Filing a Claim for Benefits

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If you would like to submit a claim for benefits, please call Customer Service at 1-800-362-0700. Our representatives will be happy to answer your questions and send you an information packet containing instructions and required forms for you to complete and mail or fax back to us.

Submitting Forms

If you have forms to submit, you can send them to us by:

Please include your policy number on all documents.

Claim Questions

When do I need to file a claim for benefits?

For potential benefits, please call Customer Service at 1-800-362-0700 to discuss filing a claim. Our representatives will be happy to answer your questions and send you an information packet containing complete instructions and required forms for you to complete and mail or fax to us.

What types of services are covered under my policy?

The types of covered services are specific to each policy. Please refer to your policy or call us to discuss.

The following Questions and Answers relate to long term care insurance policies. If you are covered by a non-LTC policy and have any questions about your coverage, please call Customer Service at 1-800-362-0700.

What types of services are not covered?

Services that are not reimbursable include, but are not limited to, pet care; trips to the beauty parlor, church, and social activities outside the home; heavy housekeeping; convenience items.

For services provided in the home, some policy terms require that care be provided to the policyholder while confined in his or her home. This varies by policy type. Please refer to your policy for specific information regarding the types of covered services or call Customer Service to discuss at 1-800-362-0700.

How is eligibility for benefits determined?

Determining eligibility is a three-step process:

1. Benefit eligibility: Your medical condition and care needs are evaluated to determine if they meet the eligibility requirements of your policy.

2. Provider eligibility: The care provider you choose is evaluated to determine if the facility, agency, private caregiver, etc., meets the criteria listed in your policy.

3. Service eligibility: The services provided to you are evaluated to determine if they are covered by the policy.

What information is required for benefit eligibility?

To simplify the claim process for you, we obtain information from two sources:

1. Your physician(s) and/or providers: Information is required from your physician(s) and/or any providers currently providing care about your current medical condition and care needs, and the anticipated length of time that care will be needed. We request this information directly from your physician(s) and/or providers. You can help by asking your physician(s) and/or providers to promptly complete and return the required information to us.

2. In-home assessment: A nurse from an independent company representing TriPlus may visit you to conduct an assessment in your home. The nurse will call to schedule the appointment directly with you or your legal representative.

Sometimes, we must request additional information to provide clarification before we can make an eligibility determination. If additional information is required, we will notify you or your legal representative by letter of the status of the claim and the additional information needed.

How is provider eligibility determined?

Eligibility requirements for care providers vary by policy. We may also require a provider license or other credentials to confirm that the provider is qualified under your policy. Please refer to your policy or call us at 1-800-362-0700 for the specific requirements for qualification.

Once the required information is received, a claim examiner will review it to determine whether your provider is eligible, based on your policy's requirements.

Once a claim is filed, how soon will I be notified about a claim decision?

We make every effort to gather the necessary information to make an eligibility determination as quickly as possible. To expedite this process, it is important that all requested information be provided to us as soon as possible.

If my claim is approved, when can I expect to receive claim payments?

We make every effort to process claim payments within 30 days of receipt of all completed information. If a bill cannot be processed for any reason, we will notify you by letter of the status of the claim and any additional information needed to complete processing.

How frequently should bills be submitted?

All bills should be submitted after services have been received.

• Bills for facility services should be submitted at the end of each month.
• Bills for home health care services can be submitted as frequently as every two weeks but must be submitted at least once a month.

Where should bills and care notes be sent?

Bills and care notes can be submitted by mail or fax:

What if my claim for benefits is denied?

If your claim is denied, you will receive written notification including an explanation of the reason for denial and the appeal process.