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Claims
You or your representative must submit Written proof of your claim to us within 12 months after the date you incurred charges for Covered Services, or by April 1st of the year following the year you incurred charges for Covered Services, whichever is later. If you or your representative do not submit proof of claim within this time limit, we may deny benefits unless you can show that it was not reasonably possible for you to submit proof of claim within the time limit, and you or your representative submitted proof of claim as soon as reasonably possible.
We must receive adequate Written proof (such as bills for services) that you have incurred charges for Covered Services. To assist us in determining whether you have incurred charges for Covered Services:
we may contact you, your Physician or other persons familiar with the services provided to you; and/or
we may access your medical records to get information about your condition or the services provided to you (we cannot approve a claim if we are not given access to your medical records); and/or
we may request to have you examined, at our expense, by a health care provider and to conduct an on-site assessment; and/or
we may require you to submit Medicare explanations of benefits or documentation from any other source from whom you may have received or are eligible to receive reimbursement for the Covered Service for which you have submitted a claim.
Notice and Review of Claim Determination
We will send you Written notice of our claim determination as soon as possible after we receive all the information we need. In general, that means within 10 business days.
If we deny your claim, in whole or in part, the notice will provide the reason(s) for the denial. You or your representative may request a review of a denial by sending a Written request to us no later than 60 days after the date of the denial. No later than 60 days after the date we receive your request, we will send you Written notice of our decision. If the initial denial is upheld on review, you may request an appeal. Please see the Appeals section.
| Call: 1-800-LTC-FEDS (1-800-582-3337) (TTY: 1-800-843-3557) |
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