When do I need to file a claim for benefits?

Once you know that you will need long-term care services, please call Customer Service at 1-800-362-0700 to discuss filing a claim. Rrepresentatives will be happy to answer your questions and send you an information packet containing complete instructions and required forms for you to complete and mail or fax back.

What types of services are covered under my long-term care policy?

The types of covered services are specific to each policy, and generally include assistance with bathing, dressing, transferring, and assistance to the bathroom.

In some policies, assistance with meal preparation, light housekeeping, laundry, grocery shopping and transportation to medical appointments may be covered.

What types of services are not covered?

Services that are not reimbursable include, but are not limited to, pet care; trips to the beauty parlor, church, and social activities outside the home; and heavy housekeeping.

Policy terms require that care be provided to the policyholder while confined in his or her home. Please refer to your policy for specific information regarding the types of covered services.

How is eligibility for benefits determined?

Determining eligibility is a two-step process:

1. Benefit eligibility: Your medical condition and care needs are evaluated to determine if they meet the eligibility requirements of your policy.

2. Provider eligibility: The care provider you choose is evaluated to determine if the agency or private caregiver meets the criteria listed in your policy.

What information is required for benefit eligibility?

To simplify the claim process for you, we obtain information from two sources:

1.  Your physician(s): Information is required from your physician(s) about your current medical condition and care needs, and the anticipated length of time that care will be needed. We request this information directly from your physician(s). You can help by asking your physician(s) to promptly complete and return the required information to us.

2. In-home assessment: A nurse from an independent company representing Davies Life & Health, Inc. may visit you to conduct an assessment in your home. The nurse will call to schedule the appointment directly with you or your legal representative.

Sometimes, we must request additional information to provide clarification before we can make an eligibility determination. If additional information is required, we will notify you or your legal representative by letter of the status of the claim and the additional information needed.

How is provider eligibility determined?

Eligibility requirements for care providers vary by policy.  Please refer to your policy for the specific requirements for qualification.

Once the required information is received, a claim examiner will review it to determine whether your provider is eligible, based on your policy's requirements.

Once a claim is filed, how soon will I be notified about a claim decision?

It takes an average of 35 to 45 days after a claim is initiated to gather the necessary information to make an eligibility determination. To expedite this process, it is important that all requested information be provided to us as soon as possible.

If my claim is approved, when can I expect to receive claim payments?

Davies Life & Health, Inc. processes 97% of all claim payments within 15 days of receipt of all completed information. If a bill cannot be processed for any reason, we will notify you by letter of the status of the claim and any additional information needed to complete processing.

What should be submitted on a regular basis in order to receive payment for covered services provided?

If care is being provided by an agency, the agency can submit the bills and care notes directly to Davies Life & Health, Inc.. If care is being provided by a private caregiver, the caregiver must complete the Home Health Care Documentation form each day that they provide services. This form also serves as a bill.

How frequently should bills be submitted?

Bills for home health care services can be submitted as frequently as every two weeks, but must be submitted at least once a month.

What kind of documentation should the caregiver keep?

The caregiver should document the types of services that he/she is providing to you during the hours worked.

Where should bills and care notes be sent?

Bills and care notes can be submitted by mail or fax:

Mailing address: Davies Life & Health, Inc., PO Box 7066, Allentown PA 18105-7066

Fax: 610-965-6962.

What if my claim for benefits is denied?

In the unlikely event that your claim is denied, you will receive written notification explaining the appeal process.