LTC claims process · Orange County

    The long-term care claims process, step by step

    Ten stages, in the order they usually happen, with the next action for the family and the documentation a licensed home care agency supplies at each one. Care can begin before a claim is approved — and generally should, so the record starts on day one.

    Coverage, benefit eligibility, elimination periods, and reimbursement are determined by the individual policy and carrier. Golden Age Companions is a licensed Home Care Organization (License No. 304700544), not an insurance company, agent, or adviser.

    Request a policy review (949) 630-0487

    Jump to a stage

    1. 1. Notify the carrier and open the claim
    2. 2. Complete the claim packet and authorization
    3. 3. Get the practitioner certification
    4. 4. Complete the care assessment
    5. 5. Submit the plan of care
    6. 6. Establish provider eligibility
    7. 7. Satisfy the elimination period
    8. 8. Submit invoices and set up payment
    9. 9. Keep the claim open through recertification
    10. 10. If the claim is delayed or denied
    1

    Notify the carrier and open the claim

    Call the claims number on the policy or the most recent premium notice and state that you are opening a long-term care claim for home care. Ask for the claim number, the name of the administrator handling the file, and how documents should be submitted.

    Your next actions

    • Locate the policy number and the current claims phone number
    • Confirm the policy is in force and premiums are current
    • Ask whether a waiver of premium applies once benefits begin
    • Write down the claim number and the administrator’s name

    What we handle

    • Explain what home care documentation the carrier will likely request
    • Start care within 24 to 72 hours so the record begins immediately

    Where families lose time: Many older policies are serviced by a third-party administrator, so the company on the policy is often not the company answering the phone.

    2

    Complete the claim packet and authorization

    The carrier sends or posts a packet: a claimant statement, an authorization to release medical information, and often an authorization naming who else may speak about the file.

    Your next actions

    • Complete every form, including the HIPAA-style authorization
    • Name the family member managing the claim as an authorized contact
    • Keep a copy of everything submitted, with the date sent

    What we handle

    • Provide agency identifying details the packet asks for
    • Accept a limited authorization so we can confirm documentation requirements directly

    Where families lose time: A missing authorization is the single most common reason a carrier will not speak with the adult child managing the claim.

    3

    Get the practitioner certification

    A physician or licensed health care practitioner certifies that the insured needs substantial assistance with activities of daily living, or has a severe cognitive impairment, and that the need is expected to persist.

    Your next actions

    • Schedule the visit and bring the carrier’s certification form
    • Bring specifics: which activities need hands-on help, how often, since when
    • Ask the office to fax or upload the completed form and keep the confirmation

    What we handle

    • Supply a written summary of the assistance actually delivered in the home
    • Document cognition-related supervision needs in shift notes

    Where families lose time: A one-line note saying the patient "needs help at home" is rarely sufficient. The certification has to speak to the policy’s benefit trigger.

    4

    Complete the care assessment

    Most carriers arrange an in-person or telephonic assessment of function and cognition, measured against the policy’s benefit trigger. Genworth policies commonly route through a CareScout assessment.

    Your next actions

    • Have the person who provides day-to-day help present for the visit
    • Describe a typical bad day, not the best day
    • Have medication lists, recent hospital records, and fall history on hand

    What we handle

    • Provide shift notes showing which activities were assisted and for how long
    • Have a caregiver present who can answer questions about daily function

    Where families lose time: Assessments are point-in-time. Written daily records are what carry the days the assessor did not see.

    5

    Submit the plan of care

    Nearly every policy requires a written plan of care describing the services to be delivered, the frequency, and who will deliver them. Some carriers require it to be prepared by a licensed health care practitioner.

    Your next actions

    • Ask the carrier who is permitted to write the plan of care under your policy

    What we handle

    • Prepare a detailed service plan with tasks, hours, and schedule
    • Update the plan as needs change and keep prior versions on file

    Where families lose time: A plan of care with vague tasks such as "companionship" can slow a claim. Carriers look for named activities of daily living.

    6

    Establish provider eligibility

    The carrier verifies that the agency delivering care meets the policy’s provider definition. For a California home care agency, that generally means Home Care Organization licensure, registered caregivers, insurance, and tax documentation.

    Your next actions

    • Ask whether the policy requires a licensed agency, and whether independent caregivers qualify

    What we handle

    • Send our Home Care Organization license (No. 304700544), W-9, and certificate of insurance
    • Confirm caregiver registry status and background clearance on request

    Where families lose time: Some older policies pay only for licensed agency care. Hiring privately can make otherwise eligible care unreimbursable.

    7

    Satisfy the elimination period

    Most policies have a waiting period, commonly 30, 60, or 90 days, before benefits are payable. Whether it counts calendar days or days of paid service, and whether it resets, is set by the policy.

    Your next actions

    • Ask whether the elimination period counts calendar days or service days
    • Ask whether it is satisfied once per lifetime or per benefit period
    • Budget for privately paid care during the waiting period

    What we handle

    • Document every service day from the first shift so nothing is reconstructed later
    • Provide itemized invoices for the waiting-period days the carrier needs to count

    Where families lose time: Care usually starts before approval. Days delivered without documentation may not count toward the waiting period.

    8

    Submit invoices and set up payment

    Once eligibility is approved, itemized invoices are submitted on the carrier’s cycle. Where the policy permits and the carrier confirms it, benefits may be assigned so the agency is paid directly; otherwise the family pays and is reimbursed.

    Your next actions

    • Ask whether the policy allows an assignment of benefits
    • Confirm the submission channel, cycle, and deadline for invoices

    What we handle

    • Issue invoices showing dates, shift start and end times, hours, caregiver, rate, and services
    • Attach daily visit notes or care logs where the carrier requires them

    Where families lose time: Several carriers, including New York Life, require shift-level visit notes alongside each invoice. Summary invoices alone are often returned.

    9

    Keep the claim open through recertification

    Carriers periodically reconfirm eligibility, often annually, through an updated plan of care, a new practitioner statement, or another assessment.

    Your next actions

    • Calendar the recertification date the carrier gives you
    • Report changes in condition promptly rather than at renewal

    What we handle

    • Retain shift notes for the length of the engagement
    • Produce historical documentation for retroactive requests

    Where families lose time: Benefits can lapse on paperwork alone. Recertification is a documentation deadline, not a medical one.

    10

    If the claim is delayed or denied

    A denial letter must state the reason. Many home care denials are documentation problems rather than eligibility problems: a missing authorization, an incomplete plan of care, or invoices without shift detail.

    Your next actions

    • Request the denial reason and the appeal deadline in writing
    • Consider a licensed insurance professional or elder law attorney for the appeal
    • File the appeal within the stated window

    What we handle

    • Reissue corrected invoices and supply the underlying care records
    • Provide licensing and caregiver documentation the appeal file needs

    Where families lose time: Golden Age Companions does not interpret policy language, determine coverage, or appeal on your behalf. Those are insurance matters.

    Your carrier handles some of this differently

    Assessment vendors, invoice cycles, and documentation forms vary by company and by policy form. The carrier guides summarize the official material for each one.

    All carrier guidesHow LTC claims workLong-term care insurance hub

    Get help with my claim

    Tell us where you are and what you need next. We'll carry both into the consultation form so you don't repeat yourself.

    Or call (949) 630-0487 and we'll start where you are.

    For families

    I have a policy and need home care now

    Request a no-cost policy review conversation, or call and speak with someone who has handled long-term care documentation before.

    For professionals

    Refer a policyholder

    Agents, advisors, fiduciaries, attorneys, care managers, and discharge planners can send a referral and receive provider documentation for the file.

    Official resources

    Information last reviewed: August 2026

    Important disclosure
    Golden Age Companions is not affiliated with, endorsed by, sponsored by, or an agent of any insurance carrier, program, or administrator named on this site. Carrier and program names are used only to identify the policy a family may hold. Coverage, eligibility, benefit amounts, provider approval, elimination periods, and reimbursement are determined solely by the individual policy and its administrator. Golden Age Companions provides non-medical home care and administrative claim support; it does not sell insurance or provide insurance, legal, tax, or financial advice.
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