I Claims Denial Reporting Form: Long-Term Care Insurance

Section 2012 Section 2012.EXHIBIT I   Claims Denial Reporting Form:  Long-Term Care Insurance For the State of  Illinois 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 format 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 Data 1 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 Claims Denied due to: 8 · Long-Term Care Services Not Covered under the Policy 2 9 · Provider/Facility Not Qualified under the Policy 3 10 Benefit Eligibility Criteria Not Met 4 11 · Other 1 The nationwide data may be viewed as a more representative and credible indicator where the data for claims 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 Example - a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.