Long term care claim not paid yet? What to check

Insurers publish their own timeframes. FLTCIP says reimbursement typically arrives within 10 days after all required documents are received. Genworth's payments page lists 20 business days for invoices in good order, or as consistent with your state's requirements. John Hancock says its eligibility review takes about 40 business days from initiation to decision.

Each of those clocks depends on the insurer having everything it needs. The checks below cover the items the insurers' own pages list, and you can run through them before you call.

Is the claim approved, or still in eligibility review?

Invoices are paid only after the claim is approved and the elimination period is met.

• Genworth's Initial Eligibility page says an approved claim stays in that phase "until payable under your policy terms," after covered care is received and invoices are submitted. Then it moves to the Ongoing Eligibility team.
• John Hancock says the eligibility review is "approximately 40 business days or less, depending on how soon we receive all requested information," and may involve an assessment or records from care providers.
• FLTCIP's guide notes that incomplete or late medical records may delay eligibility decisions.

If you haven't received an approval letter, the delay may be in eligibility review, before any invoice is processed.

Has the elimination period been met?

Days in the elimination period are not reimbursed. FLTCIP's 2.0 and 3.0 guide says its waiting period is 90 calendar days. The NAIC's shopper's guide says that under a service-day policy, only days you pay for covered professional care count, so those periods can take longer to meet. Compare your count of days with the date the insurer shows the period as met.

Is the invoice in good order?

Genworth's payments page uses the phrase "in good order" for invoices it pays within its timeframe. The insurers' forms and pages list what a complete submission includes. Check each item:

• Policy and claim number, printed clearly (Genworth's form says this routes it to the right Benefit Analyst).
• One date per line with time in and time out. FLTCIP asks for a.m. or p.m. and times rounded to the nearest quarter hour.
• Hours, rate and charge for each day, and a correct total.
• Signatures from the caregiver and the insured or legal representative, dated after the last service date. FLTCIP requires handwritten signatures, plus a third-party signature when the caregiver also signs for the insured.
• Proof of payment that matches the invoice total. FLTCIP says "The invoice total and proof of payment amount must match," and John Hancock says discrepancies "may cause processing delays."
• Payment dated on or after the last date of service (John Hancock), and made after services (FLTCIP).
• No cash. FLTCIP and John Hancock both say cash payments, including checks written to cash, are not reimbursable.
• Care notes, where they apply. Genworth says to "Ensure that care notes accompany invoices, if applicable."

Was the invoice sent the way the insurer asks?

Format and channel can hold up processing.

• MetLife says documents must be submitted as PDFs and it cannot open zip files, password protected documents or links to outside storage sites.
• FLTCIP says duplicate submissions of the same invoice cause processing delays, so send by one method only.
• John Hancock says invoices billed in advance are denied, and asks for invoices at least every 30 days, or the claim may close for inactivity.

Was the caregiver approved, and is the service in the plan of care?

FLTCIP's guide says services must match the approved plan of care, including the provider. Family member care under FLTCIP must be listed in the written plan of care, and it is limited to 500 days in the insured's lifetime. If a new caregiver started before being approved, ask the insurer whether that caregiver has been added.

How do you check status?

Start with the insurer's own tools.

• FLTCIP: the My LTCFEDS dashboard shows "real-time invoice status." FLTCIP says it confirms receipt within two to three business days. You can also email claimsinfo@ltcfeds.gov or call 1-800-582-3337.
• Genworth: manage the claim online, or call 800.876.4582 (Monday to Thursday 8:30 AM to 6 PM ET, Friday 9 AM to 6 PM ET).
• John Hancock: the online account lets you manage the claim and send messages. The claims line is 800-233-1449.

How do you request status in writing?

A short letter or secure message creates a dated record. Include:

• Insured's name, policy number and claim number.
• The invoice service dates, amount and the date and method you sent it.
• A copy of the invoice and proof of payment, or a note that they were sent on that date.
• A direct question: has the invoice been received, is anything missing, and when is payment expected?
• Your name, relationship to the insured and authority (for example, power of attorney on file).

Keep a copy and note the date. The NAIC also suggests keeping a log of every contact with the insurer, including emails, letters, calls, dates and times.

Where do complaints go if a written request doesn't resolve it?

The NAIC's How to File a Complaint page says, "If you have a problem with your insurer, you should try to resolve it with them first." After that, your state's department of insurance (DOI) takes complaints. The NAIC says the process varies by state, and most departments accept complaints online, by mail or by phone.

The NAIC suggests including:

• Your policy number, bills and documentation.
• A factual timeline of events.
• Your policy's wording, where it applies.
• The outcome you want.

The NAIC's state insurance departments page lists contact information for every state.

This is general information, not legal, tax or insurance advice. Your policy and your claim approval letter control what is reimbursed and when.

FAQ

Sources:
https://www.ltcfeds.gov/claims-information/reimbursement
https://cdn.ltcfeds.gov/planning-tools/downloads/2.0-3.0-Using-Your-FLTCIP-Benefits.pdf
https://cdn.ltcfeds.gov/planning-tools/downloads/Invoice-Submission-and-Reimbursement-Package.pdf
https://www.genworth.com/claims/long-term-care-claims/claims-process/payments
https://www.genworth.com/claims/long-term-care-claims/claims-process/initial-eligibility
https://www.genworth.com/claims/long-term-care-claims/file-a-claim
https://www.genworth.com/dam/Americas/US/PDFs/Consumer/Forms/LTC-invoice-form.pdf
https://www.johnhancock.com/individual/help-center/long-term-care/claims
https://www.johnhancock.com/help-center/long-term-care/understanding-the-claim-process/determine-benefit-eligibility.html
https://www.johnhancock.com/individual/help-center/long-term-care/understanding-the-claim-process/benefit-reimbursement
https://www.johnhancock.com/content/dam/onejohnhancock/pdfs/ltc-4208_guidelines_to_submitting_proof_of_payment.pdf
https://www.metlife.com/ltc/ltc-claims-process-claim-reimbursement
https://content.naic.org/sites/default/files/publication-ltc-lp-shoppers-guide-long-term.pdf
https://content.naic.org/consumer/how-to-file-complaint
https://content.naic.org/state-insurance-departments