Member claims submission

What should I do if I am asked to pay upfront for a service or item?

In rare instances, a provider or supplier may ask you to pay for a service, item, or medication upfront. This may happen when a provider does not accept Medicare or declines to bill insurance companies altogether. In these cases, the provider may suggest that you submit a claim directly to Clover for reimbursement.

Providers and suppliers who have a billing relationship with Clover will always submit claims directly to Clover. If you're unsure whether your provider will bill Clover, call us before you go to your appointment, or before picking up your prescription or supplies. We can contact the provider to explain your benefits and Clover's billing procedures to them so you know what to expect.

Remember, in case of an emergency, call 911 or go to the nearest Emergency Department; you will always be seen there, no matter the facility's network status with Clover.

 

What is a claim and why would I submit one?

A claim is a request for Clover to reimburse someone for your health care. Providers and suppliers who have a billing relationship with Clover will always submit claims directly to Clover, and this is the most common way Clover pays for your care.

If you agree to pay upfront for healthcare, you can also submit a claim to request that Clover reimburse you. Clover will evaluate your claim and any supporting documentation to determine if you are eligible for a reimbursement, and for how much. Clover follows Medicare guidelines in making these determinations.

 

Why should I avoid paying upfront and submitting claims to Clover myself?

We at Clover make it our highest priority to protect our members. This means ensuring that you receive the services and medications that you need, and working with you and your providers to avoid conditions that could put your health at risk. We also work hard to protect you from unexpected costs, such as for supplies, or medications. You could be taking a risk by paying up front for a service or item.

Providers and suppliers who are certified by Medicare and those who are in-network with Clover agree to follow certain rules about how much they can bill for rendering covered services, and how to bill for those services. When a provider or supplier submits a claim to Clover for payment, we are able to protect you from unexpected costs by comparing the amount billed with the amount Medicare approves. This ensures that payments made by Clover and by you are correct.

If a provider is not participating in Medicare, you may pay more than what should be asked of you, possibly even more than the service or item costs. You could receive a service or item that is not covered at all and risk being responsible for the entire cost.

 

What should I do if I've already paid upfront for a service or item and would like to be reimbursed?

  1. Collect and make copies of any receipts or records for the service(s) or item(s) you would like reimbursed.
  2. Print the Member Claim Submission form and fill it out.
  3. Mail in the form with copies of your receipts and any records to the address on the form.

Clover will contact you if we need any additional information to process your reimbursement. Our Claims department will evaluate your claim and any supporting documentation to determine if you are eligible for a reimbursement, and for how much. Clover will follow Medicare guidelines in making these determinations.

We may also contact you if you request reimbursement frequently. We will work with you to arrange access to providers and suppliers who are willing to bill Clover for your care. We will do this to protect you from necessary cost or risk by shifting the responsibility for claims submission to your providers or suppliers.

For more information on covered services or their costs to you as a Clover member, you can always refer to your Evidence of Coverage document.


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