A long-term-care claim needs the actual policy's eligibility and payment requirements. Record the benefit trigger, evidence, care arrangement and waiting provision separately. A person needing help does not automatically satisfy every contract's conditions.
Locate the applicable benefit trigger
Long-term-care contracts can use provisions involving assistance with activities of daily living or cognitive impairment. Obtain the exact definitions, required evidence and professional certification instructions. Do not diagnose an impairment or apply one policy's numerical test to every contract.
FLTCIP's own claim guidance describes ongoing eligibility review as circumstances change. That program's requirements are not a substitute for a private policy's terms. Identify the actual program and policy edition before preparing the record.
Create an evidence and decision index
| Record | What to obtain securely | Administrator question |
|---|---|---|
| Policy and schedule | Actual edition,riders and benefit limits | Which provisions apply to the claim? |
| Eligibility evidence | Required professional assessment | What must be documented,and by whom? |
| Care plan | Actual services and arrangement | Does the plan meet the contract's requirements? |
| Provider information | Required qualifications and records | Is this provider eligible under the policy? |
| Waiting provision | Counting rule and relevant dates | Which days or services count? |
| Invoices and payment | Dated itemized records | What is needed for reimbursement or other payment? |
| Ongoing review | Notices and updated evidence requests | What must be maintained to continue benefits? |
Keep each decision and submission receipt. An assessment, a submitted invoice and an accepted claim payment are different records. If a document changes, preserve the earlier version and the reason for correction.
Ask how the waiting provision is counted
Identify whether the contract counts calendar days, service days or another defined period. Ask what happens when care is interrupted, a provider changes or the person moves between settings. Do not assume an elapsed number of days proves the requirement is satisfied.
Use the care-setting worksheet to keep the actual services visible. The setting's name does not establish provider eligibility or claim approval.
Keep ongoing obligations visible
Ask which notices, assessments, invoices or other records the administrator expects while benefits are being paid. Record how a change in care need, provider or living arrangement should be reported. A prior payment does not establish that every later service is automatically payable.
If payment stops or evidence is disputed, obtain the actual written explanation and applicable response instructions. Seek appropriate professional assistance for medical or legal questions. This checklist does not decide whether an adverse determination is correct.
Confirm who may communicate about the claim
Identify the insured person, authorized contacts and anyone permitted to act on the person's behalf. Ask the administrator what authority it needs for each role. Use the caregiver record worksheet to organize the secure contact process.
Medical assessments, care notes and identifiers belong in the appropriate private claim channel. A website inquiry should not contain the claim file. The next useful outcome is a complete index, a confirmed administrator request and a clear record of what remains unresolved.
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Sources
- NAIC: Consumer Longterm Care, checked November 4, 2026
- FLTCIP: Help, Frequently Asked Questions (FAQs), checked November 4, 2026
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