CurrentHealthPartnersPolicy N/A

Group Certificate / Certificate of Coverage (Wisconsin Small Employer Plan)

This document is the Group Certificate of Coverage from HealthPartners Insurance Company describing rights, benefits, limitations, and administrative provisions for enrollees under the Wisconsin Small Employer plan; it governs coverage terms, grievance procedures, language access, and network vs. non‑network payment rules for members and providers.

Policy Summary

PayerHealthPartners

PolicyGroup Certificate / Certificate of Coverage (Wisconsin Small Employer Plan)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionMembers should contact Member Services or ask their provider for the CPT code and estimated charge before a procedure to determine the eligible expense under the Certificate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Wisconsin Small Employerplan type identified

1-800-883-2177language & communication assistance

$300predetermination threshold

14 daysstandard prior auth timeframe

72 hoursurgent decision timeframe

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31 dayspremium grace period

Coverage Rules, Eligibility and Administrative Criteria

Coverage rules and member actions

Key coverage rules and enrollee obligations from the Certificate:

When non-participating providers are used, benefit payments are determined by the policy's fee schedule, Usual and Customary Charge (determined by comparing charges for similar services adjusted to the geographic area), or other method defined by the Policy; the enrollee may be balance‑billed for amounts up to the provider's billed charge after the plan pays its portion.

Usual and Customary Charge is the maximum amount considered for payment of out‑of‑network services, is determined (in order of availability) by: (1) a percentage of the Medicare fee schedule; (2) a comparable schedule if not on Medicare; or (3) a commercially reasonable rate; amounts above it may not apply to the deductible or out‑of‑pocket limit.

Members may contact Member Services (number on ID card) or ask their Provider for the CPT code and estimated charge prior to a procedure to learn the eligible expense based on the Usual and Customary Charge.

Coverage under this Certificate begins on the effective date shown on the enrollee's identification materials and is governed by the Group Policy together with this Certificate and any amendments; the Certificate explains how to file claims and who to contact for grievances or complaints.

Coverage and administrative criteria

General coverage and administrative criteria appearing in this section of the Certificate:

Benefits Chart is attached to and incorporated into the Certificate and describes payment amounts, limits, exclusions, and applicable coverage details.

To obtain Network Benefits you must select and receive services from Network Providers except for limited exceptions (for example emergency services and specified continuity scenarios).

Certain non‑emergent services may require Prior Authorization by the Physician; medical and dental directors (or designees) make coverage determinations using established Coverage Criteria Policies.

Prior Authorization timing: initial determination within 14 calendar days if information is complete (may extend an additional 14 days); urgent determinations within 72 hours; authorizations and denials are communicated to providers by telephone with written verification as appropriate, and appeal rights exist including expedited review and external review in certain circumstances.

Predetermination and coverage determination criteria

Coverage for pediatric dental services requires predetermination when charges meet threshold and services must be Medically or Dentally Necessary as determined by plan clinicians.

Predetermination is recommended when an expected course of dental treatment will involve charges of $300 or more; the Dentist should submit a description of procedures, an estimate of the Dentist's charges, and an appropriate x‑ray in writing prior to treatment.

Timing: when predetermination is requested and all information reasonably needed is provided, an initial (standard) determination must be made within 10 business days; for urgent predetermination the initial determination must be made within 72 hours.

Validity: an approved predetermination covers services performed within 90 days from the date the course of treatment was approved; services after 90 days require submission as a new course of treatment.

Payment determination: in determining the amount payable, consideration will be given to alternate procedures, services, supplies or courses of treatment; the amount paid is the appropriate amount determined in accordance with the terms of the Certificate and as determined by dental directors or their designees.

Continuation and termination criteria

Continuation coverage eligibility and maximum durations depend on the qualifying event and group size.

Eligibility: persons eligible to elect continuation include the Enrollee, covered Spouse, other covered dependents enrolled at the time coverage would otherwise end, and a child born to or placed for adoption during the continuation period.

Standard duration: for qualifying events such as termination, reduced hours, or change in job status the maximum period of continuation coverage is 18 months; a second qualifying event (other than bankruptcy) during the 18 months may extend the maximum to 36 months.

Disabled extension: if an enrollee, spouse or dependent is determined disabled under Social Security Title II or XVI within the first 60 days of continuation, the 18‑month maximum may be extended to 29 months for the disabled person (must notify sponsor within 60 days and during the initial 18‑month period); a second qualifying event during the extended period may produce a 36‑month maximum.

Special events: for events such as divorce, death of enrollee, or other listed qualifying events the maximum continuation period is commonly 36 months (or per the specific rule shown); bankruptcy for a retired enrollee may allow continuation until the retired enrollee's death and surviving dependents up to 36 months after death.

Enforcement and Assistance Procedures

Enforcement and assistance options when rights are violated or documents not provided:

Document request failure: if requested plan documents or the latest annual report are not provided within 30 days, a participant may file suit in Federal court; the court may require delivery of materials and may award up to $110 per day until materials are received unless delay was beyond the administrator's control.

Denied or ignored claims: if a welfare benefit claim is denied or ignored in whole or in part, the participant has the right to know the reasons, obtain copies of non‑privileged documents without charge, appeal within set time schedules, and may file suit in state or Federal court if unresolved.

Remedies and assistance routes

If plan fiduciaries misuse plan assets or participants are discriminated against for asserting rights, participants may seek assistance from the U.S. Department of Labor or file suit in Federal court.
For questions or help obtaining documents or understanding ERISA rights, contact the plan administrator or the nearest Employee Benefits Security Administration office or its Division of Technical Assistance and Inquiries (contact information provided in the Certificate).

Plan Administrative Information

Required Plan Identifiers and Administrative Contacts (as furnished to participants):

Plan identifiers: name of the plan, address, IRS employer identification number, plan identification number, plan year, and plan fiscal year end are provided in or referenced to the employer's plan documents (see employer plan documents for details).

Plan administration and fiduciary: the Plan Administrator is the employer; Agent for Service of Legal Process and Named Fiduciary for this Certificate's benefits is HealthPartners Insurance Company (for other matters refer to your employer).

Funding and network: this Certificate is fully insured under Wisconsin law; Network Providers are the HealthPartners Network; contributions are employer and employee (see employer materials for details).

Eligibility and contact points: employment waiting period, eligible classes, and contact for continuation of coverage notices are detailed in the employer's plan documents and enrollment materials; see those documents for specific contact information.

Coding, Usual & Customary and Predetermination Thresholds

CPT codes referenced for estimationCPT

No codes listed

No procedure codes specified in this sectionmixed

No codes listed

inv-09: Usual and Customary Charge determination

Determination methodsUsual and Customary Charge is determined in this order (when available): 1) percentage of the Medicare fee schedule; 2) a comparable schedule if service not on Medicare fee schedule; 3) a commercially reasonable rate.

PurposeUsed as the maximum amount considered in calculating payment for certain out-of-network services; amounts above it may be the enrollee's liability and do not apply to the Deductible or Out-of-Pocket Limit.

Member actionMembers may contact Member Services (number on ID card) and provide the CPT code and estimated charge to learn the eligible expense based on the Usual and Customary Charge prior to a procedure.

inv-10: Dental predetermination financial threshold

Dental predetermination threshold$300

Provider and Member Pre-authorization, Billing and Claims Procedures

Prior Authorization

Prior Authorization Required

You or your Provider may contact Member Services or use your myHealthPartners account at healthpartners.com to determine whether Prior Authorization is required for a given service and to begin the authorization process. When Prior Authorization is required, the plan’s medical or dental directors (or their designees) make coverage determinations based on established Medical and Dental Policies.

Initial (non-urgent) determinations will be made within 14 calendar days if all reasonably needed information has been provided. This period may be extended by an additional 14 calendar days when necessary.
Urgent authorization determinations will be made within 72 hours if all reasonably needed information has been provided.
If authorized, the Health Care Provider will be notified by telephone and may receive written confirmation.
If not authorized, the Health Care Provider (and Hospital if appropriate) will be notified by telephone within one working day and will receive written verification detailing the denial.
You and your Provider have the right to request an expedited review and to appeal denials through the internal complaint and appeal process; certain denials may be eligible for external review. Refer to the Disputes and Complaints section for appeal procedures.

Terms and Definitions

inv-19: Certificate

Document identityThis document is the Group Certificate of Coverage and is your evidence of coverage while insured under the Group Policy.

Governing documentsThe Group Policy, this Group Certificate and any amendments describe the enrollee's rights and benefits.

How it is usedExplains what to do to be covered and how to file claims, grievances, or complaints.

inv-20: Usual and Customary Charge

DefinitionUsual and Customary Charge is the maximum amount allowed that we consider in calculating payment for certain out-of-network services; it reflects a range of reasonable fees charged in the same geographic region.

Determination orderDetermined using: 1) percentage of Medicare fee schedule; 2) comparable schedule if not on Medicare; or 3) a commercially reasonable rate.

Policy Summary

PayerHealthPartners

PolicyGroup Certificate / Certificate of Coverage (Wisconsin Small Employer Plan)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionMembers should contact Member Services or ask their provider for the CPT code and estimated charge before a procedure to determine the eligible expense under the Certificate.

SourceLink

On This Page

Dental predetermination: dentists should submit a predetermination when a course of treatment is expected to involve $300 or more in charges; predetermination decisions are made per the dental predetermination process.

Predetermination timing and scope: initial predetermination decision within 10 business days when information is complete (72 hours for urgent); predeterminations are limited to services performed within 90 days of approval; additional services after 90 days require a new submission.

Continuity of Care is available for defined categories (serious/complex conditions, inpatient care, scheduled nonelective surgery, terminal illness, pregnancy) and may continue until the earlier of 90 days, the plan change effective date, or when you are no longer a continuing patient, subject to exclusions such as provider termination for misconduct.

Member protections and administrative rules include

A 31‑day grace period for enrollment payments applies.
The plan may change benefits to maintain compliance with law or adjust cost‑sharing annually; amendments are incorporated into the Certificate.
The entire contract includes the Master Group Policy, this Certificate, Benefits Chart(s), amendments, and applications; the Master Group Policy is governed by Wisconsin law and is available for inspection.

Notification and appeals: approvals will be notified to the dental Provider by telephone (and may be followed by written verification); denials will be notified by telephone within one working day and followed by written verification with details; providers and members have rights to expedited review, internal appeal, and external review as described in 'Disputes and Complaints'.

Small group variations and election timing

For groups with fewer than 20 employees, the election window is 30 days (instead of 60 days) in many situations; otherwise the general election period is 60 days to elect continuation.
Premium payment timing: first premium payment is due within 45 days of election; thereafter premiums are due monthly at the start of each month of coverage.

Notices: written notices of qualifying events (e.g., divorce, change in dependent status, second qualifying event) must be provided to the Group Health Plan Sponsor within the specified timeframes (generally 60 days, and 30 days for some small‑group rules) and must include required information such as names, qualifying event or disability, and date of event.

Earlier termination: continuation coverage terminates earlier for reasons including end of the plan, failure to pay monthly premium within 30 days of due date, obtaining other group health coverage (subject to pre‑existing condition rules), termination of extended disability coverage after final determination, or other termination provisions in the Certificate.

Confinement extension: if the Group Policy is replaced and you are confined for covered care, coverage for services related to that confinement may be extended until discharge or exhaustion of benefits.

Claims timing and legal limits: provide written notice of incurred charges within 20 days; claim form supplied within 15 days of notice; provide itemized bills within 90 days (exceptions up to one year) and submit final bills no later than 15 months; payment made promptly on due proof; no legal action until 60 days after submission and within three years.

Time‑limit defenses: after two years from the Certificate effective date, misstatements (except fraud) cannot be used to void the Certificate or deny claims for losses incurred after that two‑year period.

ERISA rights and administrative access: for ERISA‑subject plans, participants have rights to examine plan documents, obtain copies, receive summary annual reports, and are informed of COBRA continuation rights and the Statement of ERISA Rights included with the Certificate.

When to submitSubmit a description of procedures, estimate of the Dentist's Charges and appropriate x‑ray in writing when a course of treatment is expected to involve $300 or more.

Who filesThe Dentist should file the predetermination with HealthPartners prior to the course of treatment.

inv-11: Predetermination financial threshold

Predetermination threshold (emphasis)$300

ApplicabilityRecommended for any course of dental treatment expected to result in Charges of $300 or more.

Provider responsibilityDentist should file predetermination materials in writing before treatment begins when threshold met.

inv-12: Predetermination validity period

Predetermination validity periodApproved predetermination is limited to services performed within 90 days from the approval date.

After expirationAdditional services required after 90 days must be submitted as a new course of treatment for approval.

Relation to approvalApproval notifications are provided to the Dentist by telephone and may be followed by written verification.

Prior Authorization

Pediatric Dental Predetermination

If a planned pediatric dental course of treatment is expected to involve charges of $300 or more, the Dentist should submit a written predetermination request prior to beginning treatment. The submission should include a description of procedures, an estimate of the Dentist’s charges, and appropriate radiographs.

A “course of treatment” is a planned program of one or more services for a diagnosed dental condition and begins on the date the Dentist first renders a service to treat that condition.
Standard predetermination (non-urgent) initial determinations will be completed within 10 business days when all reasonably needed information is provided.
Urgent predetermination initial determinations will be completed within 72 hours when all reasonably needed information is provided.
If approved, the Dentist will be notified by telephone and may receive written confirmation.
If not approved, the Dentist will be notified by telephone within one working day and will receive written verification with details of the denial.
Predeterminations apply to services performed within 90 days of approval; additional services after 90 days must be submitted as a new course of treatment.
If documentation is not submitted in advance, the plan reserves the right to determine benefits taking into account alternate procedures based on accepted standards of dental practice.
Call Member Services for more information on pediatric dental predetermination requirements.

Billing Rule

Claims Submission and Payment

Follow the plan’s claims rules to avoid delays or denials. Provide timely notice of claim and submit required documentation as described below.

Notice of claim (written) must be given within 20 days after any covered charges are incurred, or as soon as reasonably possible. Send notice to: HealthPartners Medical Claims, PO Box 21024, Eagan, MN 55121, with information sufficient to identify the enrollee and the service.
If you do not receive a claim form within 15 days after notice, submit written proof documenting date and type of service, Provider name and itemized charges.
Submit itemized proof of loss (itemized bill showing date/type of service, Provider name and charges) within 90 days after the 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.
All bills for Covered Services must be submitted within 15 months of the date of service. Claims received after 15 months can be denied unless the enrollee was legally incapable of submitting the bill.
We will make payment promptly upon receipt of due written proof of loss and will notify you of remaining liability within 30 days of receipt of a completed claim.
At our option, payments may be made directly to the Provider or the enrollee; for dependent children subject to a court order, payments may be made directly to the Provider if we are informed of the order.
No legal action on claims may be taken until 60 days after bills have been submitted, and no more than three years after due proof of loss is required to be submitted.

Note

Access to Plan Documents

Participants have a right to inspect and obtain copies of plan governing documents and related reporting information.

Examine, without charge, documents governing the plan (insurance contracts, collective bargaining agreements, and where applicable the latest Form 5500) at the plan administrator’s office and other specified locations such as worksites and union halls.
Obtain copies of plan governing documents upon written request to the plan administrator; the administrator may charge a reasonable fee for copies.
Receive a summary of the plan’s annual financial report; the plan administrator must furnish each participant with a copy of the summary annual report upon request.

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

inv-21: Network Provider

DefinitionNetwork Provider is a participating licensed physician, dentist, mental health, substance use disorder or other Health Care Provider, Facility or pharmacy listed in the network directory that has an agreement with HealthPartners to provide services.

Where to findNetwork Providers are listed in the network directory and are viewable via the member's my HealthPartners account or by contacting Member Services.

ImplicationTo obtain Network Benefits you must select and receive services from Network Providers except for limited exceptions described in the Certificate (e.g., emergency care, continuity situations).

inv-22: Designated Physician, Provider or Facility

DefinitionDesignated Physician, Provider or Facility is a current list of Network Physicians, Providers or Facilities authorized to provide certain Covered Services as described in the Certificate.

Use casesRequired for certain services to receive Network Benefits, such as convenience clinics, approved DME vendors, and designated specialty drug vendors; call Member Services for a current list.

How to verifyVerify designations via Member Services or the my HealthPartners account on healthpartners.com.

inv-23: Continuity of Care

Scope of continuityContinuity of Care may allow services from a provider who leaves the network or when the employer changes plans to continue as Network Benefits until the earlier of 90 days from termination, the plan change effective date, or when you are no longer a continuing patient.

Qualifying conditionsApplies when you are undergoing treatment for a serious/complex condition, inpatient care, scheduled nonelective surgery, terminal illness, or pregnancy (with postpartum continuation in 2nd/3rd trimester).

LimitationsContinuity benefits may be discontinued if the provider was terminated for misconduct; call Member Services for details.

inv-24: Actively at Work

Actively at Work definitionAn Enrollee is 'Actively at Work' when customarily performing all regular duties of their occupation at the usual place of employment or required travel location; vacation/holiday absences count if the enrollee was actively at work on the last regular work day.

RelevanceStatus affects eligibility and enrollment timing under the Certificate and Group Policy.

Associated termsSee Definitions section for related terms like Enrollment Date and Waiting Period.

inv-25: Authorized Representative

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

DesignationYou designate an authorized representative by completing and returning the 'Appointment of Authorized Representative' form to permit disclosure of personal health information.

LimitsIf we do not have authorization and a third party issues a Complaint or Grievance, we will investigate and respond directly to you unless otherwise permitted by law.

inv-26: CareLine SM Service

Service descriptionCareLine SM Service employs registered nurses available by phone to assist in assessing the need for medical or dental care and coordinating after-hours care as covered by the Certificate.

Access methodAvailable by telephone; details and availability described in the Certificate.

PurposeDesigned to help members determine appropriate care level and coordinate non-urgent after-hours services.

inv-27: Eligible Dependents / Child / Disabled Child

Eligible dependentsIncludes Spouse; Child (natural, adopted, legal guardian, qualified medical child support order or stepchild) who is under 26 or a Disabled Child; Qualified Grandchild under age 18 as defined.

Disabled Child criteriaA Disabled Child is chiefly dependent on the Enrollee for support, incapable of self-sustaining employment due to intellectual/mental/physical disability, with disability existing prior to limiting age; written proof and HealthPartners' approval required within 31 days.

Age exceptionsCertain exceptions to the age 26 limit apply for military service and full-time student status with documentation for medically necessary leaves of absence.

inv-28: Facility / Health Care Provider / Physician

Definition scopeFacility, Health Care Provider and Physician include licensed medical centers, clinics, hospitals, skilled nursing and outpatient facilities and licensed providers lawfully providing medical or dental services within their scope of license.

Provider typesHealth Care Provider covers licensed non-physicians (excluding naturopathic providers) such as chiropractors who render direct patient care within scope of license.

Licensing requirementServices must be provided in accordance with applicable governmental licensing privileges and limitations to be covered.

inv-30: Medical/Dental Necessity / Determination of Coverage

Medical/Dental NecessityEligible services are covered only when Medically or Dentally Necessary for proper treatment; determinations are made by our medical or dental directors or their designees.

Decision basisCoverage determinations are based on established Coverage Criteria Policies that are periodically reviewed and modified by medical/dental directors.

Scope of authorityMedical/dental directors make final authorization for certain Covered Services and determine restrictions on access and appropriateness of treatment.

inv-31: Allowable Expense

Allowable Expense definitionAn 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.

Coordination implicationWhen this Plan is primary, its benefits are determined before other plans; when secondary, benefits are determined after other plans and may be reduced accordingly.

ExampleDifference between private and semi‑private hospital room costs is not an Allowable Expense unless medically necessary or defined by the plan.

inv-32: Qualifying Events

Qualifying events listQualifying events include: termination of employment (except gross misconduct), reduction in hours/change in job status, death of the enrollee, divorce/legal separation, loss of dependent eligibility, initial eligibility of the enrollee for Medicare, and employer bankruptcy for retired enrollees.

Who may continue coverageContinuation may be elected by the Enrollee, Spouse and other dependents enrolled at the time coverage would otherwise end, and a child born to or placed for adoption during continuation.

ReferenceSee 'Continuation of Group Coverage' section for election procedures and durations.

inv-33: Extension for Total Disability

Extension triggerIf the Group Policy terminates while you are Totally Disabled and you were covered the day prior to termination, coverage is extended until the earliest of: the date total disability ends; the last day of the current Contract Year; or the date you have incurred eligible medical expenses equal to your Lifetime Maximum Benefit.

PaymentThe Group Health Plan Sponsor may require the Enrollee to pay all or part of the premium for coverage during this extension.

ApplicabilityApplies when termination of Group Policy occurs during total disability and the enrollee was covered immediately before termination.

inv-34: Fiduciaries

Fiduciaries definitionFiduciaries are the people who operate the plan and have a duty to do so prudently and in the interest of plan participants and beneficiaries.

DutiesFiduciaries must act prudently; prohibited from discriminating or retaliating against individuals for asserting rights under ERISA.

EnforcementParticipants may seek assistance from the U.S. Department of Labor or file suit if fiduciaries misuse plan assets or discriminate in enforcing rights.

inv-34: Continuation Coverage

Continuation rightYou and your dependents may have the right to continue group health plan coverage after a qualifying event (e.g., COBRA-style continuation); you or your dependents may have to pay for such coverage.

Election timing and durationsElection procedures, maximum continuation periods and premium payment requirements are governed by the 'Continuation of Group Coverage' section of this Certificate; durations vary by qualifying event and group size.

Reference to documentsReview this Certificate and plan governing documents for full rules and eligibility; see 'Continuation of Group Coverage' for specifics.