When you are ready to file a claim for long-term insurance benefits, you will need to obtain and fill out an initial claim “packet” or claim initiation kit.
Each company’s insurance claim forms will be different, and some are available online. A claim packet will typically include the following five items:
- Policyholder Statement
Also known as a claimant’s statement, individual statement, insured’s statement, or care support history – this set of forms will require basic information about the policyholder (e.g. – name, address, phone number, date of birth, policy number). It will also ask for explanations regarding the reasons for submitting the claim, including which activities of daily living help is needed with and how long assistance will be required. This component usually includes sections related to hospitalization and medical history as well. The policyholder (or their legal representative/agent under power of attorney) must sign this multi-page statement.
- Attending Physician Statement
If a long-term care administrator feels they need additional information they will contact the attending physician or someone that knows the policyholder’s health history for additional information and verifies that the care they require is medically necessary. The physician may need to attach test results, office notes, medical records, and other supporting documentation to this statement.
- Nursing Assessment and Plan of Care
Some insurance companies will not approve a long-term care insurance claim without a nursing assessment and/or a prescribed plan of care. Sometimes these components will be included in the physician’s statement mentioned above. However, if an insurance company has its own registered nurse or a third-party registered nurse, it will contact the policyholder and conduct its own assessment. The policyholder’s care provider should have a nurse on staff who can conduct and write up this initial assessment, which will include vital sign measurements, demographic information, and medical history. A physician licensed practical nurse (LPN), or social worker may have to sign to certify this information is accurate.
- Provider Statement
If the policyholder is currently receiving long-term care services, each care provider will need to complete and sign these forms to verify that it is equipped to provide the services detailed in the plan of care. Providers will need to submit proof of proper licensure, certification, etc. If the LTCI policy includes an elimination period, invoices from current care providers must also be submitted to ensure these days of care count towards the waiting period needed to begin benefits.
- Authorization to Release Information
This form ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) and permits the insurance company to collect health care documentation to process the policyholder’s claim. The policyholder or their legal representative must sign this form. If someone is signing this release on the policy’s behalf, a copy of their power of attorney (POA) or guardianship documentation must be included.