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Disability income, dental and long-term care claim research
Access date for all web sources: 2026-10-07. Primary sources only. This is research for fictional Atlas journeys, not real coverage terms or advice. Stages and screen grouping below are proposed Atlas design. Source forms establish field/evidence patterns; they do not establish Atlas eligibility, duration, limits, deadlines or payment amounts.
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Disability income
Evidence anchors:
- D1 Guardian STD claim packet, GG-011096, 12/22, linked by current claims resource center. Employee, physician and employer sections include work state, incident details, other income, delivery details, restrictions, job demands, compensation and signatures. Employer answers include whether work can be modified.
- D2 Guardian attending physician statement. A separate physician contribution carries employee/claim identifiers and authorization. Despite its URL extension the web tool served a PDF.
- D3 Guardian part-time earnings record. Employer certifies dates, hours, rate and job title; pay stubs can be requested.
- D4 Guardian current STD instructions. Waiting periods and exclusions vary by plan; extensions may need medical evidence. Recovery and supported job limitations matter. Do not turn its maternity recovery examples into universal Atlas rules.
- D5 The Standard LTD packet, SI 16261, 2/25. Uses separate employee, employer, physician and authorization contributions. Other-benefit determinations or application receipts, vocational history, resumed work, prior condition history and hospital information are relevant. Multiple physicians can each supply a statement. Its psychotherapy authorization is distinct from general authorization; do not collect sensitive notes by default in Atlas.
- D6 Department of Labor disability claim filing guide. For covered employer plans it describes denial notices, evidence access and independent appeal review. Its deadlines do not automatically apply to individual policies or every plan.
Proposed wizard and handoffs:
| Stage | Field groups / ownership | Answer-triggered branch |
|---|
| Coverage and claimant | Seeded policy, insured identity, contact, employer relationship, work location; customer | Group coverage identifies employer contribution. Individual coverage would need a separately approved variant; initial Atlas fixtures remain employer funded. |
| Work interruption | Last worked date, claimed absence interval, current work status, expected/actual return; customer | Working part time opens earnings period/hours contribution D3. Related leave is linked as a separate case. |
| Cause and treatment | Illness/injury/pregnancy selection, onset, incident, treating-provider references; customer | Injury opens date/location/description; employment-related opens workers-compensation status; pregnancy opens expected/actual delivery and complications D1. Hospitalization opens stay dates D5. |
| Income and occupation | Other income type, amount/frequency, application/award status; occupation/duties; customer and employer | Applied but not awarded requests receipt; awarded requests decision evidence D5. Employer confirms earnings, schedule and work demands D1. No automatic offset calculation. |
| Evidence and attestations | Medical authorization, requested statement/document slots, claimant acknowledgement; customer | Reviewer requests provider-specific evidence. Clinical restrictions and prognosis remain insurer-visible. Contribution received is distinct from reviewer acceptance D2. |
| Review and decision | Readable answers, contributor checklist, outstanding evidence; insurer reviewer | Missing evidence opens a same-case correction task. Approve produces seeded benefit decision; decline produces reason; approved payout uses separate account/reference and simulated payment status. |
Continuing claim forms should ask what changed, the requested extension period, updated treatment/evidence, other-income changes and resumed-work details. Employer payroll confirmation must not let a manager view diagnoses or medical files. A limited-work proposal can lead to two independent outcomes: insurer benefit review and employer RTW review. An employer saying work can be modified does not approve benefits or certify medical fitness.
Atlas-specific proposal: a denial review request captures disputed decision, explanation and new evidence, linked to the original case and assigned to a different synthetic reviewer. Appeal support is a proposed scope extension; current accepted Atlas rules only establish approve/request-information/decline. Keep legal deadlines out of prototype logic unless separately specified.
Dental
Evidence anchors:
- N1 Sun Life-hosted current ADA Dental Claim Form, GDFM-11189, 06/24. Separates subscriber/patient, other coverage, service rows, billing entity and treating provider. Has transaction type, tooth/surface/area, procedure dates and fees, orthodontic appliance/months, replacement date and accident information; patient and dentist attestations are separate.
- N2 Sun Life claim submission tips. Secondary-payer claims need primary EOB; full-time student detail can matter. Identifies billing/treating NPI differences and image labeling. Advises checking existing status instead of duplicate submission.
- N3 Sun Life procedure documentation guide, GDFL-6237-m, 04/24. Distinct evidence by procedure family: pre-operative images, periodontal charting/narrative, missing teeth/extraction dates, prior prosthetic information or orthodontic plan. Guidance is not exhaustive.
- N4 Sun Life Florida PPO certificate claim provisions. Demonstrates written denial/review reasons, policy provisions and access to relevant records. This is one specific certificate, not a universal dental appeals rule.
Proposed wizard:
| Stage | Field groups | Branch / handoff |
|---|
| Policy and patient | Seeded policy/subscriber, dependent selection, patient relationship/contact | Different patient opens dependent confirmation. Student status only appears when the seeded policy scenario requests it N2. |
| Provider and services | Treating provider, billing entity if different, service line date/type/tooth/surface/amount | Repeatable lines for a treatment episode N1. Provider simulation supplies clinical/procedure facts; customer confirms submitted information. |
| Procedure detail | Treatment-family discriminator | Crown/prosthetic replacement asks prior placement; orthodontics asks appliance date, treatment months and plan fee; accident asks date and type N1. |
| Other coverage | Other plan/carrier/subscriber relationship | Secondary-payer scenario requests primary EOB and amount; unknown payer order goes to reviewer, not browser inference N2. |
| Supporting documents | Procedure-dependent evidence slots | Periodontal treatment requests charting and relevant images; prosthetics request extraction/prior-placement detail; orthodontics requests plan N3. |
| Confirm and submit | Itemized claimed total, attachments, customer declaration, provider contribution status | Reviewer asks for a specific missing item or correction. Approval updates seeded benefit use once; no separate dental payout journey. |
Correction proposal: preserve original service-line IDs and submission snapshot; show which line/document needs attention; replacing an unreadable image marks the old version superseded. An excess amount can be corrected or declined under accepted fictional rules. A proposed appeal form collects decision reference, disputed service lines, explanation and evidence N4. Keep appeal review separate from editing an unsubmitted draft.
Predetermination exists in the real form N1, but Atlas's accepted dental journey is a claim. Do not silently add a quote/predetermination workflow. Avoid embedding the full copyrighted CDT catalog or reproducing ADA form layout; use synthetic service categories and provider-supplied synthetic codes if needed.
Long-term care
Evidence anchors:
- L1 Genworth notice of claim. Insured/representative can initiate. Intake gathers contact, diagnosis, care needs, requested benefits, location and providers; prospective providers can undergo review.
- L2 Genworth assessment. Licensed practitioner assesses daily activities, cognition, environment and support. Care coordinator contributes certification and a plan of care when approved.
- L3 Genworth initial eligibility. Insured eligibility, provider eligibility and covered services are distinct. Initial approval can precede payment while waiting period, care and invoice requirements remain outstanding.
- L4 Genworth claims forms. Includes third-party authorization, assignment to facility/agency, EFT, facility confinement, independent-provider invoicing and agency/day-care review forms. Independent care applies only to policies that cover it.
- L5 Genworth independent provider invoice, 149222, 12/12. Insured/legal representative and caregiver contribute and certify. Captures provider relationship, daily tasks, actual hours/rate; certifications follow service dates. Proof of payment may be requested. Family care is not assumed covered.
- L6 Genworth payments. Insured, representative or provider sends invoices and care notes. Facility can submit monthly invoice/confinement data; reviewer considers plan of care, expenses and remaining limits; EOB and payment follow review.
- L7 Genworth ongoing eligibility. Periodic reviews may repeat assessment/medical evidence; moves, changed care, hospitalizations, nights away and recovery should be reported.
Proposed wizard:
| Stage | Field groups | Triggered subflow |
|---|
| Identity and authority | Seeded policy, insured contact, person completing request | Representative opens relationship and synthetic authority-document evidence; permission to receive information and authority to act are distinct L1/L4. |
| Care need | Requested period, current location, daily assistance needs, cognitive-support indication | Answers tailor assessment questions and evidence request; no automatic diagnosis or eligibility finding L2. |
| Care setting/provider | Home agency, independent caregiver, facility or adult day care; provider identity, start date | Each opens matching provider-review/confinement contribution L4. Family relationship prompts manual policy review L5. |
| Assessment preparation | Practitioner contact, visit availability, support person, requested records | Synthetic assessor contribution then coordinator/reviewer decision L2. External licensed actors can remain simulated documents unless new portal roles are approved. |
| Eligibility and care plan | Reviewer-confirmed insured/provider/service eligibility, seeded plan reference | Eligible-but-not-payable remains visible until seeded waiting-period and invoice conditions are satisfied L3. |
| Expense period | Service dates, amounts, provider invoice, care notes | Independent caregiver opens daily hours/rate/tasks and dual certification L5. Facility opens confinement verification L6. |
| Decision and payment | Evidence checklist, requested seeded benefit, account reference | Reviewer accepts or requests correction; simulated payout occurs only after benefit decision. Account setup does not approve care. |
Recurring update proposal: ask whether care setting/provider/need changed. A move opens provider review; hospitalization or nights away opens date detail and expense reconciliation; recovery opens closure review L7. Do not mutate the old invoice or release another payment when its result is unknown. Missing care notes return an information task attached to that expense period L6.
An LTC appeal form is an Atlas proposal, not established by these Genworth pages. Capture disputed eligibility/provider/service decision and supporting reassessment; route to synthetic reviewer. No universal ADL count, cognitive test score, waiting period, family-care exclusion, daily cap or appeal deadline is inferred.
Shared implementation implications for later synthesis
Contentful authors stage definitions, field groups, repeaters, labels, conditional visibility and declarative constraints in immutable bilingual releases. Answer changes recompute visibility and evidence checklists; hidden stale values cannot satisfy a new branch. Define whether inactive answers are retained separately or cleared in the spec.
Camunda owns contributor tasks, information requests, reviewer decisions and workflow progression. A screen next button, completed checklist or CMS branch cannot authorize benefit/payment decisions. BFF enforces pinned declarative form constraints and record/task permissions through Fastify/TypeBox boundary contracts; React receives authorized SDUI through tRPC. Simulated business owners store claim answers, contributor evidence references, decisions and benefit use. Preserve correction lineage, stable identifiers and idempotent financial effects.
These are research-backed proposals awaiting synthesis with accepted scope. Third-party contribution portals, independent appeals, recurring claim periods and new journey variants require explicit specification treatment before issue publication. Existing manager medical/privacy boundaries and dental no-payout scope are already accepted constraints.