North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-06 - Accident and Health Insurance
Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION
Appendix E - Sample Claims Denial Format
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: ___________________ Telephone 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. Indicate the manner of reporting by checking one of the boxes below:
[] Per Claimant - Counts each individual who makes one or a series of claim requests.
[] Per Transaction - Counts each claim payment request.
"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 pre-existing condition. It does not include a request for payment that is in excess of the applicable contractual limits.
In-force Data
|
State Data |
Nationwide Data1 |
|
1 |
Total Number of In-force Policies [Certificates] as of December 31st |
Claims and Denial Data
| State Data | Nationwide Data1 |
| 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 Claims Denied Due to: |
| 8 | Long-Term Care Services Not Covered Under the policy2 |
| 9 | Provider/Facility Not Qualified Under the Policy3 |
| 10 | Benefit Eligibility Criteria Not Met4 |
| 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.
