CalPERS Long-Term Care Claim Form

CalPERS Long-Term Care
Claim Form
CLM – 001 Online Claim Form
LTCG | Proprietary and Confidential
Claim Form
This document will assist you through the claim filing process. We must receive
important information from multiple parties in order to appropriately evaluate each claim.
In order for expenses to be applied to the Deductible Period or to be considered for
reimbursement, all requested claim materials must be received.
The CalPERS Long-Term Care team is available to assist you throughout the process
at (800) 982-1775.
Long-Term Care Claim Checklist
Filing a claim can be done in 4 steps:
1. Call the Intake Team
2. Provide authorized representatives
3. Complete the claim form
4. Submit documentation
During the initial claim filing process, we may ask for additional information from you
and/or your provider(s) to learn more about your condition and care needs.
Step 1: Call the Intake Team before you file a claim
Before you file a claim, please contact one of our Intake Specialists. They will work with
you one-on-one to answer your questions, walk you through your plan benefits and
assist you with the claim filing process. You can reach an Intake Specialist at
(800) 982-1775, Monday through Friday between 8:00 a.m. and 5:00 p.m. Pacific Time.
Intake Specialists can assist with such questions as:
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Who are qualified providers in my area?
What types of services and expenses does my specific plan actually cover?
What are my dollar limits?
What factors are considered to determine if I qualify to receive plan benefits?
What is a Deductible/Elimination Period?
Must I satisfy a Deductible/Elimination Period before I file a long-term care claim?
What information may be requested during the claim process?
How quickly can I expect a decision on my claim?
What do I need to submit to receive reimbursement?
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Step 2: Fill out the claim form
Once your care begins, you will need to complete a claim form. Please keep the following
items in mind when filing an LTC claim:
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Provide as much detail as possible to each of the questions, including your and your
providers’ current addresses and telephone numbers. Providing incomplete
information may lengthen the claim processing time.
Feel free to attach additional pages if you need more room to respond to any question.
Sign the enclosed Authorization for Use and Disclosure of Protected Health
Information form included with the claim packet.
If available, please submit a copy of your Government Issued Photo Identification (ID)
such as your driver’s license, state issued ID card or passport.
Step 3: Provide authorized representatives
If you will not be handling your claim personally, CalPERS will need one of the following so
an authorized representative can manage the claim on behalf of the participant:
1. A signed Third Party Authorization Form, or
2. A copy of the Healthcare or Durable Power of Attorney document
This form is written assuming “you” are the participant.
Step 4: Submit documentation
Mail the completed claim form, a copy of your Government Issued Photo Identification (ID)
such as your driver’s license, state issued ID card or passport and all available claim
documentation to:
CalPERS Long-Term Care Program
P.O. Box 64902
St. Paul, MN 55164-0902
FAX: (866) 294-6967
We will contact you or your designated representative within five to ten business days of
receipt of your documents to advise that we have received your request for benefits and
inform you if additional information is needed.
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What to expect after submitting your claim
The following is a list of items we may request from your care provider in order to process
your claim. Your help in gathering documentation is greatly appreciated as it will decrease the
likelihood of delays or closure of your claim due to missing information. Referenced below are
Provider types along with a list of specific items we may need to collect in addition to the
claim form:
If you are unsure of what type of provider is covered by your plan or need assistance in
locating an eligible provider in your area, please contact our Intake Team for assistance at
(800) 982-1775.
Please call us throughout the duration of your claim if your care needs increase or decrease,
if you have facility room changes, or have provider changes so that we may ensure your Plan
of Care and benefit payments are accurate.
From a Nursing Home:
1. Minimum Data Set (MDS): This information is collected by the nursing home staff in
order to assess (measure) your physical, psychological, and social functioning.
2. Itemized Bill(s): This document shows the charges (by reason) you have incurred
during care. The charges need to be itemized in order for us to verify which expenses
are covered by your plan.
3. Facility License: A document showing that the Facility is licensed or certified.
From a Home Health Care Provider
1. Plan of Care: A set of actions the care Provider will implement in order to resolve
and/or support your diagnoses and/or care needs.
2. Daily Visit Notes: Documentation of the specific care provided during each visit by the
caregiver. This documentation may also be referred to as: daily progress notes,
nursing notes, staff notes, or charts.
3. Itemized Bill(s): This document shows the charges (by reason) you have incurred
during care. The charges need to be itemized in order for us to verify which expenses
are covered by your LTC plan.
4. Initial Provider Assessment: A written summary that provides a general description of
you (physical assessment, height, weight, age, etc.) and a description of your primary
medical history.
5. Provider qualifications including licensing for Agency, Aide, Caregiver, etc., as well as
certification, and/or individual training or experience, if applicable per your plan.
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From an Assisted Living Facility/Residential Care Facility
1. Facility’s Service Plan: A set of actions the care Provider will implement in order to
resolve and/or support your diagnoses and/or care needs.
2. Medication List: A list of all the medications you are taking and information on how
they are to be administered.
3. Itemized Bill(s): This document shows the charges (by reason) you have incurred
during care. The charges need to be itemized in order for us to verify which expenses
are covered by your plan.
4. Facility License: A document showing that the Facility is licensed or certified.
From an Adult Day Care Provider
1. Adult Day Care Plan of Care: A set of actions the care provider will implement in order
to resolve and/or support your diagnoses and/or care needs.
2. Itemized Bill(s): This document shows the charges (by reason) you have incurred
during care. The charges need to be itemized in order for us to verify which expenses
are covered by your LTC plan.
3. Facility License: A document showing that the Facility is licensed or certified.
Questions
If you do not see your provider type listed or have additional questions, please contact
our Intake Team at (800) 982-1775, Monday through Friday between 8:00 a.m. and 5:00
p.m. Pacific Time.
Notes
If any testing such as Mini Mental State Exam (MMSE) or a neuropsychological evaluation
has been completed, please include this information in your claim submission.
A Benefit Eligibility Assessment (BEA) may be requested during our eligibility review. This is
a visit by a qualified licensed healthcare practitioner from an independent agency (not
affiliated with the CalPERS Long-Term Care Program) who conducts an assessment with you
in your place of residence. During the assessment, this individual will gather information
about your functional abilities. They will also administer a cognitive screening and discuss
your relevant medical history and current health conditions.
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Please be advised that in order for us to process your claim it must be either mailed or faxed
to us at:
CalPERS Long-Term Care Program
P.O. Box 64902
St. Paul, MN 55164-0902
FAX: (866) 294-6967
If you have any questions about the process, please call Customer Service toll free at (800)
982-1775, Monday through Friday between 8:00 a.m. and 5:00 p.m. Pacific Time. You may
also find us online at www.calperslongtermcare.com.
Additional items
If you wish to use direct deposit for your benefit payments please complete and return the
included Direct Deposit Form for Long-Term Care Claim Reimbursements. If the direct
deposit is for a service provider, an Assignment of Benefits Form and a current W9 is
required for the direct deposit request to be completed.
You may elect to have benefits assigned directly to a service provider. To establish an
assignment of benefits you must first establish if the provider is willing to consider
assignment. The service provider will need to submit their Tax Identification Number (Social
Security Number for Independent Provider) and complete the included W-9 to have the
payment be made directly to the service provider.
The assignment of benefits will not be in effect until the CalPERS Long-Term Care Program
has received the completed form. Note the assignment of benefits may be terminated in the
future upon receipt of a written request stating you wish to revoke the assignment.
Completed Assignment of Benefits, W9, and Direct Deposit forms can be returned by mail to
CalPERS Long-Term Care Program, P.O. Box 64902, St. Paul, MN 55164-0902, or faxed to
1-866-294-6967
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Long-Term Care Claim Form
Please send completed claim form to: CalPERS Long-Term Care Program
P.O. Box 64902
St. Paul, MN 55164-0902
Fax: (866)294-6967
If you need assistance or have questions about submitting your claim, please call (800) 982-1775.
1. Participant Name:__________________________ Date of Birth:___________________
Address: ____________________ City:______________ State:_______ Zip:__________
Phone: _____________________ Gender:  M  F
2. Contact Person (if unable to reach) Name: _____________________________________
Address: ____________________ City: ______________ State: _______ Zip: ________
Phone: _____________________ Relationship: _________________________________
3. Have you appointed someone to have Power of Attorney for you, or do you have a court
appointed Conservator or Legal Guardian?
*If Yes, please complete below. If you have appointed more than one person to represent you,
provide information on the other person(s) on a separate sheet. Please attach a copy of the legal
documents executing the Power of Attorney, Conservatorship, or Legal Guardianship to this claim
form before returning.
Name__________________________________________________________________
Address:_______________________ City:______________ State:_______ Zip:_______
Phone: _____________________
Please note that in accordance with The Health Insurance Portability and Accountability Act (HIPAA), we will
not disclose information to individuals who do not hold Power of Attorney, or who are not listed in your claim
as an Authorized Individual. In order to authorize an individual please complete an Authorization for use and
Disclosure of Protected Health Information form, which requires the participant’s signature or the signature
of a legal representative.
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4. What cause(s) or condition(s) result in your need for long-term care? (i.e., illness, injury or
accident): ______________________________________________________________
_______________________________________________________________________
5. If your care needs were caused by an injury/accident, when, where and how did the
injury/accident occur?
_______________________________________________________________________
_______________________________________________________________________
6. If your care needs were caused by an injury/accident, are you represented by an attorney
in this matter? Please provide the following information about your attorney:
Name: _____________________________ Phone: _____________________________
Address: ____________________ City: ______________ State: _______ Zip: ________
7. Please describe what long-term care assistance you think you need and when the need
for such assistance began: _________________________________________________
_______________________________________________________________________
8. Are you currently hospitalized, or have you been hospitalized within the last year?
Hospital Name/Address: ___________________________________________________
From: _________________ To:________________
9. Please provide the following information:
(Please attach additional pages if necessary)
Name of Current Physician: ___________________Specialty:______________________
Address: _______________________________________________________________
City: ____________________________State:__________________ Zip:_____________
Phone: ___________________________
Condition(s) being treated __________________________________________________
From: _______________________ To:_____________________
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Name of Current Physician: ___________________Specialty:_____________________
Address: _______________________________________________________________
City: ____________________________State:__________________ Zip:_____________
Phone: ___________________________
Condition(s) being treated __________________________________________________
From: _______________________ To:_____________________
10. Please complete the information below if applicable:
(Please attach additional pages if necessary)
NURSING HOME, ASSISTED LIVING, RESIDENTIAL CARE FACILITY
Name of Facility: _________________________________________________________
Address: ________________________________________________________________
City: _________________________ State: _____________ Zip: ___________________
Phone: __________________________ Fax #: _________________________________
Date Admitted: ____________________ Date Discharged: ________________________
Payer Source: ___________________________________________________________
Name of Facility: _________________________________________________________
Address: ________________________________________________________________
City: _________________________ State: _____________ Zip: ___________________
Phone: __________________________ Fax #: _________________________________
Date Admitted: ____________________ Date Discharged: ________________________
Payer Source: ___________________________________________________________
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HOME HEALTH CARE OR ADULT DAY CARE SERVICES
Name of Provider: ________________________________________________________
Address: ________________________________________________________________
City: _________________________ State: _____________ Zip: ___________________
Phone: __________________________ Fax #: _________________________________
Date Admitted: ____________________ Date Discharged: ________________________
Payer Source: ___________________________________________________________
11. Do you currently have coverage for medical care under Medicare?
 No Medicare coverage
 Part A only  Part B only  Part A and B
Has a claim been submitted?  Yes  No
12. Do you have any other insurance that may provide coverage? (Check all that apply)
 Coverage under a Medical Plan
 Worker’s Compensation
Company _____________________
Company _____________________
Policy #: ______________________
Policy #: ______________________
Phone: _______________________
Phone: _______________________
Has a claim been submitted?
Has a claim been submitted?
 Yes  No
 Yes  No
 Supplement to Medicare
 Other Long-Term Care
Company _____________________
Company _____________________
Policy #: ______________________
Policy #: ______________________
Phone: _______________________
Phone: _______________________
Has a claim been submitted?
Has a claim been submitted?
Yes No
 Yes  No
 Other Third Party Coverage (Auto Insurance, Injury/Accident, Property
Insurance, etc.)
Company _____________________
Policy #: ______________________
Phone #: ______________________
Has a claim been submitted? Yes No
 No Insurance
 Unknown
For your protection some states require us to inform you that any person who knowingly files a statement of
claim containing false or misleading information is subject to criminal and civil penalties, depending upon the
state. Such actions may be deemed a felony and substantial fines may be imposed. If we determine that
benefits have been paid under this coverage as a result of your fraudulent action(s), we have the right to
recover those benefit amounts. We may recover those benefit amounts directly from you or by reducing any
subsequent benefit payments under this coverage. We will determine the manner in which we seek recovery
of benefit payments made under fraudulent conditions.
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I declare that all of the answers given are complete and true to the best of my knowledge and
belief. I understand that the company reserves the right to require further proof.
__________________________________________________________________________
Signature of Participant (or Participant’s Representative)
Date signed (Month, Day, Year)
__________________________________________________________________________
Participant (or Participant’s Representative) Name
Signed at (City, State)
__________________________________________________________________________
If Representative, give relationship to Participant
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AUTHORIZATION FORM
PARTICIPANT NAME: _____________________________________________ DOB:____________
I AUTHORIZE THESE PERSONS or institutions having any records or knowledge of me or my
health:
 Any physician, medical practitioner, or health care provider
 Any hospital, clinic, pharmacy or other medical or medically related facility, or association
 Any insurance company or insurance support organization
 Any employer or plan administrator
 Any government agency
 Any organization or entity administering a benefit program
 Any rehabilitation organization or program
 Any financial institution, consumer reporting agency, accountant, or tax preparer
TO GIVE THIS INFORMATION:
Chart notes, x-rays, operative reports, lab and medication records and all other medical information about
me, including medical history, diagnosis, examinations, testing and test results, prescriptions, prognosis
and treatment of any physical or mental condition including:
 Any disorder of the immune system including HIV, Acquired Immune Deficiency Syndrome (AIDS)
or other related syndromes or complexes. Note: In the state of Minnesota, this Authorization does
not include the performance of, or the results of, a test to determine the presence of the Human
Immune Deficiency Virus (HIV) antibody given to (a) an offender, as defined under Minnesota law;
or (b) a crime victim because of exposure to, or contact with, such an offender.
 Any communicable disease or disorder.
 Any psychiatric or psychological condition, including test results.
 Any condition, treatment, or therapy related to Substance Abuse, including Alcohol and Drugs; and
 Any non-medical information including such things as eligibility for other benefits, earnings, or
finances.
TO THE CALPERS LONG-TERM CARE PROGRAM:
 I understand that the CalPERS Long-Term Care Program will use the information to determine
my eligibility for benefits.
 CalPERS Long-Term Care Program may release information about me to its affiliates, or any
person performing business or legal services for the CalPERS Long-Term Care Program in
connection with my claim. I ACKNOWLEDGE THAT I HAVE READ THE AUTHORIZATION and I
understand and agree that this authorization shall remain in force throughout the duration of my
claim for benefits with the CalPERS Long-Term Care Program. A photocopy of this authorization
is as valid as the original.
 I may revoke this authorization at any time by providing written notice to the CalPERS Long-Term
Care Program.
 Information disclosed pursuant to this Authorization may be subject to re-disclosure by the
recipient and no longer the responsibility of the CalPERS Long-Term Care Program or protected
by the privacy rules under the Health Insurance Portability and Accountability Act.
 I understand that I have the right to refuse to sign this Authorization, but if I do not sign the
Authorization, the CalPERS Long-Term Care Program will not be able to determine my eligibility
for benefits.
__________________________________________________________________________
Signature of Participant (or Participant’s Representative)
Date signed (Month, Day, Year)
*All signatures, other than that of the Participant, must be identified and accompanied by
appropriate documentation of authority to represent the Participant (for example: Durable
Power of Attorney, Conservator, or Guardian).
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AUTHORIZATION FOR USE AND DISCLOSURES OF
PROTECTED HEALTH INFORMATION
TO AN AUTHORIZED INDIVIDUAL/PERSONAL REPRESENTATIVE
PARTICIPANT NAME: __________________________ Coverage ID: _______________________
I, _____________________, hereby authorize the use and disclosure of my protected health
information for: Coverage administration, billing information, and or claims information, or as
defined, or as limited to the following:
__________________________________________________________________________
__________________________________________________________________________
CalPERS Long-Term Care Program may release my protected health information as
described above to the following person(s) (Please make copies if you are designating more
than one):
_________________________________________________________________________
Printed Name of Authorized Individual
Phone Number
_________________________________________________________________________
Street Address
_________________________________________________________________________
City
State
Zip Code
This form is for use and disclosures only; it does not authorize anyone other than me or my
legal representative to make any changes to my coverage, billing or demographic
information. I understand that if the person or entity that receives my information is not
covered by federal privacy regulations, my information may be re-disclosed by such person
or entity, and will then no longer be protected.
This authorization is valid until my coverage ends, unless a specific expiration date or event
is specified here: __________. I understand that I may revoke this authorization in writing at
any time. I am entitled to make a copy of, or request to receive a copy of this authorization.
I understand that I am not required to sign this authorization and that payment or eligibility
will not be conditioned upon my choice not to sign. I further understand that my protected
health information cannot be disclosed to any unauthorized third party without my signature.
I acknowledge by my signature below that I have read and understand this Authorization, it
accurately reflects my wishes, and a photocopy, facsimile, or other electronic copy is as valid
as the signed original.
__________________________________________________________________________
Signature of Participant or *Legal Representative
Date
*If you are signing as a legal representative, describe the scope of your authority to act on
their behalf and include a copy of the documentation of your legal authority.
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DIRECT DEPOSIT FORM FOR LONG-TERM CARE CLAIM REIMBURSEMENTS
PARTICIPANT NAME: __________________________ Coverage ID: ___________________
Section I – Name for Direct Deposit Setup
______________________________________________________________________
Payee Name
______________________________________________________________________
Social Security # or Federal Tax ID #
Section II – Direct Deposit Information
Check off one:
 Initial setup
 Account Change
Enter the account where payment should be disbursed. The nine-digit transit number
and account number is encoded at the bottom of your check. A copy of a VOIDED
CHECK or SAVINGS ACCOUNT WITHDRAWAL SLIP must be attached to ensure the
correct numbers are obtained. Please allow six weeks for setup of direct deposit.
Account Type:  Checking
Bank Name
 Savings
Transit Number
Account Number
Section III – Authorization
I hereby authorize the CalPERS Long-Term Care Program to initiate credit entries to the
Bank indicated by the Transit Number on this form. If necessary, I also authorize, debit
entries and adjustments for any credit entries in error to my account indicated on this
form. The authority is to remain in full force and effect until the CalPERS Long-Term
Care Program has received written notification from me of its termination in such time
and in such manner as to afford the CalPERS Long-Term Care Program and the Bank a
reasonable opportunity to act on it.
________________________________
Signature of Account Holder
________________________________
Date
________________________________
Account Holder Name
________________________________
Account Holder Phone
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CALPERS LONG-TERM CARE PROGRAM
ASSIGNMENT OF BENEFITS
PARTICIPANT NAME: ___________________________ Coverage ID: ___________
In the event you would like to assign benefits you must first establish if the provider is willing to
consider assignment. The service provider will need to submit their Tax Identification Number
and complete the attached W-9 so the payment will be made directly to the service provider.
The additional steps required are listed below. If you and the provider have agreed to establish
an assignment of benefits, please complete the below form and W-9 and return to us at:
CalPERS Long-Term Care Program
P.O. Box 64902
St. Paul, MN 55164-0902
Fax #: 1-866-294-6967
The assignment of benefits will not be in effect until the CalPERS Long-Term Care Program has
received the completed form. Note the assignment of benefits may be terminated in the future
upon receipt of a written request stating you wish to revoke the assignment.
I,_______________________________, the Participant or the guardian of the Participant (legal
documentation of guardianship or other representative capacity, if appropriate, is attached), hereby
authorize direct payment to _____________________________________of any Long-Term Care
benefits otherwise payable to or on behalf of the Participant for the service provider at a rate not to
exceed the Provider's regular charges. It is agreed that payment to the Provider, pursuant to this
Assignment of Benefits, by the plan administrator shall discharge CalPERS Long-Term Care Program
of any and all obligation under the plan to the extent of such payments. It is understood by the
undersigned that he/she is financially responsible for any charges not covered by this Assignment of
Benefits. This Assignment of Benefits is valid for the CalPERS Long-Term Care Program.
___________________________________
________________________________________
Service Provider Representative Signature
Participant/Legal Representative Signature
___________________________________
Printed Name of Service Provider
________________________________________
Printed Name of Participant/Legal Representative
___________________________________
Date
 Financial Power of Attorney is attached or
already on file if signed by a Legal
Representative
Federal Tax ID # or Independent Provider Social Security (last 4) #: ________________________
Name of Service Provider:_________________________________________________________
Address of Service Provider: _______________________________________________________
City: _____________________________ State: _______ Zip:_________
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