Clover Health

Contract: H1902 · Plan type: HMO

Evidence lead: Top-three record · High appeal-filing share

Clover Health: Appeals followed a large share of denials

689 appeals equal 15.0% of this contract's recorded denials. That is rank #3 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Top-three record · High appeal-filing share

Appeals followed a large share of denials

689 appeals equal 15.0% of this contract's recorded denials. That is rank #3 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Bottom-seven record · Lower denial-rate cohort

One of the ten lowest denial rates

Clover Health's 5.4% rate belongs to the lowest-denial tier in this table. The exact rank is #32 of 37. This is aggregate prior-authorization activity for the reporting window, not a probability that a particular service, drug, or beneficiary request will be denied.

Ranks four through six · High overturn-rate cohort

One of the ten highest appeal overturn rates

78.0% of this contract's filed appeals were overturned in the source record. Its overturn-rate rank is #6 of 37. The denominator is filed appeals, not all authorization requests. The percentage therefore describes reviewed appeals and must not be read as an individual outcome forecast.

Ranks four through six · Broad reversal reach

Overturned appeals covered a top-ten share of denials

537 overturned appeals equal 11.7% of every denial recorded for this contract. The cross-contract rank is #6 of 37. This derived measure combines appeal filing and outcome, so it supplies scale context but does not identify clinical reasons, administrative errors, or coverage rules.

Ranks twenty-one through twenty-five · Moderate request-volume cohort

A mid-lower authorization workload

This contract's 85,000 requests form a moderate comparison base within the table. Its request-volume rank is #23 of 37. Volume shows the denominator behind approvals and denials; it is not a measure of plan quality, membership, benefit breadth, price, or future coverage decisions.

Prior Authorization Scorecard

PA Requests
85,000
PA Denial Rate
5.4%
Appeals Filed
689
Appeal Overturn Rate
78.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 85,000
PA Approved 80,410
PA Denied 4,590
Appeals Filed 689
Appeals Overturned 537
Source: CMS Office of Inspector General report OEI-09-22-00380; KFF 2023 Medicare Advantage analysis. Verify with HHS OIG → · CMS.gov →
Sources, caveats, and related notes for Clover Health
What does Clover Health's overturn rate mean? Of the appeals filed after denials in this source record, 78% were overturned (537 of 689 filed appeals, not all 4,590 denied requests).
This data is for informational purposes only and does not constitute medical, financial, or insurance advice. Contact CMS or your plan for coverage decisions. Data from CMS OIG and KFF Medicare Advantage analysis.

Data: CMS OIG OEI-09-22-00380 and KFF 2023 Medicare Advantage analysis. Not affiliated with CMS. ← All MA plans

Read our methodology - how this data is sourced, computed, and verified.

Primary data: U.S. Department of Health & Human Services, Office of Inspector General, Medicare Advantage Encounter Data (Report OEI-09-22-00380, 2024). Secondary data: Kaiser Family Foundation 2023 Medicare Advantage Prior Authorization analysis. Methodology and editorial review by PlainInsurer, see methodology.