(Prior Authorizations), Grievances, and Appeals
This section contains information on your rights as a Clover member to submit appeals, request prior authorizations, or file complaints.
As a plan member, federal law guarantees your right to make complaints if you're in any way dissatisfied with a part of your coverage. Medicare has established a variety of rules around how members should file complaints and how Clover must process them. If you file a complaint, we must process it fairly. You can't be dis-enrolled or penalized in any way for making a complaint.
Depending on the subject, a complaint will either be handled as an organization determination, an appeal, or a grievance. To obtain an aggregate number of grievances, appeals, and exceptions filed with Clover, contact us at 1-888-778-1478.
What's a prior authorization?
A prior authorization is a way for your doctor and Clover to work together to ensure you get the most appropriate and effective care. We review your medical records to make sure the care you receive is the right fit for your needs and covered by your plan.
How do I request a prior authorization?
You may file a request through our portal https://www.cloverhealth.com/pre-auth-request or contact Clover’s Member Services team at 1-888-778-1478. Alternatively, you may also request a prior authorization by filling out our website’s Prior Authorization Submission Form, subsequently faxing the Prior Authorization Request Form and faxing it to 1-732-412-4317 or mailing it to:
Attn: Utilization Management
Clover Health
P.O. Box 21672
Eagan, MN 55121
You can either ask your doctor to submit a statement supporting your prior authorization, or the provider can file the request on your behalf. Here are the timeframes you can expect for our decisions:
Items and Services
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Standard Review: You'll receive a decision within 14 calendar days.
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Expedited Review: You'll receive a decision within 72 hours if waiting could seriously jeopardize your life, health, or ability to regain maximum function. Your doctor can also inform us if your request needs expedited review.
Part B Drugs
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Standard Review: You'll receive a decision within 72 hours.
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Expedited Review: You'll receive a decision within 24 hours if waiting could seriously jeopardize your life, health, or ability to function. Your doctor can also inform us if your request needs expedited review.
Please note: We may extend these timeframes if additional information is needed from you or your doctor. We will notify you if an extension is taken.
What's an appeal?
If we issue an unfavorable decision on a prior authorization or claim you'd like us to reconsider, you may file an appeal known as a "reconsideration." And if our decision about that reconsideration is also unfavorable, you have additional appeal rights.
How do I request an appeal?
If your request is denied, you have the right to appeal by asking for a review of the prior decision. You must request this appeal within 60 calendar days from the date of our first decision. We accept Standard appeals in writing and expedited appeals both by phone and in writing To complete this process, contact us at:
Attn: Appeals
Clover Health
P.O. Box 21672
Eagan, MN 55121
Fax: (732) 412-9706
Phone: 1-888-778-1478
If the appeal is submitted for standard review and services haven't yet been provided, we must notify you of our decision within 30 calendar days. If the appeal is pre-service and is regarding a part B drug the timeframe for a decision is 7 calendar days.
If the appeal is submitted for expedited review, we will make our decision within 72 hours. Your request will be expedited if we determine—or your doctor informs us—that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard review.
If your request is regarding a reimbursement or payment for a service or item you've already received, we will make our decision within 60 calendar days. Please know that appeals regarding payment or reimbursement don't qualify for expedited review.
What's a grievance?
A grievance is any complaint other than those involving a prior authorization or appeal. You may file a grievance if you’re in any way dissatisfied with Clover or one of your doctors, so long as the grievance isn’t regarding our coverage of a particular medical service or item.
How do I request a grievance?
Contact Clover’s Member Services team at 1-888-778-1478, or write to us at:
Attn: Grievances
Clover Health
P.O. Box 21672
Eagan, MN 55121
Fax: 1-551-227-3962
If you file a grievance, we're required to notify you of our investigation no later than 30 days after we receive your grievance.
If you need assistance in requesting a prior authorization, appeal, or grievance, please call Clover at 1-888-778-1478.
For sales/marketing complaints, contact Clover Health at 1-888-778-1478 (TTY 711) or 1-800-MEDICARE
(if possible, please be able to provide the agent or broker's name).
You also have the right to file complaints directly with Medicare by filling out the Medicare Complaint Form.