Independent Eligibility Review Case Summary Form

Insurance Carrier – Please complete all sections of this form and click “submit”. We will acknowledge acceptance/rejection of this case for review within three business days. You will receive additional instructions for submitting case documentation upon notification of case acceptance.

Insurer Information: 

Date Form Completed:

Insurer Contact Phone:

Name of Insurer:

Insurer Contact Fax: 

Insurer Contact Name: 

Insurer Email:
 

Policyholder Information: 

Name:  

Age:

Sex:

State where policy was issued:

State where policyholder resides:

Policy Information: 

Policy Type: 

 Long Term Care Insurance
 Other

Type of Care Covered:  

 SNF              ALF
 Home Health   Other

Policy Effective Date:

Policy Tax Status:

 Tax Qualified
 Non-Tax Qualified

Conditions of Eligibility (Benefit Triggers): 

 2 or more ADLs
 Cognitive Impairment

 Medical Necessity
 Other

A face to face functional assessment was performed in this case? 

 Yes

 No

Please provide the basis for the Carrier's denial of eligibility: 

Please provide the basis for the policyholder's appeal of the denial: