W. Va. Code R. agency 114, tit. 114, ser. 114-32, 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. 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.
| 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 | ||
| $ Provider/Facility Not Qualified under the Policy3 | |||
| $ Benefit Eligibility Criteria Not Met4 | |||
| $ 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.
W. Va. Code R. agency 114, tit. 114, ser. 114-32, app E