Success Tips For Long-Term Care Claims – Part Three

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by Tim Colling~In Part One of this series, we offered a list, shown below, of tips about how to prepare and file claims for benefits under Long-Term Care Insurance (“LTCI”), promising to provide more detail. In Part Two, we covered the first three of them. In this Part Three, we’ll cover the fourth tip.

  1. Choose one person to be in charge of filing the claim.
  2. Be very organized, prompt and businesslike and get the claim filed right away.
  3. Get help in filing the claim from someone who knows what they’re doing.
  4. Make sure the claim is complete when you submit it, including all forms and required supporting documents.
  5. Plan ahead to pay out of pocket until the insurance company approves the claim.
  6. After you have submitted your claim, follow up at least weekly and keep notes.

Make sure the claim is complete when you submit it, including all forms and required supporting documents.

One of the primary ways that LTCI claims are delayed is when the LTCI company says that the information that it received was incorrect, incomplete or insufficient for it to determine whether the insured person is eligible to receive benefits. Every time you send the LTCI company new information or documents, it promises to respond after the passage of a specified period of time in which to “process” the new information before responding. I’ll call that period of time the “processing period” here.

A typical “processing period” is ten business days, which is two calendar weeks. That means that every time the LTCI company says that it needs more information, or more complete information, or more correct information, it can delay payment of benefits for at least as long as you take to get that information to them plus two weeks.

Therefore, you should do everything possible to make sure that the claim is complete when you submit it. The LTCI company will have provided you, or given you a site to download, a “claim package” with information and forms about how to file the claim. It’s very important to read these forms and instructions very carefully and to submit everything that the instructions say to submit.

Every form must be fully and clearly completed and signed by the correct person(s). Some forms will need to be signed by the insured or the insured’s legal agent under a power of attorney, some will need to be signed by one or more of the insured’s doctors, and still others may need to be completed and signed by others, such as the caregiving company that will provide care in the home, or the long term care facility where the insured will be residing.

AND, here’s an important tip: after you have received the claim package with the forms and instructions and understand them, call the LTCI company and ask this question:

Is there any other information, or are there any other documents, besides the ones already included and described in the claim package, that you [the LTCI company] will require from us in order to make a final determination of eligibility for benefits?

Why is this an important tip: because very often, LTCI companies ask for more information after they receive the initial claim package submission from the insured, information that it knew in advance that it would require but which it did not disclose, describe or discuss in the original claim package instructions.

Examples of such additional required, but not originally described, documentation may include, but certainly not be limited to, some of the following:

  • Copies of powers of attorney for the family member who is the project manager filing the claim on behalf of the insured.
  • Additional reports from specialist physicians.
  • Copies of state and local licenses for the caregiving service company or long term care facility.
  • Plans of care or service from the caregiving service company or long term care facility.
  • Copies of visit notes or progress notes from the caregiving service company or long term care facility.
  • Copies of invoices from the caregiving service company or long term care facility.

Finally, ask the LTCI company whether or not it is going to require that you allow one of their nurses to make an independent assessment of the insured’s condition for the sake of assessing the insured’s eligibility for benefits under the policy. If so, then ask them to make that assessment take place as quickly as possible, in order to not further delay the processing of the claim.

Summary

Make your initial claim submission as complete as you can, and then after that if any additional information is requested by the LTCI company, provide it immediately. Do everything you can to proactively ask whether any additional information will be required.

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About Tim Colling

Tim Colling has more than 30 years of experience in management in a variety of industries and has served in the past as a member of the statewide steering committee for the Home Care Aide Section of the California Association for Health Services At Home (“CAHSAH”). He is a Certified Public Accountant (licensed but not actively in practice), and received his Bachelor’s Degree in Accounting from California State University at San Diego. He has held the credential Care Manager Certified ("CMC") from the National Academy of Certified Care Managers, and has practiced actively as a Professional Geriatric Care Manager. Tim has worked as a CPA in Public Accounting, a corporate Chief Financial Officer for a chemical manufacturing company, and a software engineering manager for several private and public software companies, in addition to working as an eldercare manager, in-home caregiver agency administrator and professional geriatric care manager since 2003. Learn more about his in-home caregiving company at A Servant's Heart In-Home Care

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