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Long-term care appeals

When can I appeal?

If an insurance company says you do not qualify for long-term care benefits, you may be able to appeal. Disputes most likely involve decisions about whether you can no longer perform certain activities of daily living or have a cognitive impairment.

To avoid claim denials, it is important that the facility or caregiver keep accurate, detailed care notes about the level of help a policyholder needs to perform activities of daily living. The insurance company will use this information in the claim review process.

How do I appeal?

Your first appeal is through the company that denied coverage.

If the denial is upheld by the company, your insurer must send you a letter telling you how to file an external appeal. The letter will include this list of Independent Review Organizations.

You may select the company you want to review your case. If you don't name a company, the insurance company will do so on your behalf.

Independent Review Organizations

Federal Hearings and Appeals Services, Inc.
Attn: Oregon Long Term Care External Review
117 W. Main Street
Plymouth, PA 18651
Phone: (570) 779-5122
Fax: (570) 719-0306

LTCI Independent Eligibility Review Specialists, LLC
Attn: Oregon Long Term Care External Review
Allentown, Penn.
Stephen R. La Pierre

Managed Medical Review Organization, Inc. (MMRO)
Attn: Oregon Long Term Care External Review
44090 W 12th Mile Road
Novi, MI 48377
Phone: 866-516-6676 Expedited Phone: 248-508-1830
E-Fax: 248-327-4626

Maximus Federal Services, Inc.
Attn: Oregon Long Term Care External Review
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Phone Number (for all case types): 866.763.6395
Fax: 585.425.5296

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