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Coverage criteria policies

HealthPartners has Medical Policies that contain coverage criteria that describe how we make coverage decisions for certain health care services and items. Which coverage criteria apply to your plan depends upon the state in which the plan was purchased, which is not necessarily your state of residence. For a customized experience, log on to myHealthPartners. For questions, call the Member Services number on the back of your member identification card.

The information regarding coverage guidelines is regularly updated and is subject to change without notice. Read more…

Medicare plans

For Medicare coverage criteria, click here.

For a list of services requiring Medicare prior authorization, click here.

If unsure of the keyword spelling, enter the first three letters of the word followed by an asterisk (*). Example: enter acu* to locate the acupuncture policy.

Policy search filters

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 20 of 321 policies
Policy name Policy category Product Prior authorization required
Deep brain stimulation for neurological movement disorders Surgery
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Denosumab (Prolia® and Xgeva®) Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - accidental dental Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - ambulatory hospitalization and anesthesia for dental care Medical Dental
Iowa
MHCP
Minnesota
South Dakota
Wisconsin
Yes
Dental services - ambulatory hospitalization and anesthesia for dental care - North Dakota Medical Dental
North Dakota
Yes
Dental Services - Cone beam computed tomography (CBCT) scan for medically-related dental services Diagnostic Imaging
Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - medically necessary outpatient Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Dental services - oral surgery Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dental Services - Orthodontics Medical Dental
Minnesota
Yes
Dental Services - Orthognathic surgery Medical Dental
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Designated network for children's psychiatric residential treatment services Behavioral Health
MHCP
Minnesota
Wisconsin
Yes
Diabetic monitors/meters Equipment/Supplies
Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dietitian consultation Ancillary Services
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Direct-to-consumer (DTC) laboratory testing Administrative
Laboratory
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Discography/intradiscal steroid injections Medical Services
Spine
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
DME benefits grid Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Dressing supplies Equipment/Supplies
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
No
Duopa Pharmacy
Iowa
MHCP
Minnesota
North Dakota
South Dakota
Wisconsin
Yes
Durable Medical Equipment (DME) and prosthetics Equipment/Supplies
Iowa
Minnesota
North Dakota
South Dakota
Wisconsin
No
Durable Medical Equipment (DME) and supplies - Minnesota Health Care Programs Equipment/Supplies
MHCP
No
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All
Viewing 20 of 321 policies