Coverage criteria terms and conditions

Coverage criteria

HealthPartners reserves the right to publish additional and updated coverage criteria without specific notice to members.

Look at your membership contract or summary plan description (SPD) to see governing contractual provisions, including exclusions and limitations, that relate to your specific plan. You can find these in your online account, or you can request paper copies. These criteria apply to most, but not all, plans offered by HealthPartners. We aim to make sure the contents of this site are correct and complete, but to verify your benefits, please check your contract or SPD, or contact Member Services. If there's a conflict between your specific plan documents and this general information, your plan documents supersede this general information.

These criteria are highly technical and written to help medical professionals in making coverage decisions. They are not medical advice.

These criteria in no way imply you shouldn't receive specific services when those services are recommended by your provider. The providers treating you are responsible for medical advice and treatment of patients. If you have specific health care needs, you should talk to an appropriate health care professional.

You have rights to appeal coverage decisions. These rights are shown in your membership contract or SPD, and a summary of the appeals process is available online. If you have questions about your appeal rights, please contact Member Services.

This information isn't an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage criteria are subject to applicable laws and regulations. Your coverage is contingent on all the applicable terms, conditions, limitations and exclusions of your membership contract or SPD.

Coverage criteria for Medicare plans

The following coverage rules determine which coverage policies apply to Medicare Cost and Medicare Advantage plans:

• National coverage determinations (NCDs) and/or local coverage determinations (LCDs) from the Centers for Medicare and Medicaid Services (CMS)
• Other published guidance from CMS, including the Medicare Benefit Policy Manual and MLN Matters publications

Coverage criteria on this site are not applicable to Medicare unless specifically designated. Only services and items listed in the Medicare prior authorization (PA) lists (PDF) require authorization.