With Clever Care you are getting a quarterly allowance to pay for comprehensive dental procedures, including routine dental cleaning, exams, X-rays, fillings, crowns, and more!
How to access care
Your dentist will submit a claim to Clever Care, and we will apply the available allowance balance to the claim. If any amount is unpaid (due to lack of allowance dollars), your dental provider will send you a bill.
For questions about our dental benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).
How to access care
Using your allowance
Clever Care gives members $300, every two years, to help pay for eye glass frames, contacts, and more. Your eye care provider will walk you through all of the options and will submit the claim to Clever Care for payment.
We will apply the available allowance to the claim. If any amount is unpaid (due to lack of allowance dollars), your vision provider will send you a bill.
For questions about our vision benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).
Call NationsHearing at (866) 304-7557 Monday-Friday, 8:00 a.m. to 5:00 p.m. Pacific Time to scheduling a hearing either in-person or from your computer at home. Their trained representative will help you decide which provide to use.
Clever Care gives members an annual allowance to pay for or help pay for hearing aids for both ears. You and your hearing provider will find the right hearing aid fit your needs. You get:
1Deductibles may apply.
For questions about our hearing benefits, call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).
Clever Care members receive a pre-paid debit card that is replenished quarterly. It can be used to purchase eligible over-the-counter (OTC) items such as medications, health and wellness products, and first aid supplies.
How to purchase items:
Only items listed in the OTC Medicare Catalog are covered. You may place as many orders as you need during the benefit year. After your order has been processed it will be fulfilled and shipped within 2-5 business days.
Call Clever Care Customer Service at 1-833-388-8168 (TTY: 711).
At Clever Care, we put members’ health and safety first. As part of our Medicare Part D plan, Clever Care offers QA and UM programs at no extra cost to Part D members. These programs are designed to ensure the safe and appropriate use of prescription medications covered under Medicare Part D. The programs help identify potential risks and opportunities to improve your medication therapy.
In this program, every time a prescription is dispensed, it is reviewed for:
This program also periodically reviews claims data.
This program consists of three parts, and is designed to encourage the safe, appropriate, and cost-effective use of Medicare Part D prescription drugs.
Prior authorization (PA) A PA requirement means the member, or their doctor must get approval before your medication is covered at your pharmacy.
Step therapy (ST) A ST requirement means you must first try one drug to treat a medical condition before another drug will be covered for that same condition.
Quantity limits (QL) A Quantity Limit requirement limits the amount of a drug that will be covered with prior approval.
Together, these programs help us identify and work to resolve any health and safety risks that your medications could pose, and to help you get the most benefit from your Medicare Part D plan.
If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a Medication Therapy Management (MTM) program.
MTM is a service offered by Clever Care of Golden State at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.
To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.
You must meet ALL of the following criteria to qualify to participate in Clever Care’s MTM program,
To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:
The Personal Medication List can help you and your health care providers keep track of the medications you are taking.
If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact Customer Service at 1-833-388-8168 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays, from April 1 through September 30. Messages received on holidays or outside of our business hours will be returned within one business day.
A coverage determination is an initial coverage decision made by Clever Care regarding your Medicare Part D prescription drug. Coverage determinations you can request about your Part D drugs include:
Important Information to Know About Asking for Exceptions
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.
What to Do
You (or your representative or your doctor or other prescriber) may use the form below to submit your request for a Part D Coverage Determination.
Please note: If you do not use this form, you will need to provide us the same information indicated in the form so we can process your request in a timely manner.
To start your Part D Coverage Determination request you (or your representative or your doctor or other prescriber) should contact Medimpact at (800) 926-3004 (TTY: 711).
MedImpact Healthcare Systems, Inc.
PO Box 509108
San Diego, CA 92150-9108
For additional assistance with making your Part D Coverage Determination request you may call our Customer Service Department.
Refer to your Evidence of Coverage, Chapter 9, Section 6 to find out more about the Part D Coverage Redetermination Process.
CMS created the “best available evidence” policy in 2006 requiring plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information was not accurate.
CMS continues to require Part D plans to rely on best available evidence and considers it best practice for the Part D plans to work with pharmacies to resolve these issues at point-of-sale when beneficiaries present with appropriate evidence of correct low-income status.
For more information call Customer Service or visit the CMS website
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.
Refer to Chapter 10 of your Evidence of Coverage for a complete description of the rights and responsibilities upon disenrollment.
Clever Care is committed to protecting the health care rights of members, including the right to file a grievance. A complaint/grievance is a formal way of telling us that you are unhappy about the quality of care you’ve received, waiting times and the customer service you receive. The grievance process is fundamental to ensuring our members receive needed health care services.
If you have any grievance, please help us to make it right. We want to do the right thing for you and improve for future.
You need to file your grievance within 60 days of the occurrence. If you have a good reason for being late in filing a complaint/grievance, let us know and we will consider whether to extend the timeline for filing a complaint/grievance.
How to file a complaint/grievance:
Call Customer Service at 1-833-283-9888 (TTY: 711). We will do everything we can to resolve your concern.
Fax your complaint/grievance to us at 1-657-276-4715.
Mail your complaint/grievance to:
Attn: Grievance and Appeals
660 W. Huntington Dr. Suite 200
Arcadia CA 91007-3424
Chapter 9 in your Evidence of Coverage includes the process and more information on how to file a complaint/grievance. Or you can visit Medicare.gov.
For process, status questions, or to obtain an aggregate number of Clever Care of Golden State grievances, appeals and exceptions, please call Customer Service at 1-833-823-9888 (TTY: 711).
Prior Authorization is a decision made by the plan regarding certain medical services that require pre-approval or prior to arrangement for health care services. You, your representative, or your network Primary Care Provider (PCP), or the provider that delivers or intends to deliver services to you, may request a Prior Authorization by filing out a Request for Prior Authorization form.
Attn: Utilization Management
660 W. Huntington Dr. Suite 200
Arcadia CA 91007-3424
Medical item or service decisions will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard.
For Part B drug determination, the turn-around time for a request is 72 hours for a standard review and 24 hours for an expedited review.
If you do not get a referral, Clever Care may not cover the service. For more information, call Customer Service or refer to Chapter 9 of your Evidence of Coverage.
An advance directive (also known as a living will) is a way to make sure that your designated medical power of attorney is able to communicate your medial wishes if you cannot speak for yourself.
Together, with your doctor, you can create an advance directive that will instruct providers to withhold or withdraw life sustaining treatment in the event of a terminal condition or permanent unconscious condition.
When you have completed your advance directive, ask your doctor to put the form in your file. It is also a good idea to let your loved ones and your Medical Power of Attorney (if designated) know you have an advance directive.
You may change your advance directive at any time. Call us if you have any questions or want help.
One-time only – you can give us permission by phone, and we’ll need to speak to that person during the call.
On-going basis – mail us the Authorization for Release of Protected Health Information (PHI) form. This form lets the person of your choice access your protected health information and speak with us on your behalf.
Appointing a Representative – Instructions & Form
People who want to represent a member can be appointed or authorized by the member.
A member can authorize anyone (like a relative, friend, advocate, an attorney, or a doctor) to act as his or her representative and file a grievance, appeal, or organization determination on his or her behalf.
A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.
How to authorize a representative:
Clever Care Medicare Advantage requires a copy of the completed and signed Appointment of Representative Form to process a grievance, appeal or organization determination filed by the member’s representative. The form will be valid during the entire grievance, appeal or organization determination process. The Appointment of Representative Form is valid for one year from the date indicated on the form. A member can revoke the authorization at any time.