LTC Claims Process Explained

How to File a Long-Term Care Insurance Claim: Step-by-Step Guide

Going through a long-term care insurance claims process can feel like jumping through hoops, but we’re here to make it easier. We get it—it’s complicated, time-consuming, and often overwhelming.

Many families don’t realize how much work is involved in filing a long-term care insurance claim until they begin the process. Between claim forms, physician statements, RN assessments, care plans, invoices, and ongoing documentation requirements, it can quickly become overwhelming.

Before filing a claim, it’s helpful to understand how long-term care insurance benefits for home care work and what services may be covered.

Here’s the deal: knowing how LTC insurance claims work can help you avoid unnecessary headaches, delays, and access benefits faster. Let’s break it down step by step.

Senior reviewing long-term care insurance benefits and claim paperwork with a care coordinator

Understanding long-term care insurance benefits can be confusing. CareWorks helps families review policies, verify benefits, complete claim paperwork, and navigate the claims process with confidence

The LTC Insurance Claim Process

Here’s what typically happens:

  • Step 1: Verify Benefits, Policy Review and Open a Claim

  • Step 2:Complete and Submit Claim Forms

  • Step 3: RN Assessment

  • Step 4: Claim Review and Eligibility Determination

  • Step 5: Begin Care and Satisfy the Elimination Period

  • Step 6: Continue Submitting Care Notes

  • Step 7: Benefit Payments Begin

  • Step 8: Keep the Claim Active

Step 1. Verify Benefits, Policy Review, and Open a Claim

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During this call, we find out:

  • Whether home care is covered
  • Eligibility requirements
  • Daily or monthly benefit amounts
  • Maximum lifetime benefit amounts
  • Elimination period requirements
  • Whether any policy provisions waive the elimination period
  • Whether the policy includes inflation protection
  • How much the benefit increases over time and when those increases occur
  • Required claim forms and documentation

We’ve found that asking the right follow-up questions during this call can make a significant difference. Sometimes the answer provided by a claims representative is technically correct but doesn’t tell the whole story. This is why we often participate in benefit verification calls with families.

Some policies include waiver provisions that can be triggered under certain circumstances, such as a qualifying cognitive impairment, a recent stay in a skilled nursing facility, prior use of covered services, or other policy-specific conditions. Because these provisions vary by insurance company and policy, many families don’t realize they may exist.

For example, a “90-day elimination period” may mean 90 calendar days or 90 days of receiving care services. Some policies also contain provisions that may reduce or waive the elimination period under specific circumstances. 

Understanding whether an elimination period can be reduced, waived, or satisfied differently may help families avoid unnecessary out-of-pocket expenses and access benefits sooner.

We’ve learned that some of the most important policy details aren’t always volunteered during a benefits call. That’s why we ask detailed questions about elimination periods, benefit triggers, inflation protection, waiver provisions, and claim requirements before families make care decisions.

Not sure what your policy covers?

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Step 2: Complete and Submit Claim Forms

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After a claim is opened, the insurance company will send a claim packet containing forms that must be completed and returned.

Depending on the carrier, required documents may include:

  • Claim initiation forms
  • Physician statements
  • Care provider information
  • Invoices to show start of services date
  • Care notes (timesheets)
  • Authorization forms
  • Power of Attorney documents (if applicable)
  • Authorized representative forms

We help fill it out, collect all the documents, and submit on your behalf. We also keep copies of everything we send.

You can download many common long-term care insurance claim forms directly from our forms library.

Step 3: RN Assessment

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This 60-90 minute evaluation determines eligibility and recommends care hours. The completed assessment and care plan go to the insurer.

To keep your assessment from running longer than 90 minutes, the RN will ask that you have your identification, medical history records, and medication list ready for their arrival. 

During the assessment, the nurse may evaluate:

  • Activities of Daily Living (ADLs)
  • Mobility and transfers
  • Bathing, dressing, and toileting needs
  • Cognitive function
  • Memory loss or confusion
  • Medication management
  • Home safety concerns
  • Social support systems

The nurse may also ask questions, observe daily functioning, and perform simple cognitive exercises such as drawing a clock, recalling words, or spelling a word backward.

The information gathered during the assessment helps determine whether the policyholder qualifies for benefits and how much assistance may be needed.

Learn more about what happens during a long-term care insurance RN assessment and how to prepare.

Step 4: Claim Review and Eligibility Determination

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After the RN assessment is completed, the insurance company reviews the assessment findings, physician documentation, care plan, and policy requirements.

The insurance company may:

  • Approve the claim
  • Request additional information
  • Approve benefits with limitations on hours per day or 
  • Deny the claim

If approved, the insurance company will explain any remaining requirements, such as satisfying the elimination period before benefits become payable.

If denied, carefully review the denial letter to understand the reason. Common reasons include missing documentation, not meeting policy eligibility requirements, or insufficient evidence that assistance is needed with Activities of Daily Living (ADLs) or cognitive impairment.

A denial does not always mean the claim is over. Missing documents can often be obtained and submitted, additional information may clarify eligibility, and many policies allow for an appeal. If you believe the policyholder meets the requirements for benefits, we encourage filing an appeal and continuing to advocate for the benefits that have been paid for over the years.

Step 5: Begin Care and Satisfy the Elimination Period

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You do not need to wait for claim approval to start home care services. In fact, many families begin care while the insurance company is reviewing the claim.

Most long-term care insurance policies include an elimination period that must be satisfied before benefits become payable. Think of it as a waiting period or deductible during which the policyholder is responsible for paying for care out of pocket.

How the elimination period is satisfied depends on the policy. Some policies use calendar days, while others use service days or a deductible amount. Understanding how your policy counts elimination days can have a significant impact on when benefits begin.

During the Verification of Benefits call, we recommend confirming exactly how the elimination period is calculated and whether any policy provisions may reduce or waive the requirement.

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Calendar Day Elimination Period

With a calendar day elimination period, the countdown typically begins once eligible care starts.

For example, if a policy has a 90-day calendar elimination period and home care begins on January 1, benefits may become payable approximately 90 calendar days later, regardless of how many days care was actually received during that period.

In other words, the policyholder does not necessarily need to receive care for all 90 days. Receiving care and properly documenting the start of care may be enough to begin the countdown.

Service Day Elimination Period

With a service day elimination period, the insurance company counts the days on which qualifying care services are actually received.

For example, if a policy requires a 90-service-day elimination period and care is received only three days per week, it may take significantly longer than 90 calendar days before benefits begin.

Some insurance companies have their own method of calculating service days. In certain situations, one day of home care may count as multiple service days, while other policies require each day of care to be counted individually.

Because every policy is different, it’s important to verify exactly how the elimination period is calculated before care begins.

Step 6: Submit Ongoing Care Notes and Invoices

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Once care begins, you’ll need to submit care notes and invoices to the insurance company in order to receive reimbursement, unless your home care agency accepts Assignment of Benefits and bills the insurance company directly.

This is where the process often becomes more time-consuming than people expect. The insurance company isn’t simply sending checks each month. Care notes and invoices must be submitted on an ongoing basis, often every week or every few weeks, depending on the carrier and billing schedule.

That means keeping track of paperwork, making copies, scanning documents, uploading files to insurance portals, faxing records, mailing documents, and confirming they were received. It’s easy to fall behind, especially while coordinating care for a loved one.

We submit care notes and invoices every week because staying on top of documentation helps prevent payment delays and quickly identifies issues if benefits stop or reimbursement slows down.

After submitting more than 17,000 care notes and invoices, we’ve learned that consistency matters. Missing dates, signatures, care notes, invoices, or documentation supporting Activities of Daily Living can delay reimbursement and create additional work later.

Step 7: Benefit Payments Begin

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Once the claim is approved, required documentation has been submitted, and the elimination period has been satisfied, benefit payments can begin.

Depending on the policy, benefits may be paid:

  • Directly to the policyholder through reimbursement
  • Directly to the home care agency through Assignment of Benefits (when available)

With each payment, the insurance company will typically issue an Explanation of Benefits (EOB). The EOB outlines what was paid, what dates of service were processed, and any amounts that were reduced, denied, or held for review.

If you are not reimbursed in full, review the EOB carefully. The insurance company will usually provide a reason, such as missing documentation, incomplete care notes, policy limitations, an updated assessment requirement, or questions regarding eligibility.

Payment timelines vary by insurance company and how quickly care notes, invoices, and supporting documentation are reviewed. Some reimbursements are processed within a few weeks, while others may take longer if additional information is requested.

If your current home care agency does not accept Assignment of Benefits, you may be responsible for managing ongoing paperwork, reimbursement submissions, and insurance follow-up on your own. Learn how Assignment of Benefits and professional claims management can simplify the process.

Step 8: Keep the Claim Active

After benefits begin, the paperwork does not stop. Insurance companies may periodically request updated care plans, RN reassessments, physician documentation, care notes, invoices, or other records to continue paying benefits.

The best way to avoid interruptions is to stay on a routine. Submit care notes and invoices consistently, track what was sent, save confirmation receipts, and keep notes from every conversation with the insurance company. If documents need to be resubmitted, document when they were sent and how they were submitted.

It’s also important not to let documentation lapse for an extended period of time. Some insurance companies may place the claim under review, request updated documentation, or require a new RN assessment before resuming benefits.

This is one reason many families choose Assignment of Benefits with CareWorks when available. We handle the ongoing paperwork, weekly submissions, follow-up requests, and claim documentation so you can live your life,  instead of managing insurance paperwork week after week.

Common Reasons Long-Term Care Insurance Claims Are Delayed

Many delays can be avoided when documentation is complete and submitted correctly.

Common reasons for delays include:

  • Missing physician statements
  • Incomplete claim forms
  • Missing signatures
  • Missing invoices
  • Incomplete care notes (timesheets)
  • Documentation that doesn’t support eligibility requirements
  • Delays scheduling the RN assessment
  • Requests for additional information

Keeping organized records and responding quickly to requests can help prevent many of these issues. We like to organize our records by the week, keeping our invoices and care notes together.

Frequently Asked Questions

1. Do I need to call the insurance company myself?

Not necessarily. Many families choose to have us participate in the Verification of Benefits call so we can help ask detailed follow-up questions about eligibility requirements, elimination periods, inflation protection, and policy benefits. Having clear answers from the beginning can help avoid confusion later in the claims process. If you don’t have the time to call, we can do that for you.

2. What if the insurance company keeps asking for the same documents?

It happens more often than families expect. Keep copies of everything you submit, including claim forms, physician statements, care notes, invoices, and confirmation receipts. Review them for errors, correct and resubmit them.

3. Can I start home care before my claim is approved?

Yes. You need to begin home care before the claim is fully approved. Starting care may also be necessary to satisfy an elimination period, depending on the policy. Keep all invoices, care notes, and supporting documentation so you can show proof the policy holder is receiving in-home care services.

4. What documents are required to file a claim?

Requirements vary by insurance company, but most claims require claim forms, physician statements, care provider W-9, Care plan, home care invoice, care notes,  HIPPA and authorization to disclose forms, and supporting medical documentation.

5. What is an elimination period?

An elimination period is the waiting period that must be satisfied before long-term care insurance benefits become payable. Depending on the policy, it may be measured in calendar days, service days, a deductible amount, or a combination of these methods. Understanding how your policy counts elimination days is important because it can significantly affect when benefits begin and how much you pay out of pocket.

Need Help Filing a Long-Term Care Insurance Claim?

Whether you’re opening a new claim, preparing for an RN assessment, waiting for benefits to begin, or trying to understand what documentation is required, our team can help.

After assisting hundreds of seniors and families with long-term care insurance claims, we’ve developed a process designed to help avoid delays, reduce paperwork, and simplify the experience.

CareWorks Health Services can also directly bill many long-term care insurance companies through Assignment of Benefits when available, reducing the amount of paperwork families must manage on their own.

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