Pa. Code tit. 31, pt. IV, ch. 89a, 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:
___
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 a 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.
Pa. Code tit. 31, pt. IV, ch. 89a, app E
This appendix cited in 31 Pa. Code § 89a.114 (relating to reporting requirements); and 31 Pa. Code § 89a.121 (relating to suitability).