from Network Providers, except for limited exceptions described in the Policy.

Designated providersSome services require use of a Designated Physician, Provider or Facility to receive Network Benefits (call Member Services for a current list).

Out-of-Network Provider

DefinitionOut-of-Network Provider — a provider who is not contracted as part of the HealthPartners Network; limited Out-of-Network Benefits may apply as described in the Policy and Benefits Chart.

Payment implicationsWhen using non-participating providers, benefit payments are determined by the plan's fee schedule or Usual and Customary Charge rather than the billed amount (see payment rules).

Member responsibilityNon-participating providers may bill enrollees for amounts above plan payment as permitted by the Policy.

Authorized Representative (short)

Short definitionAuthorized Representative — anyone acting on your behalf in connection with an initial claim or to issue a Complaint or Grievance.

PurposeAllows a third party to act for the Enrollee in claims or complaints processes.

Form availableAn authorization form is available via 'myHealthPartners' or upon request to designate an Authorized Representative.

CareLine SM Service (summary)

Service summaryCareLine SM Service — phone-based service staffed by registered nurses to assist in assessing need for medical or dental care and to coordinate after-hours care, as covered by this Policy.

AccessAvailable by phone to help determine care needs and coordinate services outside regular hours.

Coverage noteService use and coordination is as covered in this Policy.

Authorized Representative — designation & requirements

Designation requirementsTo designate an Authorized Representative you must complete and sign the 'Appointment of Authorized Representative' form and return it to us; the form should specify the extent of authority.

PHI disclosure authorizationThe authorization permits us to disclose your personal health information to the Authorized Representative; we will provide the form upon request or via 'myHealthPartners'.

Limitation without authorizationUnless otherwise permitted by law, if a third party issues a Complaint or Grievance and we do not have authorization, we will investigate and respond directly to you rather than the third party.

CareLine SM Service (phone-based description)

Phone-based nurse serviceCareLine SM Service employs registered nurses available by phone to assist in assessing need for medical or dental care and coordinate after-hours care.

RoleAssists members in care assessment and after-hours coordination as covered by the Policy.

Access methodAvailable by telephone; details in Policy and Member Services.

Enrollee / Insured

Enrollee / Insured definitionEnrollee — a person eligible and accepted by us as an Insured per a signed enrollment form and responsible for payment of premium; 'Insured' includes the Enrollee and all eligible and enrolled dependents.

TerminologyWhen used in this Policy, 'you' or 'your' has the same meaning as the Insured.

ResponsibilitiesThe Enrollee is responsible for premium payment and for providing required documentation for dependents and coverage matters.

Eligible Dependent / Child / Disabled Child / Qualified Grandchild

Eligible Dependent / ChildIncludes spouse; Child — natural or legally adopted child, child under legal guardianship, child covered under a qualified medical child support order, or stepchild; generally under age 26 unless defined as a Disabled Child.

Qualified GrandchildAn unmarried child of a covered Child who is younger than age 18 (or a Disabled Child as defined).

Disabled ChildA Child or Qualified Grandchild who is incapable of self-sustaining employment due to intellectual, mental or physical disability, chiefly dependent on the Enrollee; coverage requires written request and proof and must be approved by us, received within 31 days of eligibility event.

Provider / Physician / Facility

Provider / Physician / Facility definitionPhysician — a licensed medical doctor or doctor of osteopathy lawfully performing medical services; Facility — licensed medical centers, clinics, hospitals, skilled nursing or outpatient facilities lawfully providing services within licensing limitations.

Health Care Provider (Provider)Any licensed non-physician (excluding naturopathic providers) performing medical or dental services within the scope of their license and applicable governmental licensing privileges and limitations.

Network contextProviders and Facilities may be part of the HealthPartners Network (see Network Provider definition) to deliver Network Benefits.

Adverse Determination

Adverse Determination definitionAn Adverse Determination is a denial, reduction, termination of, or failure to provide or make payment for a benefit for reasons such as utilization review or a determination that the benefit is investigational or experimental; includes rescissions.

Rescission noteA rescission is a discontinuance or cancellation of coverage with retroactive effect; cancellations retroactive for nonpayment are not rescissions.

ScopeApplies to determinations about coverage, payment, and benefit continuance as described in Policy processes.

Grievance

Grievance definitionA Grievance is a written statement of dissatisfaction by you or your Authorized Representative regarding concerns about the provision of services, claims practices or benefit administration during enrollment or application for enrollment under this Policy.

Complaint distinctionA Complaint is an expression of dissatisfaction that may be resolved informally by calling Member Services; a Grievance is a formal written statement.

Who may fileYou or your Authorized Representative may submit a Grievance per the Policy's Disputes and Complaints procedures.

Termination (definition)

Termination definitionTermination — termination of coverage for the Enrollee constitutes automatic termination of coverage for all enrolled dependents unless otherwise specified by the Enrollee.

Effect on dependentsDependents' coverage ends automatically upon Enrollee termination unless Enrollee specifies otherwise.

Policy contextTermination provisions and notices are detailed in the Policy's Termination and Involuntary/Voluntary termination sections.

Voluntary termination — notice & effective date

Advance notice requirementVoluntary termination — Enrollee may terminate at any time but must give 14 days advance written notice for termination to take effect on the date specified.

Effective date if less notice givenIf less than 14 days' notice is given, coverage terminates 14 days following the request for termination.

No retroactive cancellationYou cannot retroactively cancel this Policy; written notice address is provided in the Policy.

Involuntary termination — grounds

Grounds for involuntary terminationWe may terminate coverage if we no longer offer coverage in the individual market (180 days' notice), terminate a particular plan/product (90 days' notice), you move outside the service area (31 days' notice), or an enrolled dependent no longer meets eligibility (end of calendar year or end of month as specified).

Rescission notice requirementTo the extent a termination would be considered a rescission under law, we are required to give you 30 days advance notice of termination.

Medicare duplicationWe cannot renew coverage if renewal would duplicate Medicare Part A or B benefits to which you are entitled.

Termination for cause — nonpayment & misstatements

Nonpayment grace periodPremium due on or before the first of each month with a 10-day grace period to pay; coverage continues during the grace period but terminates retroactive to the paid-through date if not paid within 10 days.

Misstatement time limitNo misstatement (except fraudulent misstatements) may be used to void this Policy or deny a claim for loss incurred after two years from the issue date of the Policy.

Fraud exceptionFraudulent misstatements remain actionable beyond the two-year limit and may void coverage or deny claims as allowed by law.