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HealthPartners

Coverage criteria policies

In-network benefit requests

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.

This policy addresses requests for reimbursement of out-of-network care at in-network benefit levels. To be considered for this policy, an in-network healthcare provider will need to submit sufficient documentation for the plan to determine that treatment for the member’s current condition is not available within the member’s plan network.

For behavioral health services, see the Access to Out-of-Network Behavioral Health Services coverage policy.

Members living or traveling out of the health plan service area (e.g. vacation, business trips, and students) are outside the scope of this policy

Members on plans that require insurance referrals should talk with their primary care physician for direction.

Administrative Process

Not all benefit plans allow for consideration of reimbursement of out-of-network healthcare providers or facilities at the in-network benefit level. Contact member services for additional information.

The in-network healthcare provider must complete and submit the In-Network Benefit Request Form and receive a health plan decision, prior to the service being rendered.

In addition, for medical services that require prior authorization, see any coverage policies specific to those services and submit a separate prior authorization request form for those services.

Coverage

Indications that are covered at the in-network benefit level

Out-of-network providers or facilities may be covered at the in-network benefit level if criteria 1-4 listed below are all met:

  1. The service must be eligible for coverage under the terms of the member’s benefit plan.
  2. The service must be medically necessary. Medical necessity is the primary criterion that is considered in determining whether a health care service is eligible for coverage for a specific benefit under a member contract. Other definitions that are also used in determining coverage of eligible services are "custodial", "rehabilitative", "reconstructive", "investigative", and "cosmetic" as well as explicit contract exclusions. When more than one definition applies to a service, the most restrictive applies, and specific exclusions take precedence over general benefit description (e.g., medically necessary, custodial care is not covered). The Health Plan Medical Director or designee makes determinations of medical necessity. Provision or authorization of a health care service by a network provider does not establish coverage for that service.
  3. The service must be provided by a licensed healthcare professional and/or facility.
  4. The service, alternative service, or sequence of services, which are likely to produce equivalent results for treatment of the member’s current condition, are not currently available within the member’s network.

The health plan medical director or designee will determine the appropriate time and/or treatment parameters applicable to the requested in-network benefit request. This decision is based on the member’s current clinical status and health history, according to the supporting documentation submitted to the health plan for review at the time of the request for an in-network benefit request.

Requests for extension of a previously approved in-network benefit request must continue to meet the above coverage criteria.

Indications that are not covered at the in-network benefit level

  1. Coverage at the in-network benefit level for services or care received from an out-of-network provider or facility is not available when the equivalent service or care to evaluate, diagnose, and/or treat the specific medical condition is available with an in-network provider or facility. Not all providers or facilities are in all HealthPartners member benefit plan networks. Please contact member services to confirm member network status.
  2. Coverage at an out-of-network facility will not be covered at the in-network benefit level on the basis of the service being performed by an in-network provider. Please contact member services to confirm the network status of providers and facilities.
  3. Coverage at the in-network benefit level for services or care received from an out-of-network provider or facility is not available for reasons of preference and/or convenience of the patient or provider.

Definitions

In-network refers to eligible care received from licensed physicians, dentists, health care professionals, facilities, pharmacies, or vendors who participate in the network applicable to the member’s plan.

Medically necessary care is diagnostic testing and medical treatment which is medically appropriate to the member's physical or mental diagnosis for an injury or illness, and preventive services covered in the member’s contract. Medically necessary care must meet the following criteria: 

  1. It meets clinically accepted medical services and practice parameters of the general medical community; and
  2. It is an appropriate type of service delivered at an appropriate frequency and level of care, and in an appropriate setting for the member's condition; and
  3. It restores or maintains health; or
  4. It prevents deterioration of the member's condition; or
  5. It prevents the reasonably likely onset of a health problem or detects an incipient problem. 

Out-of-network refers to eligible care received from licensed physicians, dentists, health care professionals, facilities, pharmacies, or vendors not participating in the network applicable to the member’s plan.

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

  • 08/08/2017 - Date of origin
  • 06/05/2018 - Effective date
Review date
  • 08/2018
Revision date
  • 06/05/2018

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