Filig a first time Log-Term Care (LTC) Isurace Claim with Bakers Life ad Casualty Compay The purpose of this istructioal documet is to assist you through the claim filig process. There is importat iformatio we must receive from multiple parties i order to appropriately evaluate each claim. Required claim material must be received i order for paymet to be cosidered. Bakers provides resources to assist you throughout the process. LTC Claim Checklist Filig a claim ca be doe i 4 steps! Please refer to the detailed iformatio below. 1: Call the Itake Team 2: Fill out the claim form 3: Provide authorized represetatives 4: Submit documetatio Durig the iitial claim filig process, we may ask for additioal iformatio from you ad/or your provider(s) to lear more about your coditio ad care eeds. Step 1: Call the Itake Team before you file a claim Before you file a claim, please cotact oe of our Itake Specialists. They will work with you oe-o-oe to aswer your questios, walk you through your policy beefits ad assist you with the claim filig process. You ca reach a Itake Specialist at 1(800) 621-3724 betwee the hours of 8:00 AM 4:30 PM Cetral Time, Moday through Friday. Itake Specialists ca assist with such questios as: Who are the qualified Providers i my area? What types of services ad expeses does my specific policy actually cover? What are my dollar limits? What factors are cosidered to determie if I qualify to receive policy beefits? What is a Elimiatio Period? Must I satisfy a Elimiatio Period before I file a log-term care claim? What iformatio may be requested durig the claim process? How quickly ca I expect a decisio o my claim? What do I eed to submit to receive reimbursemet? Step 2: Fill out the claim form Oce your care begis, you will eed to complete a claim form. Please keep the followig items i mid whe filig a LTC claim: Provide as much detail as possible to each of the questios, icludig you ad your providers curret addresses ad telephoe umbers. Providig icomplete iformatio may legthe the claim processig time. Feel free to attach additioal pages if you eed more room to respod to ay questio. Sig the eclosed Authorizatio for Claims Processig Purposes form icluded with the claim packet.
Step 3: Provide authorized represetatives If the isured will ot be hadlig his/her claim persoally, Bakers will eed oe of the followig so a authorized represetative ca maage the claim o the policyholder s behalf: 1. A siged Third Party Authorizatio Form 2. A copy of Healthcare or Durable Power of Attorey documet Step 4: Submit documetatio Mail the completed claim form ad all available claim documetatio to: Bakers Life ad Casualty Compay PO Box 1902 Carmel, IN 46082-1902 Or sed via fax at (312) 396-5952. You or your desigated represetative will be cotacted withi te to fiftee busiess days of receipt of your documets to advise that we have received your request for beefits ad iform you if additioal iformatio is eeded. What to expect after submittig your claim For a accurate ad timely review of your claim, we will eed to gather specific iformatio. Followig is a list of items we may request from your care Provider. Your help i gatherig documetatio is greatly appreciated as it will decrease the likelihood of delays or closure of your claim due to missig iformatio. Refereced below are Provider types alog with a list of specific items we may eed to collect i additio to the claim form: If you are usure of what type of Provider is covered by your policy or eed assistace i locatig a eligible provider i your area, please reach out to our Itake Team for assistace at 1(800) 621-3724. From a Nursig Home Miimum Data Set (MDS): This iformatio is collected by the ursig home staff i order to assess (measure) the physical, psychological, ad social fuctioig characteristics of the residet. Itemized Bill(s): This documet shows the charges (by reaso) you have icurred durig care. The charges eed to be itemized i order for us to verify which expeses are covered by your policy. Facility Licese: A documet showig that the Facility is licesed or certified. From a Home Health Care Provider Pla of Care: A set of actios the care Provider will implemet i order to resolve ad/or support the diagoses ad/or care eeds of the Policyholder. Daily Visit Notes: Documetatio of the specific care provided durig each visit by the caregiver. This documetatio may also be referred to as: daily progress otes, ursig otes, staff otes or charts. Itemized Bill(s): This documet shows the charges (by reaso) you have icurred durig care. The charges eed to be itemized i order for us to verify which expeses are covered by your policy.
Iitial Provider Assessmet: A writte summary that provides a geeral descriptio of the Policyholder (physical assessmet, height, weight, age, etc.) ad a descriptio of their primary medical history. Provider qualificatios icludig licesig for Agecy, Aide, Caregiver, etc., as well as certificatio, ad/or idividual traiig or experiece, if applicable per your policy. From a Assisted Livig Facility Facility s Service Pla: A set of actios the care Provider will implemet i order to resolve ad/or support the diagoses ad/or care eeds of the Policyholder. Medicatio List: A list of all the medicatios the Policyholder is takig ad iformatio o how they are to be admiistered. Itemized Bill(s): This documet shows the charges (by reaso) you have icurred durig care. The charges eed to be itemized i order for us to verify which expeses are covered by your policy. Facility Licese: A documet showig that the Facility is licesed or certified. From a Adult Day Care Provider Adult Day Care Pla of Care: A set of actios the care Provider will implemet i order to resolve ad/or support the diagoses ad/or care eeds of the Policyholder. Questios Itemized Bill(s): This documet shows the charges (by reaso) you have icurred durig care. The charges eed to be itemized i order for us to verify which expeses are covered by your policy. Facility Licese: A documet showig that the Facility is licesed or certified. If you do ot see your provider type listed or have additioal questios, please cotact our Itake Team Moday through Friday betwee 8:00 AM 4:30 PM Cetral Time at 1(800) 621-3724, or visit our website at www.bakers.com. Notes If ay testig such as Mii Metal State Exam (MMSE) or a europsychological evaluatio has bee completed, please iclude this iformatio i your claim submissio. For o-facility claims; a Beefit Eligibility Assessmet (BEA) may be requested durig our eligibility review. This is a visit by a qualified licesed healthcare practitioer from a idepedet agecy (ot affiliated with Bakers) who coducts a assessmet with the Claimat i their place of residece. Durig the assessmet, this idividual will gather iformatio about the fuctioal abilities of the Isured. They will also admiister a cogitive screeig ad discuss relevat medical history ad curret health coditios of the Isured.
Claims Authorizatio for Medical Iformatio Coforms to HIPAA Privacy Rule 1. My Iformatio the idividual who is the subject of the iformatio Prited Name Date of Birth Soc. Sec. Number (Last 4 Digits) Policy Number Address City State Zip 2. Disclosig Party the party or parties authorized to release iformatio about me Ay physicia or other health care provider, hospital, cliic, medical facility, cliical lab, pharmacy, pharmacy beefit maager or pharmacy related orgaizatio, isurace compay or health pla, Social Security Admiistratio or govermetal agecy 3. Descriptio of my iformatio authorized for release Ay/all iformatio related to my past, preset or future health coditio(s), medical care/treatmet or prescriptio drug history, which icludes iformatio about metal health (excludig psychotherapy otes), commuicable disease, HIV/AIDS, alcohol ad substace abuse 4. Purpose of Authorizatio how my iformatio will be used To admiister beefits uder a policy or certificate of isurace 5. Duratio of Authorizatio Twety four (24) moths from the date writte below, uless I specify a earlier date here: 6. Receivig Parties the parties authorized to receive iformatio about me Bakers Life ad Casualty Compay, its agets, represetatives ad reisurers Bakers Coseco Life Isurace Compay*, its agets, represetatives ad reisurers *domiciled ad licesed i the State of New York 7. Importat iformatio review carefully before sigig Refusig to sig this Authorizatio does ot affect my ability to obtai medical treatmet, but may prevet my isurace compay from beig able to determie if beefits are payable uder the terms of my coverage. This Authorizatio may be revoked at ay time uless it was already relied upo. Sed a writte revocatio to: LTC Claims Admiistratio P.O. Box 1902, Carmel, IN 46082 1902. The Receivig Parties amed above are subject to federal privacy laws. However, if I authorize parties who are ot subject to these laws to receive medical iformatio about me, the such iformatio could be re disclosed ad would o loger be protected. I uderstad that I have a right to a copy of this Authorizatio, ad that a photocopy or facsimile is as valid as the origial. Califoria residets are etitled to a large prit versio of this form by callig 800 621 3724 to request form 18727 LARGE. 8. Approval must be siged ad dated by me or my Legal Represetative* to be valid Prited Name Sigature Relatioship to the isured Date siged *Legal Represetatives must provide documetatio of legal authority 18727 (05/12)
Volutary Authorizatio to Disclose Iformatio to Third Party Pursuat to the HIPAA Privacy Rule For use i cojuctio with Log Term Care policies oly I. My Iformatio The idividual whose iformatio will be released Prited Name Date of Birth Policy Number Social Security Number Address City State Zip Code Telephoe II. Disclosig Party Orgaizatio authorized to release my iformatio Bakers Life ad Casualty Compay*, Bakers Coseco Life Isurace Compay**, Washigto Natioal Isurace Compay* *ot licesed i the State of New York **domiciled i ad licesed i the State of New York III. Descriptio of my iformatio authorized for release All iformatio pertaiig to my isurace trasactios, claims ad coverage icludig health ad fiacial iformatio Oly iformatio pertaiig to IV. Purpose of release Describig how my iformatio will be used by the Receivig Party after it is released At the request of the idividual idetified above. V. Duratio of authorizatio This authorizatio will expire 24 moths from the date writte below, uless I specify a alterate expiratio date here: VI. Receivig Party Idividual(s) or orgaizatio(s) authorized by me to receive my iformatio Name: Compay Name (if applicable) Address: Telephoe: Name: Compay Name (if applicable) Address: VII. Approval Siged ad dated by me or my legal represetative Telephoe: I uderstad that this authorizatio to release iformatio to a third party is optioal ad I am ot required uder the terms of my policy to give such authorizatio. I uderstad that I ca revoke this authorizatio at ay time, except to the extet it has already bee relied upo, by sedig a writte revocatio to the address below. I uderstad that my treatmet, paymet ad eligibility for beefits may ot be coditioed o this authorizatio. I uderstad that if the perso or orgaizatio I authorize to receive the iformatio described above is ot subject to federal health iformatio privacy laws, it could be re-disclosed ad o loger protected by federal health iformatio privacy laws. I uderstad that I am etitled to a copy of this authorizatio, ad that a photocopy or facsimile is as valid as the origial. Prit Name: Relatioship: Sigature: * Legal Represetatives provide documetatio of legal authority VIII. RETURN SIGNED AND DATED FORM Date: Log Term Care Claims - P.O. Box 1902, Carmel IN 46082-1902 Phoe: (800) 621-3724 Fax: (312) 396-5952 18493 11/11
www.bakers.com POLICY NUMBER: Date: If you would like assistace i completig this claim form, please call 1-800-621-3724. LONG-TERM CARE AND SHORT TERM CARE CLAIM FORM Please sed completed claim form to: Bakers Life ad Casualty Compay PO Box 1902 Carmel IN 46082-1902 1. Claimat Name: Date of Birth: / / Address: City: State: Zip: To make a address chage, please fill out the Address Chage Request Form attached to this form. Phoe: ( ) Sex: M F 2. Cotact Perso (if uable to reach) Name: Address: City: State: Zip: Phoe: ( ) Relatioship: 3. Describe your limitatios. Idicate the first day the limitatios were preset, if applicable, or provide a approximate time frame: 4. Cause or Coditio which requires you to eed Log-Term Care: Sickess Ijury If limitatios caused by a ijury, whe, where, ad how did it happe? 5. Are you curretly, or have you bee, hospitalized withi the last year? Yes No From: / / To: / / Hospital Name: Address: 15626 (1/13)
POLICY NUMBER: CLAIMANT NAME: 6. List your medical history durig the last two years below, startig with most recet treatmet. (Please attach additioal pages if ecessary.) Name of Physicia: Phoe: ( ) Address: City: State: Zip: Coditio(s) treated: Date(s): Name of Physicia: Phoe: ( ) Address: City: State: Zip: Coditio(s) treated: Date(s): Name of Physicia: Phoe: ( ) Address: City: State: Zip: Coditio(s) treated: Date(s): 7. Please complete the iformatio i either Box A or Box B for services already provided. (Please attach additioal pages if ecessary.) A. NURSING HOME OR ASSISTED LIVING FACILITY CONFINEMENT: Name of Facility: Tax ID: Cotact Perso, if kow: Address: City: State: Zip: Phoe Number: ( ) Fax Number: ( ) Admitted: / / Discharged: / / Payer Source: B. HOME HEALTH CARE, ADULT DAY CARE OR OTHER CARE SERVICES: Name of Care Provider: Tax ID: Cotact Perso, if kow: Address: City: State: Zip: Phoe: ( ) Fax: ( ) Admitted: / / Discharged: / / Payer Source: 8. Do you curretly have coverage for medical care uder Medicare? (If yes, is coverage for Part A or Part B oly, or for both?) Part A oly Part B oly Parts A&B No Medicare Coverage Has a claim bee submitted? Yes No 15626 (1/13)
POLICY NUMBER: CLAIMANT NAME: 9. Do you have ay other isurace that may provide coverage? Check all that apply: Coverage uder a Medical Pla Compay Phoe Number: ( ) Medicare Supplemetal Policy Compay Phoe Number: ( ) Policy Number: Has a claim bee submitted? Yes No Policy Number: Has a claim bee submitted? Yes No Other Third Party Coverage (Auto Isurace, Ijury/Accidet, Property Isurace, etc.) Compay Policy Number: Phoe Number: ( ) Has a claim bee submitted? Yes No Workers Compesatio Compay Phoe Number: ( ) Other Log-Term Care Isurace Compay Phoe Number: ( ) Policy Number: Has a claim bee submitted? Yes No Policy Number: Has a claim bee submitted? Yes No No Isurace Ukow 10. Do you have a Power of Attorey, Coservator, or Guardia or other perso who ca legally represet you?* If Yes, who? Name: Phoe Number: ( ) Address: City: State: Zip: *Please attach to this form a copy of the documet givig this perso legal authority. For your protectio some states require us to iform you that ay perso who kowigly files a statemet of claim cotaiig false or misleadig iformatio is subject to crimial ad civil pealties, depedig upo the state. Such actios may be deemed a feloy ad substatial fies may be imposed. If we determie that beefits have bee paid uder this coverage as a result of your fraudulet actio(s), we have the right to recover those beefit amouts. We may recover those beefit amouts directly from you or by reducig ay subsequet beefit paymets uder this coverage. We will determie the maer i which we seek recovery of beefit paymets made uder fraudulet coditios. I declare that all of the above aswers are complete ad true to the best of my kowledge ad belief. I uderstad that the compay reserves the right to require further proof. X Sigature of Policyholder (or Legal Represetative) Policyholder (or Legal Represetative) Name (Please Prit) If Legal Represetative, give relatioship to Policyholder / / Date siged (Moth/Day/Year) Siged at (City, Couty, State) 15626 (1/13)
AK residets: A perso who kowigly ad with itet to ijure, defraud, or deceive a isurace compay files a claim cotaiig false, icomplete, or misleadig iformatio may be prosecuted uder state law. AZ residets: For your protectio Arizoa law requires the followig statemet to appear o this form. Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss is subject to crimial ad civil pealties. AL residets: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or who kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to restitutio fies or cofiemet i priso, or ay combiatio thereof. AR / LA ad RI residets: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to fies ad cofiemet i priso. CA residets: For your protectio Califoria law requires the followig to appear o this form. Ay perso who kowigly presets false or fraudulet claim for the paymet of a loss is guilty of a crime ad may be subject to fies ad cofiemet i state priso. CO residets: It is ulawful to kowigly provide false, icomplete, or misleadig facts or iformatio to a isurace compay for the purpose of defraudig or attemptig to defraud the compay. Pealties may iclude imprisomet, fies, deial of isurace ad civil damages. Ay isurace compay or aget of a isurace compay who kowigly provides false, icomplete, or misleadig facts or iformatio to a policyholder or claimat for the purpose of defraudig or attemptig to defraud the policyholder or claimat with regard to a settlemet or award payable from isurace proceeds shall be reported to the Colorado divisio of isurace withi the departmet of regulatory agecies. DC residets: WARNING: It is a crime to provide false or misleadig iformatio to a isurer for the purpose of defraudig the isurer or ay other perso. Pealties iclude imprisomet ad/or fies. I additio, a isurer may dey isurace beefits, if false iformatio materially related to a claim was provided by the applicat. DE residets: A perso who kowigly ad with itet to ijure, defraud, or deceive ay isurer, files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy. FL residets: Ay perso who kowigly ad with itet to ijure, defraud, or deceive ay isurer files a statemet of claim or a applicatio cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy of the third degree. ID residets: Ay perso who kowigly ad with itet to defraud or deceive ay isurace compay, files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio is guilty of a feloy. IN residets: A perso who kowigly ad with itet to defraud a isurer files a statemet of claim cotaiig ay false, icomplete, or misleadig iformatio commits a feloy. KY residets: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a statemet of claim cotaiig ay materially false iformatio or coceals, for the purpose of misleadig, iformatio cocerig ay fact material thereto commits a fraudulet isurace act, which is a crime. MD residets: Ay perso who kowigly or willfully presets a false or fraudulet claim for paymet of a loss or beefit or who kowigly or willfully presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to fies ad cofiemet i priso. ME / TN / VA ad WA residets: It is a crime to kowigly provide false, icomplete or misleadig iformatio to a isurace compay for the purpose of defraudig the compay. Pealties iclude imprisomet, fies ad deial of isurace beefits. MN residets: A perso who files a claim with itet to defraud or helps commit a fraud agaist a isurer is guilty of a crime. NH residets: Ay perso who, with the purpose to ijure, defraud or deceive ay isurace compay, files a statemet of claim cotaiig ay false, icomplete or misleadig iformatio is subject to prosecutio ad puishmet for isurace fraud, as provided i N.H. Rev. Stat. A. 638:20. NJ residets: Ay perso who kowigly files a statemet of claim cotaiig ay false or misleadig iformatio is subject to crimial ad civil pealties. NM residets: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to civil fies ad crimial pealties. NY residets: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio or coceals, for the purpose of misleadig, iformatio cocerig ay fact material thereto, commits a fraudulet isurace act, which is a crime ad shall also be subject to a civil pealty ot to exceed five thousad dollars ad the stated value of the claim for each such violatio. OH residets: Ay perso who, with itet to defraud or kowig that he is facilitatig a fraud agaist a isurer, submits a applicatio or files a claim cotaiig a false or deceptive statemet is guilty of isurace fraud. OK residets: Warig: Ay perso who kowigly, ad with itet to ijure, defraud or deceive ay isurer, makes ay claim for the proceeds of a isurace policy cotaiig ay false, icomplete or misleadig iformatio is guilty of a feloy. PA residets: Ay perso who kowigly ad with itet to defraud ay isurace compay or other perso files a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio or coceals for the purpose of misleadig, iformatio cocerig ay fact material thereto commits a fraudulet isurace act, which is a crime ad subjects such perso to crimial ad civil pealties. PR residets: Ay perso who, kowigly ad with the itetio of defraudig presets false iformatio i a isurace applicatio, or presets, helps or causes the presetatio of a fraudulet claim for the paymet of a loss or ay other beefit, or presets more tha oe claim for the same damage or loss, shall icur a feloy, ad upo covictio shall be sactioed for each violatio with the pealty of a fie of ot less tha five thousad (5,000) dollars ad ot more tha te thousad (10,000) dollars, or a fixed term of imprisomet for three (3) years, or both pealties. Should aggravated circumstaces be preset, the pealty thus established may be icreased to a maximum of five (5) years; if atteuatig circumstaces are preset, it may be reduced to a miimum of two (2) years. TX residets: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss is guilty of a crime ad may be subject to fies ad cofiemet i state prisio. WV residets: Ay perso who kowigly presets a false or fraudulet claim for paymet of a loss or beefit or kowigly presets false iformatio i a applicatio for isurace is guilty of a crime ad may be subject to fies ad cofiemet i priso. All other states residets: Ay perso who kowigly ad with itet to defraud ay isurace compay that submits a applicatio for isurace or statemet of claim cotaiig ay materially false iformatio, or coceals iformatio cocerig ay fact material thereto for the purpose of misleadig, may be committig a crime which is subject to crimial ad civil pealties. 15626 (1/13)
www.bakers.com ADDRESS CHANGE REQUEST All address chage requests must be submitted i writig. Use this form to request a permaet chage of address. Please allow 30 days for the address chage to be processed. Policyholder s Name: Claimat s Name: Policy Number(s): PLEASE CHANGE MY ADDRESS TO: Address: City: State Zip code Effective Date of Chage: (This address chage will remai i effect util further writte otificatio is received.) Name of perso completig this form (please prit): Sigature of Policyholder (or Legal Represetative) Policyholder (or Legal Represetative) Name (Please Prit) Date Siged (Moth/Date/Year) Siged at (City/Couty/State) If Legal Represetative, give relatioship to Policyholder (Attach a copy of your legal authority, Power Of Attorey, guardiaship, etc. if applicable) PLEASE NOTE: This address chage will affect all correspodece beig set to the policyholder by Bakers, such as: Premium Statemet, Claim Checks, Explaatio of Beefits (EOB). This form must be siged ad dated by the policyholder or Legal Represetative i order to be cosidered valid. Without proper sigature(s) or documetatio, this documet is ull ad void. If you have further questios please feel free to cotact our Customer Service Departmet at 1-800-621-3724 betwee the hours of 8:00 AM 4:30 PM Cetral Time, Moday through Friday. Please mail Address Chage Request Form to: Policy Beefits Departmet PO Box 1902 Carmel, IN 46082-1902 Or Fax to: 312-396-5952 18895 (8/12) Copyright 2012 Bakers Life ad Casualty Compay. Chicago, IL All Rights Reserved.