Requesting Prior Authorization

For some types of service or medications, your doctor will need to ask Clever Care for permission before you can receive the service or medication. This is called asking for prior authorization (pre-approval). It means that Clever Care must make sure that the service or medication is needed (medically necessary).

Medically necessary is a decision made by the health plan that says that your treatment, test, medication, or procedure is necessary to maintain or restore your health or to treat a diagnosed medical problem. To be covered under the health plan, a service must be considered medically necessary.

The following services always need pre-approval (prior authorization), even if you get them from a provider who is in-network:

• Hospitalization, if not an emergency
• Services that are not in Clever Care’s service area, if not an emergency or urgent
• Outpatient surgery
• Long-term care or skilled nursing services at a nursing facility
• Specialized treatments, imaging, testing, and procedures
• Medical transportation services when it is not an emergency
• Major organ transplant

To ask for a Prior Authorization you, your representative (a person that you have said can act on your behalf), or your doctor can call, fax, or mail the information to us.

Call: 1-833-388-8168 (TTY: 711), For April 1 through September 30, Monday – Friday and 8 a.m. to 8 p.m. October 1 through March 31, Sunday – Saturday, 8:00 a.m. to 8:00 p.m.

Fax: Fax the Request for Prior Authorization form to 1-657-276-4179.

Mail: Clever Care
Attn: Utilization Management
7711 Center Avenue, Suite 100
Huntington Beach, CA 92647

When will you hear back from us:
We will get back to you within:

• 72 hours if you request a fast decision (Urgent or Expedited)
• 14 calendar days, if you submit your request before the service is performed
• 30 calendar days, if you submit your request after the service is performed (there is no option for a fast decision)