Clover Health Policies
DECLARATION OF DISASTER OR EMERGENCY
If you're affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.
- Part A, Part B, and supplemental Part C plan benefits are to be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare-certified facilities);
- Where applicable, requirements for gatekeeper referrals are waived in full;
- Plan-approved out-of-network cost-sharing amounts are temporarily reduced; and
- The 30-day notification requirement to members is waived, as long as all the changes (such as reduction or cost-sharing and waiving authorization) benefit the member.
If CMS (Centers for Medicare and Medicaid Services) hasn't provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.
Reimbursement Policies
| Policy Number | Policy Name | Effective Date | Revision Date | Brief Description |
|---|---|---|---|---|
| #RP-004 | 30 Day Readmission Review and Reimbursement Policy | 1/1/22 | 1/1/22 | This policy addresses the process and rules around prepay readmission review |
| #RP-062 | 340B Drug Pricing Reimbursement Policy | 9/1/22 | 6/30/22 | The Health Resource and Services Administration (HRSA) 340B Drug Pricing Program allows 340B eligible facilities to purchase drugs at a discounted rate through the 340B program. When facilities participate in the 340B program, outpatient claim submissions are required to include specific modifiers to indicate whether or not the drug billed was purchased as part of the 340B program. |
| #RP-034 | Add on Codes Reimbursement Policy | 4/1/22 | 6/30/22 | This policy reviews billing requirements for codes considered to be add on codes per CMS. |
| #RP-008 | Ambulance Reimbursement Policy | 8/1/19 | 1/1/22 | This policy describes the requirements and limitations for joint response ambulance claims when billing services for Clover members. |
| #RP-007 | Anesthesia Reimbursement Policy | 1/1/22 | 1/1/22 | Outlines requirements and guidelines used in the payment of an anesthesia claim. |
| #RP-058 | Annual Wellness Services Reimbursement Policy | 4/1/22 | 6/30/22 | Clover Health allows members to receive annual preventative wellness visits with no cost share required. This policy describes the codes permitted to be billed, as well as frequency limitations for the services provided. |
| #RP-010 | Assistant at Surgery Reimbursement Policy | 1/1/22 | 1/1/22 | Outlines requirements and guidelines used in the payment of assistant surgeon charges submitted on a claim. For examples required modifiers 80, 81,82 and AS. |
| #RP-009 | Bilateral Procedures Reimbursement Policy | 1/1/22 | 1/1/22 | Outlines requirements of when bilateral pricing is applied to a claim. For example Bilateral specific codes or procedure codes on the RBRVS fee schedule with specific bilateral indicators. |
| #RP-049 | Billed Charges Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the payment calculation made when the amount billed on a claim is less than the CMS or Clover allowed amount. |
| #RP-024 | Carrier Priced Codes Reimbursement Policy | 1/1/22 | 1/1/22 | This policy describes the reimbursement methodology for codes submitted by a provider that are covered by Medicare, but are not priced by Medicare. These codes are referred to as carrier priced codes. |
| #RP-026 | Chiropractic Reimbursement Policy | 1/1/22 | 1/1/22 | This policy outlines Clover Health’s chiropractic service requirements for both contracted and non-contracted providers for all plans. Guidelines are based on national policy; however, Local Coverage Determinations will apply for specific regions. |
| #RP-025 | Clinical Laboratory Improvement Amendments (CLIA) Policy | 1/1/22 | 1/1/22 | This policy outlines Clover’s adherence to Clinical Laboratory Improvement Amendments (CLIA) reimbursement guidelines according to Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and Centers for Medicare & Medicaid Services (CMS) regulations. Clover applies CLIA reimbursement rules to both contracted and non-contracted providers for all Medicare Advantage products. |
| #RP-001 | Clinical Trial Reimbursement Policy | 1/1/22 | 1/1/22 | Outlines the requirements and guidelines for billing and reimbursement of a clinical trial claim |
| #RP-029 | Clover Discontinued Procedures - Modifier 53 Reimbursement Policy | 1/1/22 | 1/1/22 | This policy outlines Clover Health’s guidelines for payment of discontinued services submitted with a modifier 53. Clover will apply this logic to all Medicare Advantage plans for both contracted and non-contracted providers. |
| #RP-017 | Co-Surgeon/Team Surgeon Reimbursement Policy | 1/1/22 | 1/1/22 | Outlines requirements and guidelines used in the payment of Co-Surgeon/Team surgeon charges submitted on a claim. For examples required modifiers 62, 66 and RBRVS indicators for Co-Surgeon/Team surgeon procedures. |
| #RP-013 | Coordination of Benefits (COB) Reimbursement Policy | 1/1/22 | 1/1/22 | This policy covers instances when a member has reported to the CMS that they have other insurance as primary over their Medicare coverage, Clover may not be the responsible party for that member’s claim liability. |
| #RP-015 | Cosmetic Service Reimbursement Policy | 1/1/22 | 1/1/22 | This policy describes the guidelines and requirements Clover Health uses in order to determine whether or not a procedure or surgery considered cosmetic is covered. |
| #RP-027 | CT Cerebral Perfusion Studies Reimbursement Policy | 1/1/22 | 1/1/22 | Computed Tomography (CT) Cerebral Perfusion Studies are required to be billed with certain conditions in order to be considered covered by CMS. This policy reviews the Clover Health requirements in order for a claim to be paid. |
| #RP-005 | Diagnosis Related Grouper (DRG) Validation Review Reimbursement Policy | 1/1/22 | 1/1/22 | This policy describes the process, timelines and rules/regulations around prepay DRG review. |
| #RP-018 | Discarded Drugs and Biologicals Remibursement Policy | 1/1/22 | 1/1/22 | The Discarded Drugs and Biologicals policy addresses reimbursement guidelines for appropriately reporting wasted drugs and biologicals administered from single use vials, single use packages, and multi-use vials. |
| #RP-041 | Distinct Procedural Service, modifiers 59 and XE, XP, XS & XU Reimbursement Policy | 4/1/22 | 6/30/22 | Modifiers 59, XE, XP, XS, and XU have been created to allow providers to report distinct procedural services on claims, however appropriate use of the modifiers is required by Clover Health for providers to be reimbursed. This policy defines guidelines for contracted and non-contracted providers for Clover Health’s Medicare Advantage plans. |
| #RP-035 | Drug Testing Reimbursement Policy | 1/3/23 | 1/3/23 | Drug testing provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and making treatment decisions. |
| #RP-022 | Durable Medical Equipmet (DME) Limits Reimbursement Policy | 1/1/22 | 1/1/22 | This policy addresses Durable Medical Equipment (DME) frequency limitations. It defines the Clover Health policy on how the frequency is calculated based on CMS rules and regulations. These calculations are based on Medically Unlikely Edits (MUEs) as published by CMS. |
| #RP-036 | Durable Medical Equipment Charges in a SNF Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes how payment is made for durable medical equipment (DME), Parental and Enteral Nutrition (PEN) Items and Services when supplied in a skilled nursing facility (SNF). |
| #RP-016 | Durable Medical Equipment, Orthotics, and Prosthetics Reimbursement Policy | 1/1/22 | 1/1/22 | Medicare payment for durable medical equipment (DME), prosthetics and orthotics (P&O), parenteral and enteral nutrition (PEN), surgical dressings, and therapeutic shoes and inserts is based on the lower of either the actual charge for the item or the fee schedule amount calculated for the item. Each state has a different fee schedule. |
| #RP-063 | Established Patient vs New Patient Billing for E/M Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses the appropriate submission of a New Patient Evaluation and Management (E/M) service code vs an Established Patient service code. In order to bill with a New Patient E/M code the member needs to meet certain criteria. This policy describes what defines a New patient. |
| #RP-037 | Evaluation and Management Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the E/M coding section of the CPT® book, which is divided into broad categories with further sub-categories which describe various E/M service classifications. Clover may review medical records to verify the correct E/M code was billed on a claim. |
| #RP-043 | From-to Date Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses the From-to date billing requirements for reimbursement. When grouping services, the place of service, procedure code, charges, and individual provider for each line must be identical for that service line. Grouping is allowed only for identical services on consecutive days. In those instances where Grouping of services applies, the number of units submitted should be equally divisible by the number of days indicated in the 'from' and 'to' dates reported. |
| #RP-019 | Global Days Reimbursement Policy | 1/1/22 | 1/1/22 | The Global Period assignment or Global Days Value is the time frame that applies to certain procedures subject to a Global Surgical Package concept whereby all necessary services normally furnished by a physician (before, during and after the procedure) are included in the reimbursement for the procedure performed. Modifiers should be used as appropriate to indicate services that are not part of the Global Surgical Package. |
| #RP-078 | Guidelines for reporting Timed Units for Physical Medicine and Rehabilitation | 1/1/23 | This policy describes Clover Health's documentation requirements for reimbursement of the Physical Medicine and Rehabilitation CPT codes that make up the timed, skilled, direct one-on-one component of treatment. This is specific to CPT codes, 97110- 97140, 97530-97542, 97750-97762. | |
| #RP-012 | Hospice Coverage Reimbursement Policy | 1/1/22 | 1/1/22 | This policy explains the payment responsibilities of Clover Health when a member has elected hospice coverage with The Center for Medicare and Medicaid Services (CMS). |
| #RP-044 | Hospital Acquired Conditions Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the payment methodology used by Clover Health when a claim is billed with a hospital acquired condition, which will impact the payment amount. |
| #RP-051 | Inappropriate Primary Diagnosis Reimbursement Policy | 6/30/22 | 6/30/22 | This policy addresses reimbursement guidelines for reporting appropriate ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) Primary diagnosis on an Inpatient Facility UB04 claim form or its electronic equivalent. |
| #RP-038 | Incident To Services Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy clarifies the coverage of services considered to be “Incident to Services”. These services must occur as incident to other procedures performed or directed by a physician. An Incident to service cannot be billed as a stand alone procedure. |
| #RP-039 | Increased Procedural Services Reimbursement Policy | 4/1/22 | 6/30/22 | Clover Health has developed this policy to define reimbursement when circumstances during a procedure require substantially greater work effort than would normally be required. This policy applies to all contracted and non-contracted Clover providers. |
| #RP-045 | Intensity Modulated Radiation Therapy (IMRT) Reimbursement Policy | 4/1/22 | 6/30/22 | This policy provides reimbursement guidelines for Intensity Modulated Radiation Therapy (IMRT) services submitted by contracted and non-contracted Clover Health providers for all Clover Medicare Advantage plans. Providers submitting under the same group tax identification number will be considered the same provider. |
| #RP-040 | Intraoperative Neuromonitoring Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses the reimbursement of Intraoperative Neuromonitoring (IONM) services performed during surgery. |
| #RP-081 | Inpatient Psych Hospital Reimbursement Policy | 10/1/22 | This policy describes how Clover Health reimburses claims billed for members when they are admitted to an inpatient psychiatry hospital or inpatient psychiatry bed. | |
| #RP-006 | Itemized Bills Reimbursement Policy | 1/1/22 | 1/1/22 | This policy outlines the process and procedure for itemized bill reviews for qualified inpatient claims. |
| #RP-052 | Laboratory Services Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the billing requirements for Clinical diagnostic laboratory tests. Laboratory tests include certain blood tests, urinalysis, tests on tissue specimens, and some screening tests. |
| #RP-021 | Leadless Cardiac Pacemakers Reimbursement Policy | 1/1/22 | 1/1/22 | The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminate an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. |
| #RP-050 | Magnetic Resonance Imaging Reimbursement Policy | 4/1/22 | 6/30/22 | This reimbursement policy describes the billing and coding for Magnetic Resonance Imaging (MRI). |
| #RP-053 | Medicare Physician Fee Schedule Status Indicator Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses reimbursement guidelines for the Medicare Physician Fee Schedule status indicator codes of B, I, M, N, P & T. |
| #RP-028 | Member Balance Billing Reimbursement Policy | 1/1/22 | 1/1/22 | This policy describes the Center for Medicare and Medicaid Services (CMS) rules around member balance billing. When an item or service is non-covered, in certain situations, the member may be billed. If an item or service is denied by Clover Health, the provider may not balance bill the member. |
| #RP-060 | Modifier 25 Reimbursement Policy | 4/1/22 | 6/30/22 | Modifier 25 is used to indicate that a significant, separately identifiable evaluation and management (E/M) service was performed above and beyond the procedural code provided on the same day. |
| #RP-031 | Modifiers Not Reimbursable to Healthcare Professionals Reimbursement Policy | 1/1/22 | 1/1/22 | In accordance with the CPT book and CMS, the following modifiers have been approved and designated for use by ambulatory surgery centers (ASC) or in the outpatient hospital setting. |
| #RP-064 | Mohs Micrographic Surgery Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy provides the guidelines for reporting Mohs Micrographic Surgery. |
| #RP-065 | Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures | 10/1/2021 | 10/1/2022 | This reimbursement policy describes how the Multiple Procedure Payment Reduction (MPPR) Policy will be applied when multiple Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures are performed on the same day. |
| #RP-054 | Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Reimbursement Policy | 4/1/22 | 6/30/22 | Clover Health has developed this policy to define reimbursement for multiple diagnostic imaging procedures. This policy applies to both Clover Health contracted and non-contracted providers. |
| #RP-030 | Multiple Procedure Payment Reduction (MPPR) for Therapy Services Reimbursement Policy | 1/1/22 | 1/1/22 | This reimbursement policy describes how the Multiple Procedure Payment Reduction (MPPR) methodology will be applied for Therapy Services billed to Clover Health. The MPPR applies to services identified as “always” therapy and applies to the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service. This policy will apply to all outpatient therapy services paid under Part B, including those furnished in office and facility settings. |
| #RP-011 | Multiple Surgery Reduction (MSR) Reimbursement Policy | 1/1/22 | 1/1/22 | Multiple surgeries are separate procedures performed by a single physician on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants at surgery may participate in performing multiple surgeries on the same patient on the same day. |
| #RP-066 | National Drug Code (NDC) Requirement | 10/1/2022 | 10/1/2022 | This policy describes the National Drug Code information that is required on professional and facility drug claims that are reported for reimbursement. |
| #RP-020 | Nerve Graft After Prostatectomy Reimbursement Policy | 1/1/22 | 1/1/22 | This policy describes the coding requirements for nerve grafting, which is performed to replace cavernous nerves that have been resected during radical prostatectomy for prostate cancer. |
| #RP-067 | New Patient Visit Reimbursement Policy | 10/1/2022 | 10/1/2022 | The appropriate submission of a New Patient Evaluation and Management (E/M) service code and an Initial Visit HCPCS code. |
| #RP-068 | Non-Chemotherapy Injection and Infusion Services | 10/1/2022 | 10/1/2022 | This policy describes reimbursement for non-chemotherapy injection, infusion services, and intravenous hydration services when billed with Evaluation and Management (E/M codes). This policy applies to contracted and non-contracted Clover Health providers for all Clover, Medicare Advantage plans. |
| #RP-069 | Non-physician Health Care Professional Billing Evaluation and Management Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy describes reimbursement for Evaluation and Management (E/M) services (99202–99499) reported by non-physician health care professionals |
| #RP-032 | Observation and Discharge Hours Reimbursement Policy | 1/1/22 | 1/1/22 | This policy provides direction to physicians and facilities when billing claims for observation services. It defines and differentiates between billing an initial observation service and subsequent observation service and clarifies the coding permitted depending on the number of hours billed. |
| #RP-070 | Once In a Lifetime Procedure Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy identifies procedures that because of the Current Procedural Terminology (CPT®) code description and/or human anatomy can be performed by a physician(s) or other health care professional(s) only once in a patient’s lifetime |
| #RP-014 | Outpatient Observation Reimbursement Policy | 6/30/21 | 1/1/22 | Reimbursement for observation services when provided by the order of a physician or another individual authorized by state licensure law and facility staff bylaws to admit members to the hospital or to order outpatient tests unless provider, state federal, or CMS contracts and/or requirements indicate otherwise |
| #RP-059 | Oxygen Supplies Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the requirements for billing oxygen therapy to Clover Health. This includes coding requirements, medical necessity and physician referrals. |
| #RP-002 | Postpay Review Reimbursement Policy | 1/1/22 | 1/1/22 | This policy explains how Clover engages in a variety of post payment reviews of claims including coding reviews and medical record reviews. |
| #RP-003 | Prepayment Emergency Department Claim Review Reimbursement Policy | 1/1/22 | 1/1/22 | This policy addresses the review of facility outpatient Emergency Department (ED) claims for incorrect billing. |
| #RP-055 | Procedure and Place of Service Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses the reimbursement of Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes that are reported in a Place of Service (POS) considered inappropriate based on the code’s description or available coding guidelines when reported by a physician or other health care professional. |
| #RP-047 | Procedure to Modifier Reimbursement Policy | 4/1/22 | 6/30/22 | This policy addresses the appropriate use of modifiers with individual CPT and HCPCS procedure codes. |
| #RP-046 | Professional and DME Medically Unlikely Edits MUE Reimbursement Policy | 4/1/22 | 6/30/22 | This communication describes the Clover Health policy when applying Medically Unlikely Edits (MUEs) to professional and DME claims. MUE edits are applied when the maximum units of an item or service have been supplied or rendered to a member. |
| #RP-071 | Professional and Technical Component | 10/1/2022 | 10/1/2022 | This policy outlines Clover Health’s reimbursement of professional and technical services submitted by both contracted and non-contracted providers for Clover’s Medicare Advantage plans. |
| #RP-061 | Professional Place of Service During Inpatient Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes the appropriate Place of Service (POS) to be billed on a professional claim when the item or service is supplied in a facility or when a member is currently admitted to inpatient care. |
| #RP-056 | Rebundling and NCCI Edits Reimbursement Policy | 4/1/22 | 6/30/22 | Clover Health had developed this policy to outline the use of NCCI editing as well as application of rebundling rules used when appropriate. |
| #RP-077 | Reduced Services and Discontinued Procedures Payment Reimbursement Policy | 1/1/23 | This policy describes Clover’s reimbursement policy for reduced services and discontinued procedures. As stated in the Current Procedural Terminology (CPT®) book, under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified healthcare professional. This will be reported by billing with the appropriate modifier. | |
| #RP-048 | Same Day Same Service Reimbursement Policy | 4/1/22 | 6/30/22 | For the purpose of this policy, the Same Specialty Physician or Other Qualified Healthcare Professional is defined as a physician and/or other qualified health care professional of the same group and same specialty reporting the same Federal Tax Identification number. |
| #RP-057 | Services Included in Facility Reimbursement Policy | 4/1/22 | 6/30/22 | This policy describes how Clover Health reimburses Services Included in Facility reimbursement. |
| #RP-074 | Sexually Transmitted Infection Testing | 10/1/2022 | 10/1/2022 | Clover Health has created this policy to outline the reimbursement and frequency requirements related to testing for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC). |
| #RP-080 | Skilled Nursing Facility PDPM Validation Reimbursement Policy | 1/1/23 | This policy describes a post pay review process for Clover Health, where the billed Health Insurance Prospective Payment System (HIPPS) is validated using medical records. | |
| #RP-072 | Split Surgical Package Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy addresses reimbursement when components of a split surgical package are provided by two or more physicians. |
| #RP-073 | Standby Services Reimbursement Policy | 10/1/2022 | 10/1/2022 | This reimbursement policy addresses reimbursement for standby services and hospital mandated on call services. |
| #RP-076 | Supply Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy describes reimbursement of supplies provided in a Physician’s or Other Qualified Health Care Professional’s Office and Other Nonfacility Places of Service. |
| #RP-042 | Telehealth and Telemedicine Reimbursement Policy | 4/1/22 | 6/30/22 | Reimbursement for Telehealth/Telemedicine and virtual health services. For the purpose of understanding the terms in this policy, Telehealth/Telemedicine and virtual health occurs when the Physician or Other Qualified Health Care Professional and the patient are not at the same site. |
| #RP-075 | Time Span Codes Reimbursement Policy | 10/1/2022 | 10/1/2022 | This policy addresses reimbursement of codes that contain specific time span verbiage in their description in the Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) coding manuals, or in definitive expanded sourcing. |
| #RP-033 | Unpriced Drugs Reimbursement Policy | 4/1/22 | 6/30/22 | The Unpriced Drugs policy addresses reimbursement guidelines on drugs that do not have pricing on the CMS ASP fee schedule or have pricing available via WAC pricing. |
| #RP-023 | Varicose Veins Reimbursement Policy | 1/1/22 | 1/1/22 | This reimbursement policy describes the billing and coding for the Treatment of Chronic Venous Insufficiency of the lower Extremities (Varicose Veins). The treatment of Varicose Veins has numerous LCD’s. The LCD’s listed will be for the states that Clover Health has membership. |
| #RP-079 | Vitamin B12 | 1/1/23 | In certain circumstances the administration of Vitamin B12 injections may be reimbursed if they are considered reasonable and necessary for the treatment of an illness or injury. |
Utilization Management Policies
| Policy Number | Policy Name | Effective Date | Revision Date | Brief Description |
| #UM-29 | Business Continuity - System and Disaster Plan | 11/29/23 | 11/29/23 | The purpose of this policy is to establish a plan for business continuity in the event of a natural disaster or system failure that disrupts the flow of day-to-day business in Utilization Management. |
| #UM-021 | Clinical Guidelines for inpatient stays | 6/6/24 | 5/28/24 | The purpose of the policy is to provide guidance for the prior authorization process on Inpatient Notice of Admission (IP NOA) requests. IP NOA request with certain diagnosis and/or clinical indications will require two days of clinical information prior to the Medical Director Determination when applicable |
| #UM-20 | Clover Health Administration DME Policy | 6/6/24 | 2/18/22 | Authorization for Particular Brand, Item, of Mode of Delivery |
| Clover Health Utilization Management ProgramDescription 2024 | 2024 | 2024 | The UM Program Description is an overview and guide utilization management activities conducted by Clover Health. | |
| #UM-30 | Concurrent Review | 6/6/24 | 6/4/24 | This policy and procedure establishes Clover Health’s policy and procedure for concurrent review. |
| #UM-018 | IP-PreService Auths not on the CMS IPO list criteria | 6/6/24 | 5/28/24 | The purpose of this policy is to establish Clover Health’s review process to determine when hospital inpatient care meets medical necessity and is appropriate for the care needed by the member. |
| #UM-004 | Peer-to-peer review | 6/6/24 | 5/28/24 | This Policy and Procedure (P&P) establishes Clover Health’s (“Clover”) policy and procedure for Peer-to-Peer (P2P) Review |
| #UM-025 | Post Stabilization Policy | 6/6/24 | 6/4/24 | To state Clover’s compliance with CMS post-stabilization requirements |
| #UM-010 | Denials and Terminations | 6/6/24 | 5/21/24 | The purpose of this policy is to establish Clover Health’s procedures on when and how to use the Integrated Denial Notice (IDN), Notice of Medicare Non-Coverage (NOMNC), Detailed Explanation of Non-Coverage (DENC), Notice of Denial of Coverage for Services (NDCS) and the Detailed Notice of Discharge (DND). |
| #UM-022 | Part C Retrospective Review | 6/6/24 | 1/11/23 | To establish consistent and compliant processing of Retrospective Reviews if Clover’s Utilization Management department receives an authorization request from a provider or member after a service or item has been furnished by the provider. |
| #UM-001 | Prior Authorizations Organizations Determinations | 6/6/24 | 5/21/24 | Establish a process for members or their authorized representative and providers to submit requests for medical services. |
| #UM-016 | Reopenings for organization determinations | 6/6/24 | 12/20/22 |
The purpose of this policy is to establish Clover Health’s (Clover) procedures for the |
| #UM-026 | Medical Necessity Guidelines for Coverage Determination | 5/31/24 | 4/24/24 |
This policy establishes the hierarchy of application of CMS policy documents to ensure the decision making process is based on accurate and consistent review of CMS policies. |
| #UM-032 | Utilization Management Committee Policy | 6/6/24 | 6/6/24 |
The Utilization Management Committee (UMC) is a regulatory body within Clover Health that annually reviews and updates utilization management policies to ensure they align with Medicare guidelines and promote timely access to care. Additionally, the UMC monitors the implementation of these policies to safeguard beneficiary access to appropriate services while ensuring compliance with Medicare regulations. |
Quality Policies
| Policy Number | Policy Name | Effective Date | Revision Date | Brief Description |
| #CQI-018 | Assessing Member Experience Satisfaction | 9/1/20 | 11/15/20 | To define the manner of how Clover Health collects, analyzes and acts on Member Experience/Satisfaction data |
| #CQI-008 | Evaluation of Chronic Care Improvement Program | 1/27/16 | 11/15/20 | To state the components and steps necessary to carry out the Chronic Care Improvement Program evaluation. |
| #CQI-006 | Health Outcome Survey (HOS) | 2/1/16 | 11/15/20 | To establish requirements and processes to conduct HOS survey, report and manage results |
| #CQI-007 | Health Risk Assessment | 10/16/13 | 11/15/20 | To ensure proper assessment and reporting on member's risk levels and monitoring timeliness. To define guidance in which Clover Health attempts to conduct Health Risk Assessments (HRA) of all new enrollees and upon an annual basis. |
| #CQI-003 | Healthcare Effectiveness Date and Information Set (HEDIS) | 2/1/16 | 11/15/20 | To state the requirements and process for HEDIS reporting and manage results |
| #CQI-019 | Monitoring for Cultural and Linguistic needs | 9/1/20 | 11/15/20 | To demonstrate Clover Health's assessment evaluation of the cultural and linguistic needs of its population |
| #CQI-021 | Quality of Care Investigations | 10/22/20 | 10/22/20 | To have a process to properly investigate, respond to, track and trend quality of care member complaints and grievances. |
| #CQI-013 | Quality of Care Monitoring- HAC, Avoidable Readmissions, and Mortality Rates | 6/1/20 | 11/15/20 | To have a process in place to help evaluate the quality of care of institutions where our members receive care. |