054.00.13 Appendix E. Claims Denial Reporting Form Long-Term Care Insurance.
AR ADC 054.00.13 Appendix EArkansas Administrative Code
Ark. Admin. Code 054.00.13 Appendix E
054.00.13 Appendix E. Claims Denial Reporting Form Long-Term Care Insurance.
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 Data 1 | |||
|---|---|---|---|---|
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 Policy 2 | |||
9 | • Provider/Facility Not Qualified under the Policy 3 | |||
10 | • Benefit Eligibility Criteria Not Met 4 | |||
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.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.13 Appendix E, AR ADC 054.00.13 Appendix E
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