South Dakota Administrative Rules
Title 20 - PUBLIC SAFETY
Article 20:06 - INSURANCE
Chapter 20:06:21 - Long-term care insurance
Appendix H - 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: _____________________________________ 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.
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 preexisting condition. It does not include a request for payment that is in excess of the applicable contractual limits.
Inforce Data
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State Data |
Nationwide Data |
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Total Number of Inforce Policies [Certificates] as of December 31 |
Claims & Denial Data
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State Data |
Nationwide Data1 |
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1 |
Total Number of Long-Term Care Claims Reported |
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2 |
Total Number of Long-Term Care Claims Denied/Not Paid |
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3 |
Number of Claims Not Paid due to Preexisting Condition |
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Exclusion |
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4 |
Number of Claims Not Paid due to Waiting (Elimination) Period |
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Not Met |
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5 |
Net Number of Long-Term Care Claims Denied for Reporting |
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Purposes (Line 2 Minus Line 3 Minus Line 4) |
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6 |
Percentage of Long-Term Care Claims Denied of Those |
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Reported (Line 5 Divided By Line 1) |
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7 |
Number of Long-Term Care Claims Denied due to: |
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8 |
. Long-Term Care Services Not Covered under the Policy2 |
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9 |
. Provider/Facility Not Qualified under the Policy3 |
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10 |
. Benefit Eligibility Criteria Not Met4 |
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11 |
. Other |
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1. |
The nationwide data may be viewed as a more representative and credible indicator |
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where the data for claims reported and denied for your state are small in number. |
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2. |
Example-home health care claim filed under a nursing home only policy. |
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3. |
Example-a facility that does not meet the minimum level of care requirements or the |
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licensing requirements as outlined in the policy. |
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4. |
Examples-a benefit trigger not met, certification by a licensed health care practitioner |
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not provided, no plan of care. |
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