Nebraska Administrative Code
Topic - INSURANCE, DEPARTMENT OF
Title 210 - NEBRASKA DEPARTMENT OF INSURANCE
Chapter 46 - LONG-TERM CARE INSURANCE
Appendix 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 #: _____________________________________________

Contact Person: _______________________Phone #:_____________________

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. .

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.