Out-of-Network Coverage Rules
It’s important to understand your benefits when receiving services from doctors who are outside of our provider network.
For PPO Plans
As a member of a PPO plan, you can choose to receive care from out-of-network providers. However, please note, providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our plan will cover services from out-of-network providers, as long as the services are covered benefits and are medically necessary. “Medically necessary” means the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition, and meet all accepted standards of medical practice.
You may contact us in advance of any service or procedure to confirm it will be covered by our plan by calling 1-888-778-1478 (TTY 711) 8 am–8 pm EST, 7 days a week. Please note, if you use an out-of-network provider, your share of the costs for your covered services may be higher. In addition, if you move forward with a service or procedure that is not medically necessary with an out-of-network provider, you will be responsible for the full cost.
For HMO Plans
As a member of a HMO plan, you must use network providers to get your medical care and services. The only exceptions are emergency or urgently needed services, out-of-area dialysis services, and when Clover Health authorizes the use of out-of-network providers.
Please be advised, if you obtain routine care from an out-of-network provider without our authorization, you will be responsible for the full cost. For assistance locating a network provider, please call Member Services at 1-888-778-1478 (TTY 711), 8 am–8 pm local time, 7 days a week, or visit our Provider Search page.