The following form is to be used for reporting claim denials made by each insurer as required by Regulation .24G of this chapter: For the State 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. StateData NationwideData1 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: 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.