Documents for 2019 Arizona plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form (English | Spanish) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2020 Arizona plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form (English | Spanish) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 Georgia plans

• Plan Details (Summary of Benefits and Evidence of Coverage)
• 2018 Welcome Booklet ( English | Español )

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

 

Documents for 2020 Georgia plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 New Jersey plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

 

Documents for 2020 New Jersey plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination - PPO
• Request For Redetermination Of Medicare Prescription Drug Denial - PPO
• Request for Medicare Prescription Drug Coverage Determination - HMO
• Request For Redetermination Of Medicare Prescription Drug Denial - HMO
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• PPO - 2020 Medicare Plan Ratings ( English | Español )
• HMO - 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2020 Pennsylvania plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 Pennsylvania plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 South Carolina plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

 

Documents for 2020 South Carolina plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 Tennessee plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2019 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

 

Documents for 2020 Tennessee plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Spanish ) 
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial
• Low Income Subsidy for Medicare Prescription Drug Coverage

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

Documents for 2019 Texas plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2018 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination
• Request For Redetermination Of Medicare Prescription Drug Denial

 

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2019 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission

 

Documents for 2020 Texas plans

• Plan Details (Summary of Benefits and Evidence of Coverage)

 

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Continuity of Care Form
• 2020 Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )
• Health Assessment ( English | Spanish )

 

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

 

Drug Coverage

• Part D Coverage Determinations, Exceptions, Grievances, and Appeals
• Prescription Drug Transition Policy
• Request for Medicare Prescription Drug Coverage Determination - PPO
• Request For Redetermination Of Medicare Prescription Drug Denial - PPO
• Request for Medicare Prescription Drug Coverage Determination - HMO
• Request For Redetermination Of Medicare Prescription Drug Denial - HMO

​​​​​​​

Reference

• Notice of Privacy Practices
• How to Disenroll from Clover
• Multi-language Interpreter Services
• PPO - 2020 Medicare Plan Ratings ( English | Español )
• HMO - 2020 Medicare Plan Ratings ( English | Español )
• Provider Directory
• Out-of-network Coverage Rules
• Utilization Management
• Member Claims Submission