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If a contracted or non-contracted provider does not agree with Clover’s payment of services, the provider is able to dispute payment. This includes:
A dispute of medical necessity or administrative determinations resulting in no payment, or
A dispute of the amount Clover paid on a claim and a request to obtain a higher level of payment.
A contracted provider may submit a payment dispute within the contractually agreed timeframe upon receipt of the remittance notice or within 90 days if not specified otherwise in your Provider Agreement. A non-contracted provider has up to 120 days to submit a payment dispute upon receipt of the remittance notice.
Please fill out the Claims Payment Dispute Form (English | Spanish) and send it via fax to (888) 240-7243 or mail to:
P.O. Box 471
Jersey City, NJ 07303
Along with your dispute, please also submit any of the below relevant documents needed for completing the process:
A copy of the original claim form
Date(s) of service
The basis for the dispute
The remittance notice showing the denial
Any clinical records supporting your request for reimbursement
We will take reasonable efforts to review and resolve the dispute within 60 calendar days of receipt of the Claims Payment Dispute Form and supporting documentation. The resolution may result in reprocessing of the claim(s) and issuing an EOP and/or payment and letter of determination of the outcome of the request. All decisions made in connection with our review shall be final.
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