Form LTC-E "Claims Denial Reporting Form" - Missouri

What Is Form LTC-E?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 15, 2007;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC-E by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form LTC-E "Claims Denial Reporting Form" - Missouri

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Claims Denial Reporting Form
Long-Term Care Insurance
For the State of Missouri
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. “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.
State
Nationwide
1
Data
Data
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 Claim Denied due to:
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of Missouri
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. “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.
State
Nationwide
1
Data
Data
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 Claim Denied due to:
• Long-Term Care Services Not Covered under the Policy
2
8
• Provider/Facility Not Qualified under the Policy
3
9
• Benefit Eligibility Criteria Not Met
4
10
• Other
11
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.
Form LTC-E
(Rev 11/15/2007)
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