Clover Health | Plan Documents

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Documents for 2018 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
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

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2018 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management
Member Claims Submission

Documents for 2018 New Jersey 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
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

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2018 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management
Member Claims Submission

Documents for 2018 Pennsylvania 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
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

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2018 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management
Member Claims Submission

Documents for 2018 Texas 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
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

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2018 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management
Member Claims Submission

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
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

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 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
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

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 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
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

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2019 Medicare Plan Ratings - PPO ( English | Español )
2019 Medicare Plan Ratings - HMO ( 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
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

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
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

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 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
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

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 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
2019 Enrollment Form - Bexar County ( English | Spanish )
2019 Enrollment Form - El Paso County ( 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

Reference

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