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.

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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: Complete and Submit Claim Forms

  • Step 4: RN Assessment

  • Step 4: Claim Review and Eligibility Determination

  • Step 6: Begin Care and Satisfy the Elimination Period

    An elimination period is similar to a deductible or waiting period. During this time, the policyholder is generally responsible for paying for care out of pocket before insurance benefits begin.

    How the elimination period is counted depends on the policy.

  • Step 7: Claim Decision (1 Week to ?)

    The insurer will approve, deny, or partially approve your claim. If it’s denied or incomplete, we dig into the reasons and work to resolve the issues.

  • Step 8: Submit Ongoing Care Notes and Invoices

    Once care begins, the insurance company typically requires ongoing documentation before benefits continue to be paid.

    Common requirements include:

    • Care notes
    • Timesheets
    • Invoices
    • Care plans
    • Updated assessments
    • Physician documentation

    This is where many payment delays occur.

    Something as simple as a missing signature, missing date, unchecked box, or incomplete documentation of Activities of Daily Living can delay payment.

    We’ve submitted more than 17,000 care notes and invoices and have learned that consistency and attention to detail are critical for keeping benefits to be paid.

  • Step 9: Receive Benefit Payments (4-6 Weeks)

    Depending on the policy and carrier, benefits may be paid:

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

    If payments are partial or delayed, we figure out the issue and submit what’s needed to get things moving.

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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.

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

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.

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.

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.

We also provide in-home care services throughout Orange County for seniors using long-term care insurance benefits. If you’re in Huntington Beach, Laguna Woods, Laguna Hills, Seal Beach, Mission Viejo, or anywhere else in Orange County, we’re here to help.

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