This is the continuation of the answer to this question; filing a LTCI claim.
You have called the company and started the claims process. You will receive a packet from your LTCI which includes claim forms you must complete and return within 30-days. There may be a form to be completed by your physician. There is a form to be completed by you, indicating your physical situation and medical history, and a HIPAA (Health Insurance Portability and Accountability Act of 1996) release form. The HIPAA form authorizes someone else to give and receive information/correspondence with the LTCI Company. The HIPAA form is very important to complete because every time you or your family call later on with questions or concerns, they will ask to speak with the insured individual first in order to get permission to talk with you.
Once the required forms have been completed, send them back to the LTCI Company for processing. The LTCI Company will have a healthcare professional perform a face to face assessment of your situation. This individual is usually a Registered Nurse (RN) who will complete one to two hour personal needs assessment and home evaluation. The RN’s evaluation will determine whether or not you need help with what you have reported on the paperwork. There is a prescribed list of questions and physical assessments that will be completed. The nurse will also evaluate the living situation to see if adjustments need to be made, grab bars, raised toilet seats, walkers, ramps, etc.
During this evaluation it is important to be truthful in your answers about care. It is also important to portray ‘your worst days’. Think about and describe those days that reflect how much care is required. We often want to portray ourselves in the best light. Here we need to portray our worst self.
The nurse’s evaluation is sent to the LTCI Company, where a case review is completed. Once this review is completed, the company informs you of their determination to cover care. That means they’ve either approved your ‘claim’ (will help to pay for care), or they’ve determined you do not need enough care/help to qualify for benefits at this time.
If the claim is approved they will mail a new packet of material to you. This packet will include a description of your coverage, benefits and the amount of money you can receive for services provided. This amount is your daily or monthly benefit level. That amount could be per day amount (for example $150 per day) or a monthly benefit ($4000 per month). The determination letter will include the length of your elimination period (30 days or 100 days) and your coverage period (how long the coverage lasts -for example -3 years).
The packet will also contain forms to be completed by care providers. More on these forms in next week’s article. The packet may contain Direct Deposit Authorization forms which enable you to have LTCI reimbursement payments deposited directly into your bank account. I would recommend using this Direct Deposit option as you will receive your reimbursement quicker. The LTCI will mail you a monthly statement including claim coverage and payments.
In the event that your claim for coverage is denied, you have a couple of choices; either you can appeal the decision with the LTCI Company, allowing you to provide additional information indicating why you feel the claim was justified and should be covered. This will likely require supporting documents from your physician.
Or you can wait a month or two and begin a new claim. Be sure that care is still necessary, and evaluate why the claim was denied. Make sure this time you address those issues more comprehensively. You are allowed to make as many attempts using the claim process as necessary to ensure coverage of your care.