Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 9
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: Individual Group
INSTRUCTIONS
The purpose of this form 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 Data1 |
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 Claim Denied due to: |
8 | Long-Term Care Services Not Covered under the Policy2 |
9 | Provider/Facility Not Qualified under the Policy3 |
10 | Benefit Eligibility Criteria Not Met4 |
11 | Other |
1 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.
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 Examples-a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 9