Long-term care claim and plan of care

How do we take a long-term care claim from the policyholder or their family, get the care assessment and plan of care, and approve benefits against the policy and the state's rules?

Run the claim as a care case with the family inside it. Callvu takes the claim from the policyholder, a family member or a care manager, captures the authorized representative and the authorizations, schedules the benefit eligibility assessment (activities of daily living or cognitive impairment) with the assessor and chases the result, chases the plan of care from the licensed practitioner and the provider's license and invoices through links, checks the elimination period and the policy's benefit triggers, routes the eligibility and the plan approval to the claims examiner in the Decision Desk, and writes the approved plan, the benefit and the recertification date to the claims system with the state's claim timing met.

In scopeComplex: multi-party handoffsCallvu moves: chase and verify, decide, write back

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Last updated November 7, 2026.

The problem today

The daughter sent the plan of care twice; the assessment was scheduled by phone and nobody told the facility.

Today, without Callvu

A long-term care claim usually starts with a family member of someone who cannot manage it themselves. The carrier needs an authorized representative, an assessment of the insured's ability to perform the activities of daily living or their cognitive state, a plan of care from a licensed practitioner, the provider's license and invoices, and proof the elimination period has run. Each comes from a different party, and the family is the courier.

State long-term care rules (the NAIC Long-Term Care Insurance Model Act and Regulation as adopted) set the benefit triggers a policy may use (inability to perform a number of activities of daily living, or a severe cognitive impairment), require that eligibility be certified by a licensed health care practitioner, set the claim handling and appeal rights, require prompt payment, and give the policyholder the right to designate a third party for notices. The policy sets the elimination period, the daily or monthly benefit and the covered providers.

The family should give each thing once, and the carrier should chase the rest from the professionals who owe it.

How it runs

From the requestto the system of record.

The policyholder, a family member, a power of attorney or a care manager reports a need for care in any channel. Callvu opens the claim and the representative record.

Policyholder and authorized representative: Report the need, provide the authorizations and the power of attorney, and confirm the care arrangement.
Assessor and licensed health care practitioner: Perform the benefit eligibility assessment and certify the plan of care through links.
Care provider or facility: Provides the license, the service agreement and the invoices through a link.
Claims examiner: Decides eligibility and approves the plan in the Decision Desk.
Callvu: Captures, schedules, chases each professional, checks against the policy, routes and writes back.

Capture the claim and the representative
The insured, the person reporting and their authority (a power of attorney, a third-party designee under the policy), the HIPAA authorizations, the care need and the proposed provider are captured on a secure screen; the policy's benefit triggers, elimination period, benefit amounts and covered care types are prefilled for the examiner.
Chase and verify the assessment and the plan of care
The benefit eligibility assessment is scheduled with the assessor (in person or by telehealth where the policy allows) and the result chased; the plan of care is requested from the licensed health care practitioner through a link and checked for the certification the policy and the state require (the activities of daily living affected or the cognitive impairment, the services and frequency, the expected duration); the provider's license, the service agreement and the first invoices are chased and checked against the plan.
Decide
The claims examiner decides in the Decision Desk with the assessment, the plan, the provider documents and the elimination period computation, and only the allowed outcomes: approve the plan and the benefit, approve with changes to the plan, request named material, or deny with the specific reasons and the appeal rights.
Write back and recertify
The approved plan, the benefit amount and frequency, the elimination period dates, the provider and the recertification date are written to the claims system, invoices are paid against the plan as they arrive through the provider's link, and the recertification opens on its date with the same chases.

Where it ends: The family gave their part once, the professionals supplied the assessment, the plan and the invoices through their own links, and benefits were approved against the policy and the state's rules with the recertification scheduled. The Decision Trace shows the triggers, the checks and the decision; the Audit Trace shows every request, document and the write.

Runtime enforcement

What is enforcedwhile the work runs.

The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.

Regulations

State long-term care rules (NAIC Long-Term Care Insurance Model Act #640 and Model Regulation #641 as adopted by the states): A tax-qualified policy may condition benefits on the inability to perform at least two of the activities of daily living for at least 90 days or on severe cognitive impairment, certified by a licensed health care practitioner with a plan of care; the state rules set the standards for claim handling, prompt payment and appeal, the right to designate a third party to receive lapse notices, and limits on the elimination period and on requiring prior hospitalization.
Internal Revenue Code 7702B and HIPAA long-term care provisions: For a tax-qualified contract, the chronically ill definition (activities of daily living or cognitive impairment certified within the preceding twelve months) and the plan of care requirement govern eligibility; the claim records the certification date for recertification.
State prompt pay rules: Once benefits are approved, invoices are paid within the state's period from receipt, with interest on late payment where the state requires.

Company policies

The authorized representative is captured on the first contact, and every notice goes to them and the policyholder.
The assessment and the plan of care are chased from the professionals who owe them, never through the family.
Eligibility is decided on the policy's triggers with the certification attached.
The claims system holds the plan, the benefit, the invoices and the recertification date.

Controls

Representative and authorization capture.
Assessment scheduling and result chase.
Plan of care and provider document chases with checks.
Elimination period computation.
Decision Desk decision with required outcomes.
Claims system write with invoice payment and recertification.

Clocks and deadlines

Elimination period: The policy's days of covered care before benefits begin, computed from the plan and the invoices.
Recertification: Within the twelve months of the practitioner's certification, opened on its date.
Invoice payment: Within the state's prompt pay period from receipt.

Documents and checks

The claim and the representative's authority
The benefit eligibility assessment
The plan of care with the certification
The provider's license, agreement and invoices
The decision and the claims system record

In the Decision Trace

The policy's triggers and the assessment result.
The plan's checks.
The decision and the examiner.

In the Audit Trace

Each request and document with time.
The decision and the notice.
The write and each invoice payment.

The handoff

Between the front doorand the back office.

The front door

The policyholder or the family in any channel; the assessor, the practitioner and the provider each through their own link.

The back office

The examiner decides on a complete care case; invoices pay against the approved plan.

The Decision Desk

The eligibility and the plan go to the claims examiner in the Decision Desk with the assessment, the plan and the provider documents, and only approve, approve with changes, request named material, or deny with reasons and appeal rights.

Proof

In scope.Proof at scale, not one process at a time.

The kind of process Callvu runs in production for customers in this industry. Ask for a reference on this exact process. The results below are the industry's published proof; each claim code links to its record on agents.callvu.com.

Phoenix put more than 100 processes live in under 3 months.

Across Callvu customers

More than 1,000 processes are live across Callvu customers.

Across Callvu customers

Questions

What buyers ask next,answered plainly.

Who can file the claim?

The policyholder, a family member with a power of attorney, a designated third party or a care manager; the process captures their authority and the authorizations on the first contact.

What proves eligibility?

A benefit eligibility assessment and a plan of care certified by a licensed health care practitioner against the policy's triggers, chased from the professionals through their own links.

How are the care invoices paid?

Against the approved plan as the provider submits them through its link, within the state's prompt pay period, with the recertification opened on its date.

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