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.

PDFWAC 284-83-185

Sample claims denial reporting form.