Filing a Grievance

A grievance is a formal way of telling us that you are unhappy about the quality of care you’ve received, waiting times, customer service, or another aspect of your experience with Clever Care.

Clever Care is committed to protecting the health care rights of members, including the right to file a grievance, request a coverage decision, or file an appeal. These processes help ensure members receive the health care services and benefits to which they are entitled.

Members are encouraged to report concerns so that the plan can address them and improve services.

Understanding Your Options

Depending on your situation, you may choose one of the following processes:

Grievance (Complaint)

You may file a grievance if you are dissatisfied with the quality of care you received, customer service, waiting times, access to services, or other aspects of your health care experience.

Coverage Decision (Organization Determination)

You may request a coverage decision if you want Clever Care to make a decision about coverage for a medical service, item, Part B drug, or payment. You, your authorized representative, or your provider may request a coverage decision. Additional information regarding coverage decisions is available in Chapter 9 of the Evidence of Coverage.

Appeal

You may file an appeal if you disagree with a coverage or payment decision made by Clever Care. You, your authorized representative, or your provider may be able to file an appeal on your behalf, depending on the type of appeal involved. Additional information regarding appeal rights and procedures is available in Chapter 9 of the Evidence of Coverage.

Grievance and Appeal Forms

Available in five languages (all updated 03/12/2026):

• Grievance and Appeal Form in English (updated 03/12/2026)
• Grievance and Appeal Form in Chinese (updated 03/12/2026)
• Grievance and Appeal Form in Korean (updated 03/12/2026)
• Grievance and Appeal Form in Vietnamese (updated 03/12/2026)
• Grievance and Appeal Form in Spanish (updated 03/12/2026)

Filing Deadline

Members generally must file a grievance within 60 days of the event. Those with a valid reason for late filing should notify Clever Care. Clever Care will consider whether to extend the timeline for filing a grievance.

Coverage decision and appeal timeframes vary depending on the type of request. Members should refer to Chapter 9 of the Evidence of Coverage for information about applicable coverage decision and appeal procedures and deadlines.

How to File a Complaint/Grievance

Call Customer Service at 1-833-283-9888 (TTY: 711)

Fax to 1-657-276-4715

Mail to:
Clever Care
Attn: Grievance and Appeals
7755 Center Avenue, Suite 700
Huntington Beach, CA 92647

Members may also use the Grievance and Appeal Form available above.

Additional information regarding grievance procedures, coverage decisions, appeal rights, representative requirements, and related processes is available in Chapter 9 of the Evidence of Coverage.

Medicare Resources

Members who wish to file a complaint with Medicare may do so using the official Medicare Complaint Form (https://www.medicare.gov/my/medicare-complaint):

Members may also visit Medicare.gov for additional information about Medicare coverage, rights, appeals, and complaints.

For process or status questions, or to obtain aggregate grievance, appeal, and exception numbers, members may call Customer Service at 1-833-283-9888 (TTY: 711).