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HealthPartners

Coverage criteria policies

Authorized care outside the service area

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Requires prior authorization.

Coverage

Authorized Care Outside the Service Area is generally covered per the indications listed below for members who do not have an out of network benefit available.

For travelling members, care must be follow-up services to a condition which was diagnosed and treatment started prior to the member leaving the service area. Coverage is available for 3 one week periods per calendar year. Authorizations are given in one week intervals regardless of the number of visits/services utilized within that week. They may be consecutive or non-consecutive weeks.

The DME (durable medical equipment) benefit applies to DME required outside the service area. Call Member Services for national contracted providers.

These coverage criteria do not apply to emergency care. Please see your member contract/summary plan description for this coverage.

Indications that are covered

  1. Allergy injections (travelers should obtain serum prior to leaving the service area)
  2. Lab draws
  3. Office visits
  4. Rehabilitative physical/occupational/speech/chiropractic therapy
  5. Mental/chemical health office visits
  6. Dialysis
  7. IV (intravenous) therapy
  8. X-rays

Indications that are not covered

  1. Services for travelers received after the initial 3 one-week periods (consecutive or non-consecutive) or services per year (except for students).
  2. Services for travelers which did not initiate prior to leaving the service area.
  3. Services for students who are no longer covered as a dependent on another person’s policy and have their own coverage.
  4. Inpatient stays, skilled or unskilled nursing home stays.
  5. Elective or scheduled surgeries.
  6. Habilitative therapies.
  7. Follow-up CT/MRI/PET scans for travelers.
  8. Home care.
  9. Preventative care including, but not limited to, eye exams, annual physicals, screening mammograms, pap smears, and immunizations.
  10. OB (obstetrics) services.
  11. Abortions
  12. Care which is not medically necessary during the timeframe the member is outside the HealthPartners service area.
  13. Follow-up to emergency care for travelers.

Definitions

Authorized Care Outside the Service Area – A benefit available to HealthPartners dependent students and members temporarily outside the service area for short term travel. It covers certain medical outpatient services that cannot wait until the member will be back in the service area. Care needs to be medically necessary during the member’s time outside the HealthPartners service area.

Short Term Travel – Up to 3 consecutive weeks per year of travel outside of HealthPartners’ service area.

Traveler – A member who travels outside the service area.

Full-time Student – An enrollee’s dependent who is enrolled in, and attending full-time, a recognized course of study or training in a public or private secondary school, college, university or licensed trade school.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 12/09/2003 - Date of origin
  • 05/03/2017 - Effective date
Review date
  • 04/2017

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