Prior Authorization

This is a way to find out if we'll cover a certain medical service or item. Clover reviews your medical records to make sure the care you receive is the right fit for your needs and covered by your plan.
 

When do I need a prior authorization?

Medicare guidelines, known as National Cover Determination (NCD) and Local Coverage Determination (LCD), are used to confirm the medical service or item is the right one for your health needs. When an NCD or LCD is not fully established for an item or service, Medicare allows Clover to use our internal coverage criteria.

Clover's Internal Coverage Criteria are publicly available for you and your doctor to review before requesting prior authorization.

Clover does not require prior authorization for all services or items. Be sure to check your Evidence of Coverage (EOC) to see if you require a prior authorization. You can find plan documents here.
 

How do I ask for prior authorization?

Typically, your provider will handle prior authorizations for you. However, you or a representative can also request one by completing our online Prior Authorization Request Form then faxing the request to 1-732-412-4317 or mailing it to: 

Attn: Utilization Management
Clover Health
P.O. Box 21672
Eagan, MN 55121

Alternatively, you can contact Clover’s Member Services team at 1-888-778-1478.
 

What happens next?

Our team will make a careful decision based on your medical needs and Medicare’s guidelines. Then we’ll send you a letter explaining what we decided.

Here are the timeframes you can expect for our decisions.

Items and Services:

• Standard Review: You'll receive a decision for non urgent items or services within 7 calendar days. 

• Expedited Review: You'll receive a decision within 72 hours if waiting could seriously jeopardize your life, health, or ability to regain maximum function. Your doctor can also inform us if your request needs expedited review.

Please note: We may extend these timeframes if additional information is needed from you or your doctor. We will notify you if an extension is taken.

Part B Drugs

• Standard Review: You'll receive a decision for non urgent drugs within 72 hours.
   
• Expedited Review: You'll receive a decision within 24 hours if waiting could seriously jeopardize your life, health, or ability to function. Your doctor can also inform us if your request needs expedited review.

Appeal

If you disagree with a decision we’ve made you can file an appeal (request a reconsideration). These decisions may include a denial of coverage of health care services, payment for services you already received, or to stop services that you are receiving.

How do I request an appeal?

If your health could be seriously harmed by waiting, you can ask for an appeal by calling 1-888-778-1478.

Otherwise, you should submit your appeal in writing within 65 calendar days from the date on the denial notice. If you are filing your appeal after the 65 calendar days, let us know why. 

To ensure your request has all of the relevant information, please use Clover Health’s appeal form. 

You can fax it to: (732) 412-9706

Or, you can mail it to: 

Clover Health
Attn: Appeals
Clover Health
P.O. Box 21672
Eagan, MN 55121

What happens next?

Appeal decision timeframes:

• All expedited (urgent) appeals are handled in 72 hours
   
• Standard prior authorization appeals are handled in 30 days
   
• Appeals about payments  are handled in 60 days

Grievance

A grievance is a complaint about the plan other than those related to coverage problems (use prior authorizations and appeals for that). You may file a complaint if you are dissatisfied with Clover or one of your doctors.
 

How do I file a grievance?

Contact Clover’s Member Services team at 1-888-778-1478. 

You can also submit a written complaint, like Clover’s grievance form, and fax it at 1-551-227-3962

Or write to us at:

Attn: Grievances
Clover Health
P.O. Box 21672
Eagan, MN 55121

What happens next?

If you file a grievance, we're required to notify you of our investigation no later than 30 days after we have received it.

If you have questions or concerns about your rights, please call us at 1-888-778-1478. You can also reference your Evidence of Coverage found here or the Medicare website for additional information.