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For assistance, call Clover at 1-888-778-1478 (TTY 711)

You can now call Member Services on Saturday and Sunday from 8am to 8pm local time*

 

Prior Authorization

Clover’s Internal Coverage Criteria

 

Where criteria for coverage are not fully established in applicable Medicare statutes, regulations, National Coverage Determinations, or Local Coverage Determinations, Clover may rely on internal coverage criteria in evaluating pre-authorization requests for products or services for which coverage may be available under Original Medicare. Clover has adopted as its internal coverage criteria guidelines developed by its vendors, with different vendors’ guidelines used for different categories of products and services. Please refer to the below list for the designated vendor for specific categories of products or services, and for information on how you can access the guidelines.

 

Vendor Applicable Products & Services How to Access Coverage Criteria
Novologix Medicare Part B Drugs Available HERE
Evicore

Pain and joining surgery
Sleep disorders
Cardiology and radiology
Radiation oncology
Physical and occupational therapies
Speech language pathology
 

Available HERE
MCG Please see the table below for MCG guidelines adopted by Clover as internal coverage criteria

In order to access the MCG guidelines used by Clover you will need to request a one-time username and passcode by calling one of the following numbers:

Provider Services: 1-877-853-8019 (TTY 711)
Customer Services: 1-888-778-1478 (TTY 711)

Once you obtain that information, please enter it into the pertinent forms on the web page linked HERE
 

 

 

 MCG Guidelines Used by Clover
ORG: S-1310 (ISC) Percutaneous Revascularization, Lower Extremity
ACG: A-0395 (AC) Gastric Stimulation (Electrical)
ACG: A-0353 (AC) Wheelchairs, Power
ACG: A-0407 (AC) Cranial Orthotic Devices
ACG: A-0701 (AC) Myoelectric Prosthesis
ACG: A-0773 (AC) Colorectal Cancer-Gene Testing (Somatic or Therapeutic)
ACG: A-0795 (AC) Non-Small Cell Lung Cancer-Gene Testing (Somatic or Therapeutic)
ACG: A-0649 (AC) HLA Pharmacogenetics-HLA Testing
ACG: A-0709 (AC) Proteomics-Ovarian Cancer Biomarker Panel (OVA 1)
ACG: A-0693 (AC) Proteomics (VeriStrat)
ACG: A-0195 (AC) Blepharoplasty, Canthoplasty, and Related Procedures
GRG: SG-MS (ISC GRG)Musculoskeletal Surgery or Procedure GRG
ACG: A-0247 (AC) Mandibular Osteotomy
GRG: SG-HNS (ISC GRG) Head and Neck Surgery or Procedure GRG
GRG: SG-TS (ISC GRG) Thoracic Surgery or Procedure GRG
ORG: S-1210 (ISC) Wrist Arthroplasty
ORG: S-710 (ISC) Knee Arthrotomy
ACG: A-0492 (AC) Temporomandibular Joint Arthroscopy
GRG: SG-NS (ISC GRG) Neurosurgery or Procedure GRG