Conn. Gen. Stat. § 38a-477

Current with legislation from the 2024 Regular and Special Sessions.

Section 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 Number	Item Description
1a	Insured's identification number
2	Patient's name
3	Patient's birth date and sex
4	Insured's name
10a	Patient's condition - employment
10b	Patient's condition - auto accident
10c	Patient's condition - other accident
11	Insured's policy group number
	(if provided on identification card)
11d	Is there another health benefit plan?
17a	Identification number of referring physician or
	advanced practice registered nurse
	(if required by insurer)
21	Diagnosis
24A	Dates of service
24B	Place of service
24D	Procedures, services or supplies
24E	Diagnosis code
24F	Charges
25	Federal tax identification number
28	Total charge
31	Signature of physician, advanced practice
	registered nurse or supplier with date
33	Physician's, advanced practice registered nurse's
	or 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 Number	Item Description
1	Provider name and address
5	Federal tax identification number
6	Statement covers period
12	Patient name
14	Patient's birth date
15	Patient's sex
17	Admission date
18	Admission hour
19	Type of admission
21	Discharge hour
42	Revenue codes
43	Revenue description
44	HCPCS/CPT4 codes
45	Service date
46	Service units
47	Total charges by revenue code
50	Payer identification
51	Provider number
58	Insured's name
60	Patient's identification number
	(policy number and/or
	Social Security number)
62	Insurance group number
	(if on identification card)
67	Principal diagnosis code
76	Admitting diagnosis code
80	Principle procedure code and date
81	Other procedures code and date
82	The identification
	number of the attending physician or advanced
	practice registered nurse

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

Conn. Gen. Stat. § 38a-477

( P.A. 93-109; P.A. 03-57, S. 2; P.A. 12-197, S. 41.)

Amended by P.A. 12-0197, S. 41 of the the 2012 Regular Session, eff. 10/1/2012.