Long-Term Care Claim

Long-Term Care Claims

Frequently Asked Questions

Initiating a Claim

1. How do I request a claim form for long-term care benefits?

Call the OneAmerica^® Long-Term Care Claims Department toll free at (800) 352-6608. Care Specialists are available Monday through Friday, 8 AM – 5 PM EST to discuss the claim process and the benefits available. Based on your preference, the Care Specialist sends you the claim form by e-mail, fax, or mail. To access the claim form online, go to https://www.oneamerica.com/claims, click the “Long-Term Care Claims” tab, then click the “Begin the Claims Process” tab.

2. To whom can OneAmerica^® release policy information?

OneAmerica^® can release policy information only to the:

• policyowner;
• policyowner’s validated legal representative; or
• policyowner’s active broker/agent of record (excluding medical information).

An insured/annuitant who is not the policyowner is only entitled to receive policy information relevant to his/her claim.

3. When should one initiate contact with OneAmerica^® regarding a long-term care benefit claim?

When contemplating the need for long-term care services, you should contact OneAmerica® before any substantial expenses have been incurred to ensure that the condition, service(s), and care provider(s) qualify for benefits under the long-term care policy.

4. What documents are typically required as part of the claim process?

Form	Who needs to complete the form/document?	Additional Information
Long-Term Care Claim Form and Authorization I-25711	Refer to Question 5 below	OneAmerica® needs to receive this completed form and authorization before we can request any information from a care provider or ask a care provider to complete the Long-Term Care Provider Form.
Long-Term Care Provider Form	OneAmerica® sends the form directly to the provider, as needed.	OneAmerica® cannot send the Provider Form to the care provider until we receive the completed Long-Term Care Claim Form and Authorization.
Attending Physician's Statement I-25712	The insured/annuitant submits this form to his/her attending physician for completion.
Electronic Funds Transfer Form 4-12488(LTC)	The EFT form is required if the policyowner wants benefit reimbursements deposited directly into a specified bank account instead of receiving reimbursements via paper checks.
Copies of long-term care services bills for incurred expenses	Detailed bills with service dates on care provider letterhead. (For Home Health Care services, we need the service dates, types of service, claimant name, home health aide name, amount, service fees, and rate per hour).	OneAmerica® cannot reimburse long-term care expenses in advance of the insured/annuitant receiving long-term care services. Therefore, all bills submitted must be for costs incurred. (i.e., not including expenses for future service dates).

 

5. Who completes the Long-Term Care Claim form and Authorization?

The policyowner and insured/annuitant or their designated legal representative(s) must complete and sign the Long-Term Care Claim Form and Authorization. Suppose the policyowner or insured/annuitant cannot sign these forms and is helped by someone who isn't their designated legal representative. In that case, the person helping the policyowner or insured/annuitant may contact us toll-free for guidance on how to proceed.

6. Where should I send completed claim documents?

Mail, e-mail, or fax claim forms and any other requested documentation to:

OneAmerica Financial Partners, Inc.
Long-Term Care Claims
P.O. Box 6008
Indianapolis, IN 46206-6008
E-mail: longtermcareclaims.ind@oneamerica.com
Fax number: (317) 285-5239

7. Who will review the claim?

Care Specialists trained to adjudicate long-term care claims work directly with the insured/annuitant or his/her legal representative during the claim determination process.

8. Once a claim is filed, when can I expect a reply?

Claims received are acknowledged within five (5) business days. Each claim is unique regardless of claim complexity. The Care Specialists communicate regularly with the insured/annuitant or his/her legal representative throughout the process. The time required to make a benefit determination may vary.

9. Other than a claim form, does OneAmerica^® require other information to make a claim determination?

OneAmerica^® may require additional information during the claim process. Additional documentation requested may include, but is not limited to:

• Physician and/or hospital records;
• Cognitive testing and results;
• Care provider notes;
• Plan of care, prepared and signed by licensed health care practitioner;
• Assessment performed by care provider;
• Independent assessment; and
• Care provider licensure.

10. When am I eligible for long-term care benefits?

Each long-term care insurance policy specifies the conditions under which benefits are payable. The assigned Care Specialist can explain to the insured/annuitant or his/her legal representative the policy requirements and conditions under which benefits are payable.

11. What types of claims are eligible to be paid?

Your policy contains a wide variety of eligible benefits that may or may not include benefits for long-term care facilities, assisted living facilities, and home health care agencies. Refer to your policy for a detailed outline of benefits.

For example, many of our policies require an insured/annuitant to qualify as a “chronically ill individual.” Meaning the individual is unable to perform two (2) activities of daily living without substantial assistance or is severely cognitively impaired as certified by his/her licensed health care practitioner.

12. What are the policy requirements for a provider to be considered an eligible home health care services provider?

A home health care services provider must:

• Regularly engage in providing services under the regular supervision of a registered nurse;
• Provide services under a plan of care prepared and signed by a licensed health care practitioner that is consistent with an assessment; and
• Maintain daily records/care notes.

Elimination Period/Waiting Period

13. What is an elimination period/waiting period?

The elimination period/waiting period is the number of days (specified in the policy) during which the insured/annuitant’s claim must meet all qualifying policy requirements before any subsequent eligible services are reimbursed under the terms and conditions of the policy. No long-term care insurance benefits are paid during the elimination period.

Any days in which the insured/annuitant’s condition does not qualify for benefits, or days in which the insured/annuitant is receiving care from an ineligible care provider, do not count toward satisfying the elimination/waiting period.

14. Must the elimination/waiting period be satisfied before a long-term care insurance claim is filed?

The insured/annuitant should file the long-term care claim as soon as he/she begins receiving long-term care related services. The insured/annuitant is not required to satisfy the elimination/waiting period before filing. However, the insured/annuitant must meet the elimination/waiting period before subsequent eligible charges will be reimbursable under the policy's terms and provisions.

15. How often will the claim be recertified after it has been initially approved for long-term care benefits?

Recertification generally occurs on an annual basis but may occur more frequently – mainly if there is a change in provider, level of care, type of care, frequency of care, or the expected recovery period for the qualifying medical condition is less than a year.

16. What action is required if the care provider is changed?

Choosing a long-term care service provider is an important, personal decision. Please keep in mind the policy contains requirements that a long-term care service provider must meet for an otherwise eligible claim to be reimbursable. For this reason, we recommend the insured/annuitant, or his/her legal representative call the OneAmerica® Long-Term Care Claims Department at (800) 352-6608 early in the process of changing providers and provide the following to determine if the new care provider qualifies:

• Name of the new long-term care service provider;
• Address and phone number of the new long-term care service provider; and
• Date the new long-term care service provider will begin providing services to the insured/annuitant.

The Care Specialist will contact the new care provider, the insured/annuitant, or the legal representative if additional information is needed.

17. What is the appeals process for claims?

The insured/annuitant or his/her legal representative has the right to appeal an adverse benefit eligibility claim decision. If benefit eligibility is denied, the insured/annuitant or his/her legal representative receives a denial letter which provides:

• A summary of the benefit eligibility requirements;
• The reason the claim did not meet the benefit eligibility requirements;
• Sources of information used to make the determination; and
• Information and instructions for the claims appeal process.

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