Md. Code Regs. 31.14.01.32
The following form is to be used for reporting claim denials made by each insurer as required by Regulation .24G of this chapter:
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.
| StateData | NationwideData1 | ||
| 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.
Md. Code Regs. 31.14.01.32