(a) Except where there is an agreement to the contrary between a third-party payer and the health care provider, as defined in § 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.

Terms Used In Connecticut General Statutes 38a-477

  • another: may extend and be applied to communities, companies, corporations, public or private, limited liability companies, societies and associations. See Connecticut General Statutes 1-1
  • Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
  • Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
  • Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1

(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 § 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 § 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.