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Long-Term Care Insurance: How to File a Claim and Get Your Money Faster

By Anamika Huq

Assessing the benefits and process of your Long-Term Care Insurance (LTCI) policy can be challenging, but when your aging loved one needs assistance to continue living safely, we want that process to be quick and seamless.Whether they continue living independently at home or need to be moved to an assisted living facility, LTCI can make the care much more manageable.  Assuming your care recipient has a current LTCI policy, the first step to making this adjustment is gathering all documentation regarding their condition and filing a claim as soon as possible. You can find the details of your loved one’s policy by calling their insurance company directly or looking at their certificate of coverage.

Process of filing a claim:

1. Call your insurer. “I am , I would like to file a claim.” This will prompt the insurance company to send you an initiation packet of HIPPA forms, authorization to receive benefits, etc. This must be faxed to the insurance company by the client or our Long-Term Care Administrator. If you are using us as a provider, you must list us under your policy as a provider of care in your claim.
2. Prove the recipient’s need. Often insurance companies want claimants to prove that they need care to perform two or three activities of daily living (ADL) such as bathing, dressing, feeding, toileting, transferring, or incontinence. This can be done with a licensed health care provider confirming in writing the details of a patient’s care needs. When you speak with the insurance company, it is important to make it clear that you have documentation proving need from a physician and/or RN assessment. The insurer should also have a written demand to call the patient’s advocate for information only.
3. Determine the elimination period. This is the number of days before benefits kick in. In the meantime, it is the family or client’s responsibility to pay. Elimination periods can range from 20 to 60 or even 90 days. The way an insurance company counts days can vary as well. Normally they count based on “calendar days,” pay for services X amount of days after you file a claim, or the company certifies you are eligible for coverage. Other insurance companies count by “service days.” This is when the insurer counts the days a caregiver visits the patient toward their waiting period. Some insurance companies will eliminate this period all together. It can get tricky if your claim is rejected because the caregiver was not certified, you did not go through an agency, or have an assessment done prior to the elimination (waiting) period.
4. Check requirements. Before picking a caregiver, it is important to study the fine details of your insurer’s coverage. Many policies require a licensed caregiver to aide your loved one and some insist that an agency provide the care and certify the need. If your claim is rejected, work with a LTCI insurance expert.

If you are apprehensive to call your insurer, please speak with LifeWorx. Our Long-Term Care Insurance Administrator will be happy to call with you or on your behalf to determine all the details and requirements necessary for your loved one to file a claim and receive their money quickly. You can also find more information on Long-Term Care insurance in our Long-Term Care Guide.