LTC Claims Advisory Toolbox
Alternate Plan of Care Guidelines
A. Introduction
A1. The Alternate Plan of Care (APOC) is a provision which allows benefits for long-term
care services that is not specifically defined as a covered service or provider under the
policy. The service or provider must be qualified by the insurance carrier, meet the needs
of the covered person, and may be a cost-effective alternative.
B. APOC Guidelines for Non Covered Provider
B1. General Consideration
•
The insured has met Benefit Eligibility triggers under the policy
•
Provision is available in the policy
•
The insured has requested an Alternate Plan of Care and the insurance carrier has
concluded that APOC would be appropriate.
•
The insured is sent a carrier specific form to submit a written request for an
Alternate Plan of Care :
•
Reason for the request is documented
•
duties / responsibilities of the caregiver
•
amount of hours and days needed
•
cost
•
Identification and qualifications of the caregiver
•
Or type of care and level of care offered in a facility
•
The physician must also certify the plan meets the insured’s needs.
•
Retroactive dating for APOC parameters per policy / procedure addressed by
each carrier and inform insured
•
Carrier to determine if special releases are required for providers approved under
APOC
B 2. Evaluation
•
Is service from a covered provider is unavailable? - Explain
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•
Will there be supervision of the caregiver? If so, Explain by whom
•
Is frequency of service within reason?
•
Is cost of service within reason?
B 3. Approval
•
The Plan of Care reflect all services (covered and uncovered) providing care
within 24 hours
•
Documentation should clearly indicate how the plan meets the needs of the
insured.
•
Insured must submit Proof of loss before payment.
B 4. Follow up considerations
•
If services or providers are frequently changed, the APOC may need to be reevaluated
•
Possible more frequent review for recertification
•
Routine scheduled follow up reviews
•
APOC reevaluation if change in care needs / level of care.
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Alternate Plan of Care Guidelines
B 5. Provider Request Form – Facility
Generic Alternate Plan of Care Provider Request Form - Facility
Name of Insured:
______________________________________________________________
Date of Birth:_________________
Reason for APOC Request:
____________________________________________________________
Type of Facilility:________________________________________________________________
Name of Facility: ____________________________________
Tax ID #___________________
Street Address:_______________________________________________________
City:_____________________ State: _______Zip:______
Facility licensed
_____ Yes
_____No (Enclose copy)
# of years in operation _________
# of Beds ________
Are Residents related to the owner or manager
_____ Yes
_____ No
Medications dispensed by who? __________________ Medication Records kept _____Yes
_____ No
Type of documentation
maintained_________________________________________None__________
Frequency of documentation
_____ Daily _____ Weekly _____ Monthly _____Event Only
Number of available staff: Day __________
Staff is awake:
____ 24 hours
Qualifications: ___ CNA
Evening __________
Night _____
_____ normal waking hours
____ onsite training
____ none
Staff delivering care is supervised by:
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Alternate Plan of Care Guidelines
____RN ____ LPN ____ Administrator
Other _
____ Aide
____ None
____
Supervisor is available onsite:___ 24 hours ____ Days/Evening ____ Day only
_______ Intermittently (how often) _________
Explain Procedures in place of an emergency:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
To The Physician:
In your professional, medical opinion, please check the statement that applies:
I certify that this plan of service adequately meets the
needs of my patient.
I do not feel this is an appropriate plan of service for my
patient.
Comments: ___________________________________________________
______________________________________________________________
______________________________________________________________
Physician Name:
______________________________________
Signature: ____________________________________________
Date: _____________________
Any person who knowingly and with intent to defraud any insurance company or other
person files a claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties
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Alternate Plan of Care Guidelines
B 6. Provider Request Form – Home Care
Generic Alternate Plan of Care Provider Request Form - Home Care
Name of Insured:
______________________________________________________________
Date of Birth:_________________
APOC Request From:
________________________________________________________________
Requestor Relationship to Insured:
_________________________________________________________
Reason for APOC:
____________________________________________________________
___________________________________________________________________________
_
___________________________________________________________________________
___________________________________________________________________________
__
___________________________________________________________________________
_
___________________________________________________________________________
_
Type of caregiver: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
Training/certification/licensure / if applicable: (enclose copies)
___________________________________________________________________________
___________________________________________________________________________
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Alternate Plan of Care Guidelines
Prior Caregiving Experience: yes_______ No ______ (may enclose letters of reference)
If yes, describe:
_______________________________________________________________________
___________________________________________________________________________
_________
___________________________________________________________________________
________
Hours/days:
_________
Days/week: ________________Cost per hour: ___________
Duties/responsibilities
___________________________________________________________________________
__________
___________________________________________________________________________
___________________________________________________________________________
____________________
___________________________________________________________________________
__________
Supervisor of Caregiver:
_______________________________________________________________
Qualifications:_______________________________________________________________
___________________________________________________________________________
How supervision provided:
__________________________________________________________________________
___________________________________________________________________________
Comments:__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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_**(if physician approval needed by carrier- include or not?)**
To The Physician:
In your professional, medical opinion, please check the statement that applies:
I certify that this plan of service adequately meets the needs of my
patient.
I do not feel this is an appropriate plan of service for my patient.
Comments:
______________________________________________________________
______________________________________________________________
Physician Name:
______________________________________
Signature: ____________________________________________
Date: _____________________
Any person who knowingly and with intent to defraud any insurance company or other
person files a claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
C. APOC for Non Covered Durable Medical Equipment
C1. General considerations
•
The insured must be eligible for benefits accordingly to policy provisions
before any DME will be approved.
•
•
The DME is required for the insured to remain in the residence
The insured is sent a carrier specific form to submit a written request for DME
:
- Insured document Type of DME
- Submits at least 3 written estimates over $xxxx (individual carriers sets
own standard)
- Signed by insured / authorized representative
•
A DME requires approval in advance of its purchase.
•
Any DME without prior approval from insurance carrier will not be paid.
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Alternate Plan of Care Guidelines
o All DME with a cost of $xxxxx or more (individual carriers sets own
standard) require three estimates to be submitted with the Application
for DME Benefit and approval prior to the purchase. The company
reserves the right to determine which product is approved. The
insured may identify which product is preferable and explain the
reason for the preference.
•
All price estimates must be on supplier stationary and must be itemized in
order to ensure compatible estimates are submitted.
•
The Company will reimburse only the actual expense occurred for the
product.
•
The Company will only reimburse for lowest cost products required to meet
the needs of the insured to remain in a residential setting.
•
The Company reserves the right not to pay for a specific product more than
once, or for more than one residence.
•
Copies of front and reverse of cashed checks or copy of credit card receipt
must be provided for reimbursement.
C 2. Guideline
•
Is DME included in policy language under APOC
•
Each carrier to determine approval hierarchy of review for estimates of $xxxx to
be determined.
•
DME Agreement must be signed by the insured and Company representative
before reimbursement is paid.
•
Proof of payment made by the insured is required prior to reimbursement by the
Company.
•
Invoice approval must be documented prior to payment by processor.
•
Each carrier to determine $xxxx guidelines for audits
C 3. Application for DME Reimbursement under APOC
Application for DME Benefit
Insured’s Name
___________________________________
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Alternate Plan of Care Guidelines
Policy Number
____________________________________
Description of the DME
_______________________________________________________________________
_______________________________________________________________________
Reason meets needs of Policy Holder
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________
This section only if applicable (ie, installation needed)
List contacts of the three contractors who are providing estimates (only if
applicable)
(attach estimates)
1._____________________________________________________________
2._____________________________________________________________
3._____________________________________________________________
Estimated start date
_________________________
Estimated completion date
_________________________
Anticipated payment schedule for contracted modification:
________________________________________________________________________
Insured / Responsible Party signature
Date
Any person who knowingly and with intent to defraud any insurance company or other
person files a claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
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D. APOC for Home Modification
D1. General Consideration
• The insured must be eligible for benefits accordingly to policy provisions
before any Home Modification will be approved.
•
•
The home modification is required for the insured to remain in the residence
The insured is sent a carrier specific form to submit a written request for
Home Modification :
- Insured document Type of modification
- Submits at least 3 written estimates over $xxxx (individual carriers sets
own standard)
- Estimated start date
- Estimated end date
- Estimated fee schedule
- Signed by insured / authorized representative
•
A Home Modification requires approval in advance of its installation or
construction.
•
A Home Modification Agreement signed by both a company representative
and the insured is required before any payment will be made.
•
Any Home Modification purchased without a signed agreement from
insurance carrier will not be paid.
•
All Home Modifications require photographs showing the setting before and
after the installation of the modification.
•
Home Modifications are limited to modifying the existing residential
structure. No new construction which expands the existing residential
structure will be approved for benefits.
All Home Modification with a cost of $xxxxx (individual carriers sets own
standard) or more require three estimates to be submitted with the
Application for Home Modification Benefit and approval prior to the
installation or construction of the modification.
The company reserves the right to determine which contractor or product is
approved. The insured may identify which contractor or product is preferable
and explain the reason for the preference.
•
•
•
All price estimates must be on contractor or suppliers stationary and must be
itemized in order to ensure compatible estimates are submitted.
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• The Company will reimburse only actual cash value of the product or
installation.
•
•
The Company will only reimburse for lowest cost materials or products
required to meet the needs of the insured to remain in a residential setting
and meet building construction codes.
•
The Home Modification is solely the purpose of the insured to remain in a
residential setting and not to increase the value of the residence or upgrade
existing materials or products in the residence.
•
The Company will only pay for a specific product or construction project once.
The Company will not pay for reimbursement of a product or construction
project in more than one residence.
•
Copies of front and reverse of cashed checks or copy of credit card receipt
must be provided for reimbursement.
Copies of front and reverse of cashed checks or copy of credit card receipt must be
provided for reimbursement.
D 2. Guidelines
•
Verify Home Modification included in the Policy
•
Each carrier to determine approval hierarchy of review for estimates of $xxxx to
be determined.
•
Home Modification Agreement must be signed by the insured and Company
representative before reimbursement is paid.
•
Proof of payment made by the insured is required prior to reimbursement by the
Company.
•
Invoice approval must be documented prior to payment by processor.
•
Each carrier to determine $xxxx guidelines for audits
•
Through date for contractors must be submitted along with price for materials
•
Before and after photos must be submitted prior to payment
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D 3. Application for Home Modification APOC Benefit
Application for Home Modification Benefit
Insured’s Name
Policy Number
___________________________________
____________________________________
Location of Residence for Home Modification:
_______________________________ ______________
Street
apt number
_______________________________ ______________
City
State
zip
Room(s)______________________________________________________________
Reason meets needs of Policy Holder________________________________
Description of the Home Modification – Submit photo
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Is the Home Modification:
□ New Construction _____________________________________________
□ Addition
______________________________________________
□ Changing existing structure
__________________________________________________________
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List contacts of the three contractors who are providing estimates (attach
estimates):
1._____________________________________________________________
2._____________________________________________________________
3._____________________________________________________________
Estimated start date
_________________________
Estimated completion date _________________________
Anticipated payment schedule for contracted modification:
_______________________________________________________________________
Insured / Responsible Party signature
Date
Any person who knowingly and with intent to defraud any insurance company or other
person files a claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
E. APOC Approval Letter
E 1. After it has been determined that the insured qualifies for services under the
APOC benefit an approval letter should be sent that defines the scope of the
services covered and the agreed upon pricing, place time limits for further review
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when appropriate, and includes a date at which time the APOC expires. Below is
an example of an APOC letter.
(DATE)
(NAME)
(ADDRESS)
(CITY, STATE, ZIP)
Insured:
Policy #:
Dear (Insured):
Your request for an Alternate Plan of Care (“APOC”) under your (company
name) Long-Term Care Policy (“The Policy”) has been reviewed. We are
pleased to inform you that based on the criteria we employ for this benefit;
your request has been approved.
This letter together with your policy, the terms and provisions of which are
incorporated by reference herein, constitute the entire APOC Agreement
(“Agreement”). Under this Agreement, we agree to pay APOC benefits that
would not otherwise be available to you under the Policy, subject to the Plan
of Care agreed to by you and (the Company). In the event there is a
difference between the terms of this Agreement and the Policy, this
Agreement will supersede the terms of the policy.
(Describe APOC.)
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Alternate Plan of Care Guidelines
You may request that we renew this APOC or request a different APOC. Your
request for renewal or a change of this Agreement does not guarantee
approval. All determinations will be made based on eligibility conditions and
limitations as outlined in your Policy. If your request for renewal or change of
this Agreement is granted, benefits will be paid under the terms and
conditions of your policy and the APOC renewal Agreement.
Except as expressly otherwise provided in this APOC, all of the policy terms
remain in full force and effect. In order to receive payment for services, you
must complete the enclosed claim form and meet any applicable elimination
period.
If you accept this Alternate Plan of Care, please sign the enclosed copy of this
letter and return it to us in the envelope we have provided.
If another party is executing this Agreement on your behalf, please be advised
that we must have a copy of the appropriate documentation that transfers the
legal authority to execute contracts on your behalf on file. If you or another
person has not forwarded copies of said documents to us, we require these
documents to be included with the Agreement at the time the executed
Agreement is submitted to us in order for us to process your APOC benefits.
If you have additional questions please contact our office at XXX-XXX-XXXX
between the hours of _____ a.m. and ______p.m. _________Time.
Sincerely,
NAME, TITLE
LTC Claims
I, _________________________________________, have read the APOC
(Claimant or legal designee’s printed name)
Agreement and agree to the terms and conditions as outlined above.
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Signature __________________________________________
(Claimant or legal designee’s signature)
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_________________
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F. APOC Plan of Care
F 1. Services provided under an APOC should be incorporated into a written plan
of care that includes those services provided under the APOC. This provides the
insurer with the claim management objectives and the ability to track outcomes
from the provision of those services and supplies approved to achieve them.
Below is a sample of a Plan of Care.
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RECOMMENDED APOC PLAN OF CARE HOME
Insured’s Name:_______________________________________________________________________________________________________________
Diagnosis____________________________________________________________________________________________________________________
Care Coordinator’s Signature (if applicable)________________________________________________ Date _________________
Insured’s Signature
_________________________________________________
Date_________________
Intervention
Start
Date
Renew
Date
Time
Duration
(eg 2 -4hrs)
Frequency
(eg 3
days/wk)
Estimated
Duration
Identified
Deficit
Objective/Goal
% of goal
achieved at
review date
Comments
APOC Provider approved date ______
 personal care
Homemaking
cognitive supervision
other
Community Services
 MOW
 Other___________________________
__________________________________
__________________________________
Durable Medical Equipment:
 Wheelchair
 Walker
 Cane
 Bedside Commode
 Urinal
 Grab bars
 Raised Toilet
 Hand Held Shower
 Tub seat
 Other___________________________
__________________________________
__________________________________
Home Modifications:
 Wheelchair Ramp
 Widen Bathroom doors
 Other:_________________________
__________________________________
__________________________________
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The Plan of Care may include services that are not covered under the policy
Care Coordinator’s Signature)________________________________________________
Care Coordinator’s Signature)________________________________________________
Care Coordinator’s Signature)________________________________________________
Care Coordinator’s Signature)________________________________________________
Care Coordinator’s Signature)________________________________________________
Care Coordinator’s Signature)________________________________________________
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Date _________________
Date _________________
Date _________________
Date _________________
Date _________________
Date _________________
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