Important information

A covered benefit is a service or product that is paid for partially or entirely by your health plan. Examples of covered benefits may include a doctor’s office visit, lab work or a walking cast for a broken foot.

The best way to see what’s covered by your specific plan is to sign in to your HealthPartners online account. You can review your benefits by the type of care or service needed. For both in-network and out-of-network benefits (if applicable), you’ll also be able to see if any deductibles apply, coverage level differences, out-of-pocket costs, and covered and not-covered services and limitations (coverage criteria).

You can also review your insurance documents to get detailed information about what’s covered by your plan.

Every health plan has a drug list (formulary) that lists the medicines covered by the plan, plus any particular rules or limits on that coverage.

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.

HealthPartners insurance plans cover more than 1 million doctors, across all 50 states. But not every doctor is covered in every network.

The easiest way to find a doctor, clinic, hospital or other covered provider in your particular plan’s network is to sign in. You can search for a provider by name, specialty, location and more, as well as find more information on the provider’s background and qualifications.

If you need help finding in-network care, you can also contact Member Services.

Many HealthPartners plans offer both in-network and out-of-network coverage. However, you’ll pay a larger share of the cost when you choose a doctor or care that is not covered by your plan's network.

Not all plans cover out-of-network care. Please review your coverage to see if your plan includes out-of-network benefits. If it doesn’t, you’ll be responsible for the full cost of any out-of-network care you receive.

Primary care is your go-to destination for everyday health care needs. If you’re not sure where to start, a primary care doctor is usually a great first step. There are five main types of primary care doctors that are uniquely trained to guide you through all stages of life.

If you or a family member has a medical emergency, call 911 or go to the nearest hospital emergency room.

Emergency care, no matter where you are, is covered as if it were in network. That means you’ll always pay your plan’s in-network cost-sharing amounts for emergency care.

After an emergency, your follow-up care may or may not be in network, depending on where you receive that follow-up care. To take advantage of typically lower care costs at in-network providers, sign in to search your network if you need care after an emergency has passed.

Hospital care is any medical treatment provided in a hospital. This can include inpatient, outpatient, specialty, mental health or critical care services.

Emergency care provided in hospital emergency departments 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. You may also want to review your ambulance and medical transportation benefits to know what’s covered.

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 behavioral health.

You can also get help finding a provider when you contact Member Services or a behavioral health navigator.

You can see any specialist in your network, including cardiologists, podiatrists, physical therapists and many others.

Keep in mind:

• It’s often a good idea to talk first with your primary care doctor about seeing a specialist. Your doctor might be able to help you choose the right specialist or coordinate your care.
• Some specialists have their own policies of requiring recommendations from your primary care doctor before you can make an appointment. Usually, specialists have these policies to better align treatment and information sharing with your primary care doctor.

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.

• A CareLine nurse can help you find nearby care, including urgent care clinics and retail clinics, which are open evenings and weekends. (You can sign in to see which urgent care providers are in your network.)
• CareLine nurses can also give advice on home treatment options and help you decide what kind of care you need.

If you or a family member has a medical emergency, call 911 or go to the nearest hospital emergency room.

• Emergency care, no matter where you are, is covered as if it were in network. That means you’ll always pay your plan’s in-network cost-sharing amounts for emergency care.
• After an emergency, your follow-up care may or may not be in network, depending on where you receive that follow-up care. To take advantage of typically lower care costs at in-network providers, sign in to search your network if you need care after an emergency has passed.

HealthPartners offers a cost transparency tool that allows members to search for and understand the cost of hundreds of procedures at different doctors, clinics and hospitals in their network:

• When you sign in to get a cost estimate, your plan’s coverage will be taken into account to give you a personalized good-faith estimate of your out-of-pocket costs.
• You can use these estimates to compare the cost of the same service at multiple providers, find quality care that fits your budget and make more informed choices about your care.
• The cost estimate tool is available if you have any medical insurance plan with us (except Medicare or Medical Assistance).

Generally, after you receive care:

1. Your provider will submit a medical claim (invoice or bill) to us.
2. We’ll send a payment to your provider that covers all, part or none of the claim.
3. We’ll send you an Explanation of Benefits (EOB) for the claim. Your EOB explains how your plan benefits affected what we paid your provider. It also shows any amount you’re responsible for paying (for example, deductibles, copays or coinsurance as part of your plan).
4. If you haven’t yet paid your provider any part of the amount your EOB shows you’re responsible for, your provider will send you an invoice or bill. You’ll pay your provider directly.

Most claims are submitted automatically to us by your provider. But sometimes you may need to submit a claim directly to us.

If you have comments for us, we’d like to know. We review every piece of feedback we receive so we can better serve our members.

HealthPartners provides personalized support to help you feel as good as possible, no matter what your health status is. Our services can help you:

Our population health programs are integrated among our teams specializing in health and well-being, disease management, medical and behavioral health case management, utilization management, pharmacy, member services and digital experiences. Programs include interactive and non-interactive offerings. Interactive offerings include two-way interaction between yourself and HealthPartners, during which you can get self-management support, health education or care coordination via telephone, in-person or online. Non-interactive programs are self-completed. Program eligibility may vary by plan.

On our preventive care recommendations page, you can find information about preventive care services you may be due for. You can also get more information about preventive care, including what it is and how your plan covers it.

HealthPartners offers free language assistance for members whose primary language is not English.

As a member, you’re 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, contact Member Services or review our disclosures to find information about:

Member bill of rights information is available in member contracts administered by Group Health, Inc., or HealthPartners, Inc.

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 utilization management (UM) programs, such as prior authorization and case management, that support you in getting appropriate care and prevent the underuse, overuse, or misuse of health services.

Decision making in these programs is based on your plan coverage and appropriateness of care. 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 at 800-883-2177 (TTY 711).

• Member Services is available Monday through Friday, 7 a.m. to 6 p.m. CT. Staff from our medical policy, behavioral health, pharmacy and case management areas are available 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.

Importantly, HealthPartners does not use financial incentives to encourage barriers to care and service. For example, financial incentives for UM decision makers do not encourage decisions that result in underutilization, and we do 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.

You have the right to appeal the outcome of a coverage decision. We handle all appeals according to state and federal guidelines.

If you have a Medicare plan with us, get more information about Medicare determinations, appeals and grievances.

If you have a Medical Assistance (Medicaid) plan with us, call 866-885-8880 (TTY 711) for more information.

If you have any other plan with us:

• You, your health care provider or your authorized representative can fill out the HealthPartners complaint/appeal form (PDF) and return it to us via email (DRT@healthpartners.com), fax (952-883-9646, ATTN: Appeals) or mail (HealthPartners Appeals, MS 21104G, P.O. Box 1309, Minneapolis, MN 55440-1309).
  • Please include all information that’s requested, including what you’re requesting and why, the best phone number to reach you during the day, your email address (if you’d like to get the outcome of your appeal via email), and any other information you’d like us to consider, such as comments, documents or records that support your request.
  • If you’re appealing a denied authorization for future care, you can also call us at 800-331-8643. We’re available Monday through Friday, 8:30 a.m. to 4 p.m. CT.
  • If we denied coverage for urgently needed services based on our medical necessity criteria, you can request an expedited review by noting your expedited request on the appeal form or when you call us.
  • In most cases, you must send us your appeal request within 180 calendar days of our original decision. The original decision date is the date of a denial letter or the date of an explanation of benefits (EOB) statement, whichever comes first.
• After we receive your appeal request, we’ll review it and respond. Within 15 or 30 days (depending on your plan), you’ll get a letter via mail or email with our decision and explanation.
  • If we can’t respond to you within the required timeframe due to circumstances beyond our control, we’ll let you know – in such cases, we may need four to 14 additional days.
  • If you requested an expedited review and waiting the standard review time would jeopardize your life or health, you’ll get a response within 72 hours.
• If we can’t fully approve your appeal, we’ll provide information and directions regarding further appeal options available for your plan, such as external reviews. If all required reviews of your claim have been completed and your appeal still hasn’t been approved, most members have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974.

Our notice of privacy practices is available in several languages for health plan members.

We are committed to protecting the privacy of your PHI, including your race, ethnicity, language, sexual orientation and gender identity. Our policies ensure our employees have the “minimum necessary” amount of data to do their jobs:

• Access to protected health information data is controlled and limited to prevent unauthorized access. Employees can only access the type of information they need to do their jobs, and there are rules around what employees can do within our systems.
• System access is individualized to ensure users are only able to access and/or modify content appropriate to their business needs. Employees may not use their position at HealthPartners to gain access to the protected information of their friends or family members, unless there is a work-related need to know.

We also share information with practitioners and providers in the following ways:

• To treat you (treatment). Your information is shared to create a safe and more coordinated care experience for you. (Please note that we don’t need your permission to share your information in a medical emergency if you can’t give us permission due to your condition. Also, the health care systems providing treatment don’t need your permission to share your information with each other, as long as it’s for a permitted purpose.)
• To pay for your services (payment). We can use and share your information to pay providers and others for care that you receive.

We will not use data related to your race, ethnicity, language, sexual orientation or gender identity for the purpose of underwriting or denial of coverage and benefits, including utilization management denials and appeal determinations.

Members can set preferences for how we communicate non-required information to you in several ways. Non-required information includes health recommendations, preventive care reminders and tips for managing your health plan.

• To change your preferences for email communication, sign in to update your account settings.
• To change your preferences for mail or prerecorded phone messages, contact Member Services.

Members cannot opt out of required health plan documents, such as Summary Plan Descriptions (SPDs), Explanations of Benefits (EOBs), member handbooks and privacy policies. These are delivered to you electronically or by mail based on your paperless settings.

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 medically unnecessary and are generally not covered. In some cases, coverage may be limited due to contract exclusions.

HealthPartners drug lists (formularies) are developed by the HealthPartners Pharmacy and Therapeutics Committee. On our drug formularies page, you can find information about how our drug lists (formularies) are developed.

HealthPartners drug lists (formularies) are developed by the HealthPartners Pharmacy and Therapeutics Committee.

On our drug formularies page, you can find:

• The drug list for your plan
• Information about how our drug lists are developed
• Information about prior authorization and exception request processes for our drug lists

A printed version of this information is available upon request.

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.

Founded in 1957, HealthPartners is the largest consumer-governed, nonprofit health care organization in the nation, providing health care, health plan financing and administration, and medical research and education.

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.

HealthPartners conducts an annual assessment of the effectiveness of our health plan quality improvement program, which is published in the annual quality improvement evaluation.

HealthPartners is committed to preventing, detecting and reporting fraud, waste and abuse (FWA). We all can help with this important effort.