Thank you for choosing HealthPartners for your health care coverage.
This webpage 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.
The HealthPartners organization
HealthPartners is a consumer-governed, non-profit health care organization committed to improving the health of its members, patients and the community.
Founded in 1957, HealthPartners provides a full range of health plan services including insurance, administration and health and well-being programs. We serve more than 1.8 million medical and dental health plan members nationwide, and are the top-ranked commercial plan in Minnesota.
Since our combination with Park Nicollet in 2013, our care system serves more than 1.2 million patients and includes more than 1,800 physicians; seven hospitals; 55 primary care clinics; 22 urgent care locations; and numerous specialty practices in Minnesota and western Wisconsin, who are all dedicated to providing patient-centered care that includes:
- Support and coordination services for members with chronic illnesses
- Innovative inpatient and outpatient services
- Health improvement
- Medical education
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 healthpartners.com and search Member Rights and Responsibilities.
Enrollee bill of rights
Your enrollee bill of rights information is available in your member contract. Member bill of rights information is available in member contracts administration by Group Health, Inc., or HealthPartners, Inc.
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.
To obtain a copy of this report, visit the Consumer Tools section of healthpartners.com/improvequality and look under Health Care Quality. You can also request a copy of the HealthPartners Quality Improvement program description by contacting Member Services.
HealthPartners follows the evidence-based guidelines recommended by the Institute for Clinical Systems Improvement (ICSI). These health care guidelines identify best practices for preventing or treating a health condition. Guidelines are available on the ICSI website.
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, we will notify you of your right to submit an appeal. 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. 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 CareCheck® Program 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 you’re 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, a hearing before the Board of Directors Member Appeals Committee, 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 may 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. 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 at healthpartners.com/pharmacy. 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 healthpartners.com/pharmacy 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 952-883-5127). 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, go to healthpartners.com and 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 the need for 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, 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 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 by the Medical Directors, 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 of specialty and primary care physicians. Finally, the P&T Committee considers the advisory group recommendation and also considers more closely the cost implications and member service issues resulting from any formulary changes.
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.
- 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.
- 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.
- 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.
- Sometimes we have withhold arrangements with providers, 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 one or more of the following 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
- 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.
- 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.
- 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 he or she is paid.
Fraud, 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 at healthpartners.com/hp/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 firstname.lastname@example.org.