PDFWAC 284-83-185
Sample claims denial reporting form.
The following form for reporting claims denials must be used in this state.
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of
For the Reporting Year of
Company Name:
Due: June 30, annually
Company Address:
Company NAIC Number:
Contact Person:
Phone Number:
Line of Business: | Individual | Group |
Instructions
The purpose of this form is to report all long-term care claim denials under in-force long-term care insurance policies. "Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition.
State Data | Nationwide Data1 | ||
1 | Total Number of Long-Term Care Claims Reported | ||
2 | Total Number of Long-Term Care Claims Denied/Not Paid | ||
3 | Number of Claims Not Paid Due to Preexisting Condition Exclusion | ||
4 | Number of Claims Not Paid Due to Waiting (Elimination) Period Not Met | ||
5 | Net Number of Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4) | ||
6 | Percentage of Long-Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1) | ||
7 | Number of Long-Term Care Claim Denied Due to: | ||
8 | • Long-Term Care Services Not Covered Under the Policy2 | ||
9 | • Provider/Facility Not Qualified Under the Policy3 | ||
10 | • Benefit Eligibility Criteria Not Met4 | ||
11 | • Other |
| Footnotes: | |
| 1. | The nationwide data may be viewed as a more representative and credible indicator where the data for claims reported and denied for your state are small in number. |
| 2. | Example—Home health care claim filed under a nursing home only policy. |
| 3. | Example—A facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy. |
| 4. | Examples—A benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care. |