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border-top: solid windowtext 1.0pt; padding-top: 0; border-right: solid windowtext 1.0pt; padding-right: 5.4pt; border-bottom: solid windowtext 1.0pt; padding-bottom: 0; border-left: solid windowtext 1.0pt; padding-left: 5.4pt; } td.sa1ca5bac-896a-4185-857d-632edf0902b0000022 { vertical-align: top; width: 450.5pt; border-top: solid windowtext 1.0pt; padding-top: 0; border-right: solid windowtext 1.0pt; padding-right: 5.4pt; border-bottom: solid windowtext 1.0pt; padding-bottom: 0; border-left: solid windowtext 1.0pt; padding-left: 5.4pt; } span.sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000023 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">DIVISION OF INSURANCE</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">CLAIMS DENIAL REPORTING FORM FOR</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">LONG-TERM CARE INSURANCE POLICIES</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Chapter 20:</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">06:21</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">APPENDIX H</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">SEE: § </span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">20:06:21:52</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">    </span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Source:</span><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 28 SDR 157, effective May 19, 2002; 36 SDR 209, effective July 1, 2010.</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000003"><br />&#x200e;</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Claims Denial Reporting Form</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Long-Term Care Insurance</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000004"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">For the State of ____________________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000001"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">For the Reporting Year of ____________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Company Name: ______________________________________________ Due: June 30 annually</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Company</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Address: _______________________________________________________________________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Company NAIC</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Number: _______________________________________________________________________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Contact Person: _____________________________________ Phone Number: ______________</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Line of Business: Individual Group</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Instructions</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies.</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Indicate the manner of reporting by checking one of the boxes below:</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000006"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000007">¡%</span><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">  Per Claimant -- counts each individual who makes one or a series of claim requests.</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000006"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000007">¡%</span><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">  Per Transaction -- counts each claim payment request.</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">"Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition. It does not include a request for payment that is in excess of the applicable contractual limits.</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Inforce Data</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><div align="left"><table dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0000008"><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000009"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">State</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Data</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000011"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Nationwide Data</span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000009"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Total Number of Inforce Policies [Certificates] as of December 31</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000011"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr></table></div><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Claims &amp; Denial Data</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><div align="left"><table dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0000008"><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">State</span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Data</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><h3 dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Heading3"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Nationwide</span></h3><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000002">Data</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"><sup>1</sup></span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 1</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Total Number of Long-Term Care Claims Reported</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 2</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Total Number of Long-Term Care Claims Denied/Not Paid</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 3</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Number of Claims Not Paid due to Preexisting Condition</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Exclusion</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 4</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Number of Claims Not Paid due to Waiting (Elimination) Period</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Not Met</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 5</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Net Number of Long-Term Care Claims Denied for Reporting</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Purposes (Line 2 Minus Line 3 Minus Line 4)</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 6</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Percentage of Long-Term Care Claims Denied of Those </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Reported (Line 5 Divided By Line 1)</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 7</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">Number of Long-Term Care Claims Denied due to:</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 8</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> " Long-Term Care Services Not Covered under the Policy</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"><sup>2</sup></span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 9</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> " Provider/Facility Not Qualified under the Policy</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"><sup>3</sup></span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">10</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> " Benefit Eligibility Criteria Not Met</span><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"><sup>4</sup></span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000012"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont">11</span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000013"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> " Other</span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000010"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000014"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000015"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000016"> </span></p></td></tr><tr><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000017"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000018"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000019"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td class="sa1ca5bac-896a-4185-857d-632edf0902b0000020"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 1.</span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> The nationwide data may be viewed as a more representative and credible indicator</span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> where the data for claims reported and denied for your state are small in number.</span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 2.</span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> Example%home health care claim filed under a nursing home only policy.</span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 3.</span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> Example%a facility that does not meet the minimum level of care requirements or the </span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> licensing requirements as outlined in the policy.</span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> 4.</span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> Examples%a benefit trigger not met, certification by a licensed health care practitioner</span></p></td></tr><tr><td colspan="2" class="sa1ca5bac-896a-4185-857d-632edf0902b0000021"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></td><td colspan="3" class="sa1ca5bac-896a-4185-857d-632edf0902b0000022"><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal-000005"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont"> not provided, no plan of care.</span></p></td></tr></table></div><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p><p dir="ltr" class="sa1ca5bac-896a-4185-857d-632edf0902b0Normal"><span class="sa1ca5bac-896a-4185-857d-632edf0902b0DefaultParagraphFont-000023"><br />&#x200e;</span><span xml:space="preserve" class="sa1ca5bac-896a-4185-857d-632edf0902b0000000"> </span></p></div></body></html>