At Senior Health Insurance Company of Pennsylvania (In Rehabilitation) ("SHIP"), we understand that filing a long-term care insurance claim for assisted living or nursing home care benefits can be confusing. The information on this page is designed to provide straightforward instructions for filing a claim for facility benefits.

Please be sure to read the policy very carefully, with special attention to benefit eligibility requirements, current benefits for each policy feature, and the facility requirements. If you have any questions, please contact our customer service department at (877) 450-5824.

Claim Form, signed, and dated by the policyholder or their representative.
- Complete questions 1 – 14.
- If a legal representative completes and signs the form, please attach a copy of the documentation granting legal authority.
Authorization for Use of Health-Related Information Form
Authorization for Disclosure of Health-Related Information Form, if you would like our representatives to be able to speak to someone other than the policyholder about care
Other documents contained in the Claim Information Packet that apply to your situation
Invoices or billing statements (can be submitted by either the policyholder or the facility)
Direction to Pay Form (required if directing benefit payments to provider)
Eligible benefits will be paid upon receipt of appropriate forms and valid documentation, including invoices or billing statements

Important Reminder: Please make copies of all claim forms and documentation and retain for your records!

Policyholder Information to Submit

Policyholder Claim Form

Authorization for Use

Authorization for Disclosure

Claim Information Package

Direction to Pay

Facility License
Assessment
- Minimum Data Set (“MDS”), if facility has assessment tool
- Initial Admission Assessment, if facility does not have an MDS
  - Including admission notes
- Facility Service Plan
Continued Monthly Resident (“CMR”) Form
- must be completed thoroughly by facility staff each month, on or after the last day of the month, after the services have been provided and submitted for any eligible benefits
Invoices or billing statements (can be submitted by either the policyholder or the facility)
W-9 Request for Taxpayer Identification Number and Certification
- If long-term care insurance benefits have been assigned to a covered provider, this form is required from the covered provider.
Medication List and Physician’s Medication Order (if applicable)

Provider Information to Submit

Continued Monthly Resident Form

Benefit Eligibility Assessment
- An assessment of your care needs, performed by a registered nurse (R.N.) at the company's expense
Physician's Cognitive Questionnaire
- A standardized questionnaire sent by our claims department to the attending physician to assist in determining the level of care needs
Medical Records
- Any additional information that may be needed to substantiate the type and level of care needs

Medical Information That May Be Requested to Support a Claim

Policyholder Forms:

Claim Form
Authorization for Use of Health-Related Information
Authorization for Disclosure of Health-Related Information, if you would like our representatives to be able to speak to someone other than the policyholder about care
Direction to Pay Form (required if directing benefit payments to provider)

Provider Forms and Documents:

Facility License
Minimum Data Set (“MDS”) or Nursing Assessment
Plan of Care or Service Plan (if available)
Invoices or billing statements (can be submitted by either the policyholder or the facility)
Medication List and Physician’s Medication Order (if applicable)
Claimant Care Needs Assessment Form
Continued Monthly Residence ("CMR") Form
W-9 Request for Taxpayer Identification Number and Certification (required if directing benefit payments to provider)

Checklist of Documents

Nursing Facility / Assisted Living Facility Initial Claim Checklist

Policyholder Claim Form

Authorization for Use

Authorization for Disclosure

Direction to Pay

Claimant Care Needs Assessment Form

Continued Monthly Resident Form

How to Submit Claims for Facility Benefits