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

This section contains information on your rights as a Clover member to submit appeals, request organization determinations (also know as “pre-authorizations”), or file complaints.

As a plan member, federal law guarantees your right to make complaints if you're in any way dissatisfied with a part of your coverage. Medicare has established a variety of rules around how members should file complaints and how Clover must process them. If you file a complaint, we must process it fairly. You can't be dis-enrolled or penalized in any way for making a complaint.  

Depending on the subject, a complaint will either be handled as an organization determination, an appeal, or a grievance. To obtain an aggregate number of grievances, appeals, and exceptions filed with Clover, contact us at 1-888-778-1478.

 

What's an organization determination?

An organization determination is the first decision we make about covering a medical service or item you've requested. If a service or item requires Clover's pre-authorization, either you or your physician may request an organization determination.

 

How do I request a pre-auth?

You may contact Clover’s Customer Experience Team at 1-888-778-1478. Alternatively, you may also request a pre-auth by filling out our website’s Clover Pre-auth Submission Form, subsequently faxing the Pre-Authorization Request Form to (732) 412-4317 or mailing it to:

Attn: Utilization Management
Clover Health
P.O. Box 471
Jersey City, NJ 07303

You can either ask your doctor to submit a statement supporting your pre-auth, or the provider can file the request on your behalf.

If the pre-auth is submitted for standard review, we must notify you of our decision within 14 calendar days. If the request is submitted for expedited review, we must notify you within 72 hours. Your request will be expedited if we determine—or your doctor informs us—that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard review.

If you've already received a given medical service or item and are now requesting payment or reimbursement, we must notify you of our decision within 60 calendar days. Please keep in mind that requests for reimbursement don't qualify for expedited reviews.

 

What's an appeal?

If we issue an unfavorable pre-auth decision you'd like us to reconsider, you may file an appeal known as a "reconsideration." And if our decision about that reconsideration is also unfavorable, you have additional appeal rights.

 

How do I request an appeal?

If your request is denied, you have the right to appeal by asking for a review of the prior decision. You must request this appeal within 60 calendar days from the date of our first decision. We accept standard and expedited appeals by phone and in writing. To complete this process, contact us at:

Attn: Appeals
Clover Health
P.O. Box 471
Jersey City, NJ 07303

Fax: (732) 412-9706
Phone: 1-888-657-1207

If the appeal is submitted for standard review and services haven't yet been provided, we must notify you of our decision within 30 calendar days.

If the appeal is submitted for expedited review, we must notify you of our decision within 72 hours. Your request will be expedited if we determine—or your doctor informs us—that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard review.

If your request is regarding a reimbursement or payment for a service or item you've already received, we must notify you of our decision within 60 calendar days. Please know: appeals regarding payment or reimbursement don't qualify for expedited review.

 

What's a grievance?

A grievance is any complaint other than those involving a pre-auth or appeal. You may file a grievance if you’re in any way dissatisfied with Clover or one of your doctors, so long as the grievance isn’t regarding our coverage of a particular medical service or item.

 

How do I request a grievance?

Contact Clover’s Customer Experience Team at 1-888-657-1207, or write to us at:

Attn: Grievances
Clover Health
P.O. Box 471
Jersey City, NJ 07303

Fax: 1-888-240-7243

If you file a grievance, we're required to notify you of our investigation no later than 30 days after we receive your grievance.

If you need assistance in requesting a pre-auth, appeal, or grievance, please call Clover at 1-888-657-1207.

You also have the right to file complaints directly with Medicare by filling out the Medicare Complaint Form.

 

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