1 Long Term Care Insurance Claims Filing & Ongoing Claims Management How to File a Successful Long Term Care Insurance Claim
2 The claims process is complex and most often comes at an already difficult time... If you have ever experienced a sudden or deteriorating change in health of a loved one, you know that turn of events can be complex and overwhelming. Many things happen at once. Once the person is stabilized, caregiving decisions have to be made. Life savings and assets may for the first time need to be disclosed to family members and scrutinized. Decisions about whether or not the person can stay in his house need to be made. There may be a spouse or partner whose needs also must be addressed and, of course, they have opinions, too! Often, family members gather together if able and make decisions about the future and assignments are doled out. It is often a very emotional and stressful time. If your family member has a long term care insurance (LTCI) policy, that policy can help with paying for care. However, understanding how the policy s benefits and the claim process work can be overwhelming. Important Tip Do NOT file a claim until you have had a chance to get some information organized. Starting a claim too soon without complete documentation can not only cause extreme frustration, but it can delay the claims process or even result in a denial of your claim. 1 Ed1 4/2014 Copyright MMXIV ClaimJockey, LLC
3 Step 1: Understanding Benefit Triggers Understanding Benefit Triggers is one of the most important first steps. Long term care policy payments are typically triggered once the insured needs help with 2 out of 6 activities of daily living (aka ADLs). The ADLs are: Bathing, Dressing, Eating, Transferring, Toileting, and Continence. Though the ADLs are a standard list, policy language is not necessarily standardized. IA policy that requires standby assistance could be very different at claim time than a policy requiring hands-on assistance. The language in the ltci contract is what determines both whether the insured is eligible to have a claim paid, and what types of services are eligible for payment. The second way a policy is triggered is Cognitive impairment. The Center for Disease Control defines cognitive impairment as when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. This does not merely mean a diagnosis of memory loss it means the patient needs SUBSTANTIAL supervision due to a severe cognitive impairment. This condition must be diagnosed and documented in the patient s medical records in such a way that benefits which the insured is eligible for are triggered. Not all long term care policies have the same triggers. Policies issued before 1996 are often different than those issued in subsequent years (because of federal legislation defining long term care). This means it s crucial, before making caregiving decisions and prior to submitting a claim, to locate and read the specific insurance contract you or your loved one owns. 2 Copyright MMXIV ClaimJockey, LLC Ed1 4/2014
4 A Family Coordinator is extremely helpful when thinking about filing a long term care policy. This person should be extremely organized and able to pay close attention to details. They will need to have availability for the phone calls to physicians and the insurance company that are often necessary. They will also need to carefully document the process, keeping detailed notes of all phone calls and copies of all correspondence, and follow up as required. It s important that this person be able to take care of the paperwork and move the process forward without becoming overly emotional. Important Tip Read the policy thoroughly before you call the insurance company. If there is no copy of the policy available call the insurance company and ask for a copy of the policy to be sent. Make sure the insurer has the correct address on file. The insurance company will often only mail the duplicate copy to the policyholder address it has on file. DO NOT FILE A CLAIM UNTIL YOU HAVE READ THE POLICY! 3 Ed1 4/2014 Copyright MMXIV ClaimJockey, LLC
5 Step 2: Understanding the Policy Benefits Reading the policy, complete this policy checklist Nursing Home = NH, Assisted Living Facility = ALF, Home Health Care = HHC Is the current benefit stated in daily or monthly terms? n Daily n Monthly What is the benefit for NH? ALF? HHC? What is the benefit period? What is the total benefit pool (benefit amount multiplied out by benefit period)? NH? ALF? HHC? Are there separate pools of money for NH, ALF, HHC benefits, or can the total benefit pool be used in any covered setting? n separate pools of money n any covered setting OK What inflation option was selected on the policy? n none n describe: What is the elimination period (days before insured is eligible for claims payment) for NH? ALF? HHC? How is the elimination period satisfied? Is it service day or calendar elimination period? n service day n calendar day What are the specific benefit triggers? 4 Copyright MMXIV ClaimJockey, LLC Ed1 4/2014
6 Does policy pay for stand-by or hands-on assistance? Is there a waiver of premium clause (premiums aren t due when the insured is on claim)? n Yes n No Is it triggered by home-based and facility-based claims? n Yes n No What does it say? Does the policy include: n Shared Care? n Restoration of benefits? n Alternate plan of care? n Survivorship? n Any other riders? n Home Modification benefit? Important Tip Here are the 3 top reasons long term care insurance claims are denied: Benefit triggers not met Incomplete documentation Wrong type of caregiver (example: using an independent caregiver versus an approved caregiver) AVOID claims delays or denials by steering clear of these problems! 5 Ed1 4/2014 Copyright MMXIV ClaimJockey, LLC
7 Step 3: Follow Up After reviewing the policy Verify to the best of your ability that your family member meets benefit triggers. Call the insurance company and tell them you would like to initiate a claim if you believe benefits triggers will be met. Make sure you are authorized with a Durable Power of Attorney (DPOA) to take care of arrangements. Start a journal or log while waiting for claim paperwork to arrive. Collect the name, address, and phone number for hospitals, home health care workers, rehabilitation units, nursing homes, physicians, and therapists. Write down dates and levels of service provided. Make a list of medications taken in the last 12 months and get a copy of the insured s health insurance card. Within 30 days the claim paperwork should arrive. Complete every line of the claim paperwork. Write not applicable on a line that does not apply. If requested, fax a signed medical records request to all health care providers. Follow up with a phone call to make sure the faxes were received. Follow up with another phone call to make sure the request for records was fulfilled. Follow up with the insurance carrier to make sure all documentation was received. 6 Copyright MMXIV ClaimJockey, LLC Ed1 4/2014
8 Important Tip The importance of following up cannot be overemphasized. Failure to follow up often means things slip between the cracks, the insurance company doesn t get what they require, and claims decisions are delayed. Monthly review of Explanation of Benefits (EOB) and submission of bills is required on almost all policies. Many families do not realize that filing for long term care insurance is a monthly commitment. In addition to submitting new evidence of paid care, the claim should be monitored every month by reviewing the Explanation of Benefits (EOB). Filing a successful term care insurance claim can be difficult, but it is not impossible. It takes time, paying attention to detail, perseverance, and patience. It is a bit like filing your own IRS tax return but a long term care insurance claim needs to be done every month! To minimize difficulties, one person must be assigned to this task. They must be a well-organized, paperwork-oriented person. 7 Ed1 4/2014 Copyright MMXIV ClaimJockey, LLC
9 Thank You! ClaimJockey hopes this booklet has been helpful to you. If you have landed here chances are something has happened in your family and for that our hearts go out to you. We know we have been there. You can file your own or your family member s LTCI claim but, if you want help, we are here for you. Our company exists to take this one responsibility off your overloaded plate so that this time in your life can become as stress-free as possible. We want to let you spend special moments with your family member not time chasing down medical records and insurance forms. Call us. One of our caring team members will talk with you and gather information to see if this is the right time to file a claim. That call is free just to help get you started. If we believe we can help our team member will assist you in selecting a service package that fits your family s needs. Our team can do all of the paper chasing and documentation for you so that you don t have to. We are proud of our tremendous success rate in helping families receive the quick payment they need for services. Sincerely, Wendy Rinehart President ClaimJockey, Inc. 8 Copyright MMXIV ClaimJockey, LLC Ed1 4/2014
10 ClaimJockey was founded by a group of long term care insurance specialists to help fulfill the promise of long term care by helping families with claims filiing and management. ClaimJockey partners with care providers, attorneys, insurance professionals, and most importantly families to provide a service that helps get the right kind of care and payment for that care with as much ease as possible NE Missouri Road #200, Lee s Summit, MO 64086
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