Two of six activities of daily living for ninety days — or severe cognitive impairment.
LTC benefit eligibility review reads an initial claim file, and every recertification after it, against the checkable test in IRC §7702B(c): two of six activities of daily living for ninety days, or severe cognitive impairment. ADL dependency and cognitive evidence cited page by page, against the policy's own definitions of substantial and standby assistance.
The rulebook is statutory. The referee is unusually busy.
We do not build for a case type until we can name the standard that defines a correct output and the person who grades the file against it. Long-term care eligibility has both, and the standard is written as a count, a duration and a category rather than as a judgement about severity.
That is what makes the file the buildable half of the job. The benefit decision is a clinical and contractual judgement; the evidence behind it has a defined shape and an auditable trail.
A hundred and fifty pages, or fifteen hundred. Then again next year.
An LTC eligibility file runs 150 to 1,500 pages, with a midpoint around 825. It arrives as more than one production: the facility or home-care agency chart, the treating physician's records, the assessment report, and whatever the family sends in directly. The productions overlap heavily and agree with each other imperfectly.
What makes those pages hard is not their number. It is faxed scans of faxed scans, handwriting on aide flow sheets and shift notes, the same plan of care appearing in three productions under three different headers, and the occasional page that belongs to another resident entirely.
Roughly 893,000 open claims at year-end 2024, growing 2 to 3 percent a year, plus about 300,000 new claims annually. Every open claim generates one to four recertifications, which is where the review population actually comes from. Source: Milliman.
Up more than 80 percent since 2015, across carriers, runoff blocks and the TPAs that administer them. The recertification cycle, not the initial decision, is where most of that reading sits.
Four steps, starting with one real file.
Send one real file
A closed initial eligibility file or a recertification, as it actually arrived: several productions, degraded faxes, the policy language alongside the clinical record. In the demo case, 342 pages across 2 productions with a wrong-patient page quarantined before the read starts.
We return the read
A sorted, deduplicated file with a chronology, every documented activity-of-daily-living dependency located and page-cited, the cognitive testing surfaced, and your policy's own definitions of substantial and standby assistance indexed beside the evidence. You compare it against what your reviewer on that claim actually had to work from.
We scope the build
Your ADL definitions by contract vintage, your packet order, your export format, and the intake rules that separate an initial eligibility file from a recertification. If the case type is not buildable to your standard, we say so at this step rather than after.
You run it
Your intake team loads files and your nurse case managers and eligibility staff read the file and make the benefit decision. We never certify a claimant as chronically ill, never count the trigger for you, and never approve or deny a claim or a recertification.
The rules the platform never breaks.
EVERY LINE CITED
HIPAA, under a signed BAA
Every file is handled under our Business Associate Agreement, from the first byte.
Never trains a model
Your records are never used to train any AI model — ours or anyone else's.
Every line cited
If we can't cite it, we don't say it. Every sentence links to its source page.
Deleted after delivery
Files are deleted 30 days after delivery, with a full audit log of every access.
Four capabilities behind every eligibility file.
The LTC eligibility read is one deliverable of the same platform that reads, sorts, and cites the whole record.
Smart lists
Every diagnosis, medication and procedure in the file pulled into one sorted list, so the reviewer opens a claim already knowing what is in it.
Condition Progression Tracking
Whether the documented picture is getting better or worse across the recertification cycle, shown as a trend rather than a pile of separate events.
Functional Restriction Tracking
Every documented limitation and assistance need extracted from the record and held in one place, cited to the aide note or evaluation that states it.
Medical Chronology
The care timeline behind the claim builds itself across every production, synced to every source page, so the ninety-day question has a dated answer.
LTC benefit eligibility review, answered.
Send one file. We'll tell you what we can read.
No obligation. If the case type is buildable we'll scope it; if it isn't, we'll say so.