Requesting Prior Authorization

Some medical services, items, and medications require approval from Clever Care Health Plan before you receive them. This is called prior authorization or pre-approval.

How do I know if prior authorization is required?

Your Evidence of Coverage explains which medical services and items require prior authorization. Because requirements can vary by service and plan, check your plan documents before receiving care.

How to Request Prior Authorization

You, your representative, or your doctor can request a Prior Authorization by calling, faxing, or mailing information.

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

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

Mail:
Clever Care
Attn: Utilization Management
PO Box 2269
Huntington Beach, CA 92647

When will you receive a decision?

We review your request and provide a decision within the timeframes that apply to the type of request.

Standard decisions

• Medical items or services that require prior authorization: Within 7 calendar days after we receive your request.
• Other medical items or services: Within 14 calendar days after we receive your request.
• Part B drugs: Within 72 hours after we receive your request.

For medical items or services, we may take up to 14 additional calendar days if you ask for more time or if we need more information that may benefit you. If we take additional time, we’ll notify you in writing.

We cannot take additional time for a Part B prescription drug decision.

Need a decision faster?

You may qualify for a fast (expedited) coverage decision if using the standard deadline could seriously harm your health or your ability to regain function.

• Medical items or services: Within 72 hours
• Part B drugs: Within 24 hours

If your doctor tells us that your health requires a fast coverage decision, we’ll automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision without your doctor’s support, we’ll determine whether your health requires an expedited decision.

Fast coverage decisions apply to requests for coverage of medical items or services. They do not apply to requests for payment for medical items or services you have already received.

Learn more about your coverage

Your 2027 Evidence of Coverage includes detailed information about prior authorization, coverage decisions, appeals, and your rights as a member.