Prior Authorization Performance
This page summarizes how Clover reviews medical items and services that require prior authorization (excluding drugs), including approval and denial rates, appeal outcomes, and typical response times for standard and expedited requests.
Reporting period: 2025 (Jan 1 – Dec 31)
Medical Items and Services Requiring Prior Authorization
This includes all medical items and services that require prior authorization under Clover plans, excluding prescription drugs.
Clover Health Prior Authorization List
Comprehensive list of all medical items and services requiring prior authorization.
Standard Prior Authorization Requests
6 metricsStandard requests follow the usual review time frames defined by CMS. The metrics below show how often these requests are approved, denied, overturned on appeal, and how long determinations typically take.
Percentage approved in the calendar year
Standard requests82.9%
Percentage denied in the calendar year
Standard requests17.1%
Percentage approved after appeal
Appealed standard requestsNote: This is a subset of standard prior authorization requests that were appealed.
89.4%
Average (mean) response time
Standard requestsMeasured from the time the payer receives the request, not when it is sent by the provider.
1.31 days
Median response time
Standard requestsMeasured from the time the payer receives the request, not when it is sent by the provider.
0.0 days
Percentage of requests extended and approved
Standard requestsCMS recommends distinguishing between standard requests that were extended and approved and those processed on the usual timeframe.
0.0%
Expedited Prior Authorization Requests
6 metricsExpedited requests are used when waiting the standard time frame could seriously jeopardize the member's health. These metrics show how often expedited requests are approved, denied, overturned on appeal, and how quickly they are processed.
Percentage approved in the calendar year
Expedited requests80.0%
Percentage denied in the calendar year
Expedited requests20.0%
Percentage approved after appeal
Appealed expedited requestsThis optional metric is a subset of expedited prior authorization requests that were appealed.
89.4%
Average (mean) response time
Expedited requestsMeasured from the time the payer receives the request, not when it is sent by the provider.
11.5 hours
Median response time
Expedited requestsMeasured from the time the payer receives the request, not when it is sent by the provider.
0.0 hours
Percentage of requests extended and approved
Expedited requestsCMS recommends identifying expedited requests where the review timeframe was extended, per programmatic rules, and the request was approved.
0.0%