Using your coverage · Section 3 of 5
Filing a claim
Four steps from the first phone call to the first benefit payment — and what to do if the claim is denied.
Start early — request the claim packet
It is common for 60 to 90 days or more to pass between the first phone call and the first benefit payment, so contact the carrier promptly — you can begin a claim before choosing a care provider. Call the claims number for your carrier or its administrator, ask for the full claim packet, and ask these questions while you have them on the phone. Take notes, and get names.
- What documentation do you require from the physician?
- Does my elimination period count calendar days or service days?
- What are your provider eligibility requirements for home care? (Section 4 — get the answer in writing.)
- Do you require invoices, caregiver notes, or timesheets, and on what schedule?
- Is my premium waived while I am on claim?
The physician’s certification and plan of care
Benefits require certification from a licensed health practitioner that the benefit trigger has been met, along with a plan of care describing the services needed. Your parent’s primary care physician can usually provide this.
Provider approval
The carrier also confirms that your chosen care arrangement qualifies under the policy’s provider definitions (see Section 4). Submit the provider’s information as early as possible, ideally with the initial claim packet. In practice the carrier’s decision rests on two pillars: the physician’s certification of the benefit trigger, and approval of the provider.
Decision, the elimination period, and record-keeping
Once approved, the elimination period clock runs according to your policy’s rules. Keep every invoice and record of care from day one — even during the elimination period — because carriers typically require proof of qualifying care during that window, and those records establish your service days.
If the claim is denied
You have the right to appeal, and denials are frequently overturned when families supply better documentation — a more detailed physician statement, a fuller picture of the daily activities where help is needed. Request the denial reason in writing, respond to it specifically, and consider involving a care manager or elder law attorney for a contested claim.
- California Department of Insurance
Regulates long-term care insurance and assists consumers with claim disputes.
insurance.ca.gov · 1-800-927-4357