WAC 284-212-185. Sample claims denial reporting form

The following form for reporting claims denials must be used in this state. Claims Denial Reporting Form Supplemental 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 Line of Business: Individual Group Instructions The purpose of this form is to report all supplemental long-term care claim denials under in-force supplemental 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 Supplemental Long-Term Care Claims Reported 2 Total Number of Supplemental 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 Supplemental Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4) 6 Percentage of Supplemental Long-Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1) 7 Number of Supplemental Long-Term Care Claim Denied Due to: 8 • Long-Term Care Services Not Covered Under the Policy 9 • Provider/Facility Not Qualified Under the Policy 2 10 • Benefit Eligibility Criteria Not Met 3 11 • Other State Data Nationwide Data 1 1 Total Number of Supplemental Long-Term Care Claims Reported 2 Total Number of Supplemental 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 Supplemental Long-Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4) 6 Percentage of Supplemental Long-Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1) 7 Number of Supplemental Long-Term Care Claim Denied Due to: 8 • Long-Term Care Services Not Covered Under the Policy 9 • Provider/Facility Not Qualified Under the Policy 2 10 • Benefit Eligibility Criteria Not Met 3 11 • Other