N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, app E
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: IndividualGroup
Instructions
The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies. Indicate the manner of reporting by checking one of the boxes below:
Per Claimant - counts each individual who makes one or a series of claim requests.
Per Transaction - counts each claim payment request.
"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. It does not include a request for payment that is in excess of the applicable contractual limits.
Inforce Data
| State Data | Nationwide Data |
| Total Number of Inforce Policies [Certificates] as of December 31st |
Claims & Denial Data
| State Data | Nationwide Date |
| 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 |
| 9 | * Provider/Facility Not Qualified under the Policy |
| 10 | * Benefit Eligibility Criteria Not Met |
| 11 | * Other |
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.
Example - home health care claim filed under a nursing home only policy.
Example - a facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy.
Examples - a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.
N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, app E
The amended version of this appendix by New Hampshire Register Volume 35, Number 10, eff.2/13/2015 is not yet available.