CurrentHealthPartnersPolicy N/A

HealthPartners Robin-Oak Individual Policy

Governs the rights, obligations, benefits, renewal, and use of network and out-of-network services for enrollees under the HealthPartners Robin-Oak individual insurance policy.

Policy Summary

PayerHealthPartners

PolicyHealthPartners Robin-Oak Individual Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit predetermination for pediatric dental treatment expected to exceed $300.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Guaranteed renewablepolicy renewal characteristic

14 daysinitial prior auth (standard)

72 hrsinitial prior auth (urgent)

$300pediatric dental predet threshold

3 yearsgrievance filing limit

Coverage Rules and Member Benefits

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.

Network and Out-of-Network Benefits

Overview of benefits and payment basis for in-network and out-of-network services.

Network Benefits are provided when medical and dental services are delivered by participating Network Providers as described in this Policy and Network directory (see Benefits Chart for amounts and limits).

Out-of-Network Benefits are provided for services delivered by Out-of-Network Providers, but benefit payments to non-participating providers are based on the Policy's fee schedule or Usual and Customary Charge (determined by methods such as a percentage of the Medicare fee schedule, a comparable schedule, or a commercially reasonable rate). Enrollees may be billed by non-participating providers for amounts above the payment determined by the Policy.

The Benefits Chart is attached and incorporated into the Policy and details the amounts of payments and limits for coverage; refer to it for specific benefit levels and limits.

Second opinions: if an enrollee questions a decision about medical or dental care, the Policy covers a second opinion from another provider.

Coverage criteria and network rules

Network benefits and coverage determination principles

To obtain Network Benefits, services must be selected and received from Network Providers except for limited exceptions described in this Policy.

Certain services require use of Designated Physician, Provider, Facility, or designated vendors (for example: convenience clinics, approved durable medical equipment vendors, and designated specialty drug vendors) to be covered as Network Benefits; call Member Services for current lists and prior authorization requirements.

Eligible services are covered only when medically or dentally necessary as determined by the medical or dental directors or their designees using established Coverage Criteria Policies; decisions include determinations of necessity, restrictions, appropriateness, and final authorizations for certain Covered Services.

Continuity of care (exception): Continuity of care: when a Provider leaves the Network under qualifying conditions (e.g., serious/complex condition, scheduled nonelective surgery, inpatient care, terminal illness, pregnancy), services from that Provider may continue to be treated as Network Benefits until the earlier of 90 days from contract termination or the end of continuing patient status; continuity may be discontinued if the Provider was terminated for misconduct.

Pediatric dental predetermination:

Appeals and Administrative Criteria

Procedures for complaints, internal grievances (standard and expedited), and external independent review.

Complaint process: Enrollees, applicants, former enrollees, or authorized representatives may initiate a complaint by calling Member Services (866-232-1166). Member Services will investigate and notify the complainant of the outcome; if dissatisfied, parties may proceed to the grievance process or skip directly to grievance.

Standard grievance: A written request for review must be filed within 3 years of the adverse decision, including comments, documents and supporting information, submitted to Member Rights & Benefits (address and fax provided). Acknowledgment is sent within five business days, the enrollee has access to relevant records at no charge and may appear before the grievance committee, and a written decision will be issued within 30 calendar days of receipt.

Expedited grievance: For urgently-needed services, an expedited grievance may be requested verbally or in writing by the enrollee and Health Care Provider; the request will be reviewed expeditiously and notification of the outcome provided within 72 hours. An urgent internal and external review may occur concurrently.

Independent external review (IRO):

Predetermination and Coding Thresholds

Pediatric dental predetermination cost threshold

Recommended predetermination thresholdDentists are recommended to submit a predetermination for pediatric dental courses of treatment expected to involve charges of $300 or more.

What to submitDescription of procedures, an estimate of the Dentist's charges, and appropriate X‑rays must be filed in writing by the Dentist.

Decision timeframeInitial predetermination determinations are made within 10 business days after all reasonably needed information is provided (72 hours for urgent requests).

Predetermination validity period

Validity period for predetermination approvalsPredetermination for services is limited to services performed within 90 days from the date the course of treatment was approved by us.

Additional services after 90 daysAdditional services required after 90 days may be submitted in writing as a new course of treatment and will be approved on the same basis as the prior plan.

Scope of payment considerationIn determining the amount we pay, consideration is given to alternate procedures, services, supplies, or courses of treatment.

Provider Responsibilities and Authorization Processes

Note

Second Opinion Coverage

Second opinions from another provider are covered when an enrollee questions a decision about medical or dental care.

Prior Authorization

Prior Authorization process and timelines

Physicians may be required to obtain Prior Authorization for certain non‑emergent services; the Physician coordinates the authorization. Initial determinations are made within 14 calendar days (may be extended an additional 14 days); urgent service determinations are made within 72 hours. Approvals are communicated to the provider by telephone (with written verification); denials are notified by telephone within one working day with written verification. Members and providers have rights to expedited review and appeals, including external review under the Disputes and Complaints procedures.

List of services requiring Prior Authorization is available via Member Services or the myHealthPartners account.
Coverage determinations are based on established Medical and Dental Policies and made by medical/dental directors or designees.

Prior Authorization

Pediatric dental predetermination

Dentists are recommended to submit a written predetermination (description of procedures, estimated charges, and any relevant X‑rays) when a pediatric course of treatment is expected to involve charges of $300 or more. Initial predetermination decisions are made within 10 business days (72 hours for urgent requests). Decisions are communicated to the dental provider by telephone with possible written verification; predetermination approvals are limited to services performed within 90 days of the approval.

If procedures and cost estimates are not submitted in advance, HealthPartners may determine benefits payable considering alternate procedures.
Additional services after the 90‑day period must be submitted as a new course of treatment.

Documentation Required

Provider discussion of clinical denials

If a claim for medical services was denied based on clinical coverage criteria, the provider may discuss the decision with the clinician who reviewed the request; the denial notice includes information to facilitate that discussion and providers may contact Member Services for assistance.

Provider should refer to the denial notice for contact information and details.
Member Services can be called for assistance in arranging discussion with the reviewing clinician.

Defined Terms Used in This Policy

Capitalized terms

Meaning of capitalized termsCertain capitalized words have special meanings defined in the Definitions section or within applicable sections; additional capitalized terms are defined in the Benefits Chart.

Where to find definitionsDefined terms appear in the Definitions section of this Policy and in the Benefits Chart incorporated into the Policy.

Interpretation noteCapitalized terms used elsewhere in the Policy should be read with their defined meanings when applicable.

Network Provider

Network Provider definitionA Network Provider is any participating licensed physician, dentist, mental health and substance use disorder or other Health Care Provider, Facility, or pharmacy listed in the Network directory that has entered into an agreement with HealthPartners to provide Health Care Services.

How to locate Network ProvidersNetwork Providers are available to view free of charge by logging on to your myHealthPartners account or by calling Member Services.

Requirement for Network BenefitsTo obtain Network Benefits, services must be provided by Network Providers except for limited exceptions described in this Policy.

Definitions: Enrollee, Eligible Dependents, Facility, Health Care Provider

EnrolleeThe person who is eligible and accepted by us as an Insured per a signed enrollment form and is responsible for payment of premium.

Eligible DependentsIncludes spouse, natural or legally adopted child, legal guardian's child, child covered under a qualified medical child support order, or stepchild; generally under age 26 or a Disabled Child as defined.

FacilityA licensed medical center, clinic, hospital, skilled nursing care facility or outpatient care facility lawfully providing medical or dental services within applicable licensing privileges and limitations.

Health Care ProviderAny licensed non-physician (excluding naturopathic providers) or other licensed professional lawfully performing medical or dental services within the scope of their license who renders direct patient care covered by this Policy.

Denial, reduction, termination, or failure to provide/make payment for a benefit

Scope of adverse actionsAn adverse determination includes a denial, reduction, termination of, or failure to provide or make payment for a benefit, and includes rescissions.

Basis for determinationsAdverse determinations may be based on utilization review findings or a determination that the benefit is investigational or experimental.

Rescission definedA rescission is a discontinuance or cancellation of coverage that has retroactive effect; cancellations for nonpayment of premiums are not rescissions.

Adverse Determination

Adverse Determination (formal)An Adverse Determination is a denial, reduction, termination of, or failure to provide or make payment for a benefit, including rescission, as defined in this Policy.

InclusionsIncludes determinations arising from utilization review or findings that the benefit is investigational or experimental.

Effect on enrollee rightsAdverse Determinations trigger appeal, grievance, and, when eligible, external independent review rights as described in the Policy.

Experimental Treatment Determination

Experimental Treatment DeterminationA determination by HealthPartners that a proposed treatment is experimental, based on a review of the information provided, and results in denial of payment for the treatment under the terms of this Policy.

Decision basisRequires review of the proposed treatment and a finding that, per Policy terms, the treatment is experimental.

ConsequencesIf determined experimental, payment for the treatment is denied and the enrollee may pursue the Policy's appeal and external review processes as applicable.

Grievance

Grievance definitionA Grievance is a written statement of dissatisfaction by an enrollee or an Authorized Representative about the provision of services, claims practices, or benefit administration during enrollment or application for enrollment in this Policy.

Who may fileAn enrollee, applicant, former enrollee, or an Authorized Representative may submit a Grievance.

Relation to complaints and appealsGrievances follow the complaint process and may be appealed internally and, where eligible, to external independent review per Policy procedures.