Documents for 2022 Alabama Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Arizona Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Georgia Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2021 Medicare Plan Ratings
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Mississippi Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 New Jersey Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO or HMO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO or HMO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- HMO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Pennsylvania Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Forms
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 South Carolina Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Form
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Tennessee Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO
- Prescription Reimbursement Form
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Documents for 2022 Texas Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Commonly Used Forms
Click below to access forms that are regularly used by members.
- Authorization for Disclosure of Protected Health Information Form
- Appointment of Representative Form
- Continuity of Care Form
- Health Assessment Survey
- 2022 Enrollment Form
- 2022 Enrollment Attestation Eligibility Form
- 2022 Grocery Plus Attestation Form
- EFT/ACH Form for Premium Billing
- Late Enrollment Penalty (LEP) Reconsideration Request Form
- Direct Member Reimbursement (DMR) Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
- Organization Determinations (Prior Authorizations), Grievances, and Appeals
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Request for Medicare Prescription Drug Coverage Determination – PPO or HMO
- Request For Redetermination Of Medicare Prescription Drug Denial – PPO or HMO
- Prescription Reimbursement Form
- Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Reference
Read Clover Health policies and other information here.
- Notice of Privacy Practices
- How to Disenroll from Clover
- Low-Income Subsidy for Medicare Prescription Drug Coverage
- Prescription Drug Transition Policy
- Provider Directory
- Non-Discrimination Notice
- PPO - 2022 Medicare Plan Ratings
- HMO - 2022 Medicare Plan Ratings
- Out-of-Network Coverage Rules
- Quality Assurance and Drug Management Programs
- Confidential Communications Request
- Request for Access to Protected Health Information
- Request for Accounting Disclosures
- Request for Amendment of Protected Health Information
- Request for Restriction of Protected Health Information
Contact Us
We want to make sure you always have the forms and information you need. If you have questions, please don’t hesitate to reach out to Member Services at:
1-888-778-1478 (TTY/TDD 711)*
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Original Medicare
Traditional Medicare covers hospitals (Part A) and doctors (Part B), and you pay standard rates for services. You can go to any doctor, hospital or other provider that accepts Medicare patients anywhere in the country.
You can add drug coverage (Part D) by enrolling in a private "stand-alone" drug plan for an additional premium. You can buy separate Medigap insurance to cover some or most of the out-of-pocket costs of hospitals (Part A) and doctors (Part B).
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