Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. Regulations. - Connecticut Statutes

      Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. Regulations. (a) Except where there is an agreement to the contrary between a third-party payer and the health care provider, as defined in section 19a-17b, all health care providers shall submit all third-party claims for payment on the current standard Health Care Financing Administration Fifteen Hundred (HCFA1500) health insurance claim form or its successor, or in the case of a hospital or other health care institution, a Health Care Financing Administration UB-92 health insurance claim form or its successor, or in accordance with other forms which may be prescribed by the Insurance Commissioner.

      (b) For any claim submitted to an insurer on the current standard Health Care Financing Administration Fifteen Hundred health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.

Item NumberItem Description 1aInsured's identification number 2Patient's name 3Patient's birth date and sex 4Insured's name 10aPatient's condition - employment 10bPatient's condition - auto accident 10cPatient's condition - other accident 11Insured's policy group number (if provided on identification card) 11dIs there another health benefit plan? 17aIdentification number of referring physician (if required by insurer) 21Diagnosis 24ADates of service 24BPlace of service 24DProcedures, services or supplies 24EDiagnosis code 24FCharges 25Federal tax identification number 28Total charge 31Signature of physician or supplier with date 33Physician's, supplier's billing name, address, zip code & telephone number

      (c) For any claim submitted to an insurer on the current standard Health Care Financing Administration UB-92 health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.

Item NumberItem Description 1Provider name and address 5Federal tax identification number 6Statement covers period 12Patient name 14Patient's birth date 15Patient's sex 17Admission date 18Admission hour 19Type of admission 21Discharge hour 42Revenue codes 43Revenue description 44HCPCS/CPT4 codes 45Service date 46Service units 47Total charges by revenue code 50Payer identification 51Provider number 58Insured's name 60Patient's identification number (policy number and/or Social Security number) 62Insurance group number (if on identification card) 67Principal diagnosis code 76Admitting diagnosis code 80Principle procedure code and date 81Other procedures code and date 82Attending physician's identification number

      (d) The commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

      (P.A. 93-109; P.A. 03-57, S. 2.)

      History: P.A. 03-57 substituted "Health Care Financing Administration UB-92 health insurance claim form" for "UB-82" in Subsec. (a), added new Subsecs. (b) and (c) re information on HCFA1500 claim form and UB-92 claim form, respectively, redesignated existing Subsec. (b) as Subsec. (d) and made technical changes therein.