Clover Health | Medicare Plan Documents for Members

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Documents for 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
Prescription Reimbursement forms (English | Spanish)

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 Mississippi 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
Prescription Reimbursement forms (English | Spanish)
Low Income Subsidy for Medicare Prescription Drug Coverage

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
PPO - 2021 Medicare Plan Ratings ( English | Español )
HMO - 2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

Documents for 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 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
2021 Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
Prescription Reimbursement forms (English | Spanish)

Reference

Notice of Privacy Practices
How to Disenroll from Clover
Multi-language Interpreter Services
PPO - 2021 Medicare Plan Ratings ( English | Español )
HMO - 2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management

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 )
Late Enrollment Penalty (LEP) Reconsideration Request Form

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 2021 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
2021 Georgia Enrollment Form (English | Spanish)
2021 LiveHealthy: Clover Powered, Walmart Enhanced (PPO) Enrollment Form (English | Spanish)
2021 Enrollment Attestation Eligibility Form (English | Spanish)
EFT/ACH Form for Premium Billing ( English | Spanish )
Late Enrollment Penalty (LEP) Reconsideration Request Form
Direct Member Reimbursement (DMR) Form

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
2021 Medicare Plan Ratings ( English | Español )
Provider Directory
Out-of-network Coverage Rules
Utilization Management