Important information
Thank you for choosing HealthPartners for your health care coverage.
This covers important regulatory information that we are legally required to provide to members annually. Please review this information and bookmark this link so you know where to turn for answers about your health plan. If you would like this information in print, please contact Member Services at the number on the back of your member ID card.
To learn more about HealthPartners, visit About Us.
Member Information
- Member rights and responsibilities
- Quality improvement program
- Preventive care guidelines
- Financial report
- Privacy practices
- Appeals and external review
- Population health programs
- Pharmaceutical management notice
- Your health care rights
- Coverage for new treatments and technologies
- Breast reconstruction coverage
- Provider reimbursement information for medical plans
- Claims fraud hotline
- Price comparison information for providers in your network
- Your covered benefits
- Your formulary (drug list)
- Find out how much you owe after visiting the doctor
- Submit a claim
- Out-of-network benefits and getting care outside your area
- Find doctors in your network
- Know where to get any type of care 24/7
- Free language assistance
Your covered benefits
A covered benefit is a service or product that is paid for partially or entirely by your health plan. Like a doctor’s office visit, lab work or a walking cast for a broken foot, for example.
Visit My plan and click the “See what’s covered” button to view the details of your benefits by type of care or service needed. You’ll be able to see deductible, coverage level, out-of-pocket costs, covered and not covered services and limitations, for both in-network and out-of-network benefits.
For additional details, you can also explore the “insurance documents” and “coverage criteria policies” links on this page.
Your formulary (drug list)
Every health plan has a formulary, also known as an approved drug list, that includes medications that are covered by your plan and information on any particular rules or limits on that coverage.
You can find your plan formulary under Pharmacy in your online account under “See what’s covered.” If you take a medicine that isn't on the drug list, you can request to have the medicine covered by your insurance. This is called requesting a prior authorization or a formulary exception.
Find out how much you owe after visiting the doctor
After you receive care, a medical claim (invoice or bill) is submitted by your doctor’s office to your health insurance company. Once the claim is processed you’ll often receive an explanation of benefits (EOB) from your health insurer about the claim, explaining how it was paid and what you owe. And you will receive a bill from your doctor’s office for any costs not covered by your plan. You pay that directly to your doctor’s office.
You can view processed medical claims and EOBs in your online account anytime.
Submit a claim
If you have a question about how to file a claim with us, we’re here to help. Call Member Services at the number on the back of your member ID card or send us a message.
Understand your out-of-network benefits and how to get coverage outside your typical coverage area
Not all plans cover out-of-network care, so it’s important to sign in to review your benefits and see what’s covered for you. Click through each type of care or service needed to see your in-network and out-of-network coverage. And make sure to review any plan provisions for out-of-network services. You can also find more details within your plan documents.
Learn more about in-network and out-of-network coverageFind doctors in your network
HealthPartners insurance plans cover more than 1 million doctors. But not every doctor is covered in every network. Sign in to find a doctor, specialist or dentist who’s right for you and in your network. You can search for a provider by name, specialty, location and more, as well as find more information on their background and qualifications.
Know where to get any type of care 24/7
When you need advice on what type of care you need and how urgently you need it, you can call the 24/7 HealthPartners CareLine℠ at the number on the back of your member ID card or 800-551-0859.
- Primary care
Primary care is your go-to for everyday health care needs. There are five main types of primary care doctors that are uniquely trained to guide you through all stages of life.
Find a primary care doctor in your network - Specialty care
You can see any specialist in your network, including cardiologists, podiatrists, physical therapists and many others.
Find specialty care in your network - Behavioral health care
You can see a therapist, get a chemical dependency evaluation or receive other outpatient care from any clinic in your network. And most HealthPartners plans also have access to an Employee Assistance Program or Member Assistance Program, which can help support you with a variety of everyday life challenges including mental health.
Find a mental or chemical health care professional in your network or call our Behavioral Health Navigators at 888-638-8787 for help finding a provider. - Hospital care
Hospital care is any medical treatment that is provided in a hospital. This can include inpatient, outpatient, specialty, mental health or critical care services. While emergency care happens within hospitals, care that’s provided in the emergency department is covered under your Emergency and Urgently Needed Care Services benefit. Other in-network hospital care is generally covered under your Inpatient or Outpatient Hospital Services benefits. Review your benefits or call Member Services to learn more. You may also want to review your ambulance and medical transportation benefits to know what’s covered.
Find hospital care in your network - Urgent care
If you or a family member needs urgent care during clinic hours, call your regular clinic. If your clinic is closed, you can call the 24/7 HealthPartners CareLine℠ service for assistance at the number on the back of your member ID card or 800-551-0859. And don’t forget to review your benefits to see how your in-network care at any of these types of locations will be covered.
Find urgent care in your network - Emergency care
If you or a family member has a medical emergency, getting help right away is the most important thing. Call 911 or go to the nearest hospital emergency room. Emergency care, no matter where you are, is covered at your plan’s in-network levels. After an emergency, your follow-up care may or may not be in network, depending on where you receive it.
Find emergency care in your network
Free language assistance
Free language assistance (PDF)Member rights and responsibilities
As a member, you are entitled to certain rights and services. You also have a responsibility to participate in your health care. A good partnership enhances our ability to provide appropriate services and your ability to receive the maximum benefit from services. For a summary of your rights and responsibilities as a member, call Member Services or visit our HealthPartners Disclosures page to find Rights and Responsibilities, Continuing or Transitioning Care, Standing Referrals, Provider Reimbursement and Complaints and Appeals. You can find all of these in the drop down menu on the left side of the page.
Enrollee bill of rights
Member bill of rights information is available in member contracts administered by Group Health, Inc., or HealthPartners, Inc.
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Quality improvement program and evaluation
HealthPartners conducts an annual assessment of the effectiveness of our health plan quality improvement program, which is published in the annual quality improvement evaluation.
You can find a copy of this report on our website, or request a copy of the by contacting Member Services.
Population health programs
Our population health program is integrated between, health and well-being, disease management, medical and behavioral health case management, utilization management, pharmacy, member services and our digital offerings. Our programs include interactive and non-interactive offerings. Interactive offerings include a two-way interaction between HealthPartners and our members, during which the member is provided with self-management support, health education or care coordination via telephone, in-person or online. Non-interactive programs are self-completed.
Appeals and external review
We do our best to give you outstanding care and service, and when you have concerns, we have many resources to assist you. Most concerns can be resolved quickly through a telephone call to Member Services.
If your concern cannot be resolved to your satisfaction, you have the right to submit an appeal on the outcome of a coverage decision. We handle all complaints and appeals according to state and federal guidelines. You or your authorized representative may submit comments, documents, records or other supporting information relating to the appeal that you would like us to review.
Member Services will investigate your appeal; this includes a review of all the information you or your authorized representative provided, plan and claim information as appropriate. Generally, we will notify you of our decision within 30 days of receipt of your appeal request for a standard appeal (15 days for pre-service appeals). The review timeframe for a standard appeal can be extended, consistent with state and federal law if we give you advanced written notice. If your plan includes a shorter timeframe for a pre-service appeal we will respond as required. If your attending health care professional determines that the standard appeal timeframe could seriously jeopardize your life or health, we will expedite your appeal and notify you of our decision as soon as possible, but no later than 72 hours after we receive your appeal request.
If you do not agree with our response to your appeal, there are additional appeal options available to you that vary based on the type of plan in which you are enrolled and the nature of your concern.
If your plan is a fully insured plan, you may have the option to request a written reconsideration, or a hearing before the Board of Directors Member Appeals Committee for benefit disputes, or other panel reviews as determined by your plan and the state in which you receive care. Consistent with the terms of your plan, you also have the right to request an independent external review of our decision by writing to the appropriate regulatory agency; our letter will include detailed information about how to pursue this option. The external review organization will review all of the information provided by you and us, that relates to the appeal and make a decision that is binding on HealthPartners.
If you are enrolled in an employer group’s self-insured plan, or if you are a member of one of our HealthPartners® Care or Medicare plans, your appeal options are different. Our letter will include detailed information about how to further appeal. For more information about your appeal rights, review your plan documents or member contract. If you have additional questions, please call Member Services.
Pharmaceutical management notice
HealthPartners preferred drug lists (formularies) have been developed by the HealthPartners Pharmacy and Therapeutics Committee.
This committee includes physicians and pharmacists from throughout the community. Their goal for the preferred drug lists is to encourage greater safety, effectiveness and affordability of your prescription drugs.
These experts review the scientific data on new and existing drugs, select the ones that are both safe and effective, and regularly update our preferred drug lists. The committee also relies on clinical pharmacists and work groups made up of practicing experts in various areas to review drug information and make recommendations.
Some drugs may require prior authorization. The criteria are listed on our website. If coverage for a particular drug has not been approved, both you and your doctor have the option to appeal that decision.
For more information on the preferred drug lists and HealthPartners pharmaceutical management procedures (including the exception procedure), visit our website or call Member Services. A printed version of this information is available upon request.
Your health care rights
Utilization management, prior authorization, case management and financial incentives
If you have questions regarding a utilization management decision, prior authorization or case management, call Member Services at the number on the back of your ID card, or 952-883-5000 or toll-free at 800-883-2177 (TTY users should call 711). They’re available Monday through Friday, 7 a.m. to 7 p.m. CT.
Staff from one of the medical management areas, such as medical policy, behavioral health, pharmacy, or case management can answer your questions from 8 a.m. to 5 p.m. CT, Monday through Friday. Utilization management and case management staff have access to language services when needed for conversations with members in their preferred language.
HealthPartners encourages best care practices through collaboration with doctors and clinics. HealthPartners has implemented a complete set of financial rewards and incentives that encourage physicians and hospitals to provide members with the highest quality and most cost-effective care. For complete information, search Provider Reimbursement.
Our job is to ensure that you get appropriate care.
Part of helping our members stay healthy is making sure you get the care you need when you need it. We use programs that support you in getting appropriate care and prevent the underuse, overuse, or misuse of health services. Decision-making in these utilization management programs is based on your plan coverage and appropriateness of care. HealthPartners does not use financial incentives to encourage barriers to care and service. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. HealthPartners does not hire, promote, compensate, terminate, or specifically reward practitioners or other individuals based on the perceived likelihood that the practitioner or staff member supports, or tends to support, denials of coverage.
Coverage for new treatments, devices, pharmaceuticals, procedures, diagnostic tests and technologies
Our goal is to cover the use of new technologies and new uses for established technologies when they've been scientifically proven safe, effective and have a positive effect on health outcomes beyond what is currently available.
To help us decide whether to begin covering new therapies and procedures, the HealthPartners Medical Directors Committee evaluates relevant scientific evidence. This multispecialty, physician-led group follows a formal process to analyze information from such varied sources as peer-reviewed medical articles, formal technology assessments, government regulatory agencies and expert opinions from practicing physicians.
Based on the strength of the evidence reviewed, HealthPartners generally extends health plan coverage to all procedures, drugs, devices, diagnostic tests and technologies that have proven to be safe, effective and have a positive effect on health outcomes beyond what is currently available. New technologies that do not meet these standards are considered experimental/investigative or not medically necessary and are generally not covered. In some cases, coverage may be limited due to contract exclusions.
Coverage for new pharmaceuticals
HealthPartners develops and maintains a drug formulary based on several guiding principles. Effectiveness is weighted most heavily, followed by safety, and then by cost. New drugs are carefully reviewed by clinical pharmacists. This review includes a literature review, a review of the FDA-approved prescribing information, a review of guidelines and drug compendia, a comparison with current formulary products, and a pharmacoeconomics comparison. Next, the drug is reviewed by a therapeutic-specific advisory group that includes specialists and primary care providers. The P&T Committee then considers the literature and the advisory group recommendation for each medication and determines coverage status and criteria.
Breast reconstruction coverage
Under the Women’s Health and Cancer Rights Act of 1998 and state law, health plans are required to cover breast reconstruction following a mastectomy.1 HealthPartners provided this coverage prior to these laws.
The law requires coverage for reconstruction of the affected breast after mastectomy surgery, for surgery and reconstruction of the other breast, for symmetry, and for prostheses and physical complications at all stages of the mastectomy, including lymphedemas. The need for these services should be discussed with your physician.
Breast reconstruction is covered under your medical/surgical benefits and is subject to any deductible and coinsurance limitations as described in your member contract or summary plan description.
1 Minnesota state law does not apply to Medicare Advantage plans. These plans follow federal regulations applicable to the Medicare program.Provider reimbursement information for medical plans
Our goal in reimbursing providers is to provide affordable care for our members while encouraging quality care through best care practices and rewarding providers for meeting the needs of our members. Several different types of reimbursement arrangements are used with providers. All are designed to achieve that goal.
- Fee-for-service: Some providers are paid on a “fee-for-service” basis, which means that the health plan pays the provider a certain set amount that corresponds to each type of service furnished by the provider.
- Discount: Some providers are paid on a “discount” basis, which means that when a provider sends us a bill, we have negotiated a reduced rate on behalf of our members. We pay a predetermined percentage of the total bill for services.
- Case rate: Sometimes we have “case rate” arrangements with providers, which means that for a selected set of services the provider receives a set fee, or a “case rate,” for services needed up to an agreed upon maximum amount of services for a designated period of time. Alternatively, we may pay a “case rate” to a provider for all of the selected set of services needed during an agreed upon period of time.
- Withhold arrangements: Sometimes we use withhold arrangements as part of provider payments, which means that a portion of the provider’s payment is set aside until the end of the year. The year-end reconciliation can happen in a variety of ways. Withholds are sometimes used to pay specialty, referral or hospital providers who furnish services to members. The provider usually receives all or a portion of the withhold based on performance of agreed upon criteria, which may include patient satisfaction levels, quality of care and/or care management measures
- Diagnosis: Some providers — usually hospitals — are paid on the basis of the diagnosis that they are treating; in other words, they are paid a set fee to treat certain kinds of conditions. Sometimes we pay hospitals and other institutional providers a set fee, or “per diem,” according to the number of days the patient spent in the facility.
- Ambulatory payment classifications: Some providers — usually hospitals — are paid according to ambulatory payment classifications (APCs) for outpatient services. This means that we have negotiated a payment level based on the resources and intensity of the services provided. In other words, hospitals are paid a set fee for certain kinds of services and that set fee is based on the resources utilized to provide that service.
- Total cost of care: Some providers — usually primary care medical groups — are paid based on how well they manage the total cost of care associated with a patient, as well as how well they manage the patient experience and the quality of care provided.
Occasionally our reimbursement arrangements with providers include some combination of the methods described above. For example, we may pay a case rate to a provider for a selected set of services needed during an agreed upon period of time, or for services needed up to an agreed upon maximum amount of services, and pay that same provider on a fee-for-service basis for services that are not provided within the time period or that exceed the maximum amount of services. In addition, although we may pay a provider such as a medical clinic using one type of reimbursement method, that clinic may pay its employed providers using another reimbursement method.
Check with your individual provider if you wish to know the basis on which they are paid.
Network provider price transparency
Members can access our price transparency tool by signing in to their online account. The tool allows members to search for and understand the cost of hundreds of procedures at different doctors, clinics and hospitals in their network.
Learn more about how to understand the costs of care before you get itFraud, waste and abuse
HealthPartners is committed to preventing, detecting, and reporting Fraud, Waste, and Abuse (FWA). We all need to help with this important effort. There are several simple steps you can take to prevent and detect FWA including knowing the signs of FWA, asking questions when something looks or feels suspicious, and reporting your concerns.
Some examples of fraud, waste, and abuse include:
- Receiving Explanations of Benefits for services you did not receive
- Using another person’s insurance card or identity to receive health care services
- Receiving narcotics with forged or altered prescriptions
Stay informed and up-to-date with current fraud alerts
If you have any questions or suspect fraudulent activity, call HealthPartners Claims Fraud Hotline at 952-883-5099, 855-332-7194 or Member Services at the number on the back of your member ID card. Your call will be kept confidential. You can also email us.