Clover Health | Medicare Plan Documents for Members

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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

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
Health Assessment Survey
2020 Enrollment Form (English | Spanish)
EFT/ACH Form for Premium Billing ( 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
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

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
Health Assessment Survey
2020 Enrollment Form ( English | Español )
EFT/ACH Form for Premium Billing ( 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
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

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
Health Assessment Survey
2020 Enrollment Form ( English | Español )
EFT/ACH Form for Premium Billing ( 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
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
Health Assessment Survey
2020 Enrollment Form ( English | Spanish )
EFT/ACH Form for Premium Billing ( 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
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

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

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
Health Assessment Survey
2020 Enrollment Form ( English | Spanish )
EFT/ACH Form for Premium Billing ( 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
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

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
Health Assessment Survey
2020 Enrollment Form ( English | Spanish )
EFT/ACH Form for Premium Billing ( 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
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

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
Health Assessment Survey
2020 Enrollment Form ( English | Español )
EFT/ACH Form for Premium Billing ( 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
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