2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479. - Definitions. Access to fee schedules. Fee information to be confidential.

(a) As used in this section and section 38a-479b:
(1) “Contracting health organization” means a managed care organization, as defined in section 38a-478, or a preferred provider network, as defined in section 38a-479aa.
(2) “Provider” means a physician, surgeon, chiropractor, podiatrist, psychologist, optometrist, dentist, naturopath or advanced practice registered nurse licensed in this state or a group or organization of such individuals, who has entered into or renews a participating provider contract with a contracting health organization to render services to such organization's enrollees and enrollees' dependents.
(b) Each contracting health organization shall establish and implement a procedure to provide to each provider:
(1) Access via the Internet or other electronic or digital format to the contracting health organization's fees for (A) the current procedural terminology (CPT) codes applicable to such provider's specialty or, upon request, current dental terminology (CDT) codes, (B) the Health Care Procedure Coding System (HCPCS) codes applicable to such provider, and (C) such CPT codes, CDT codes and HCPCS codes as may be requested by such provider for other services such provider actually bills or intends to bill the contracting health organization, provided such codes are within the provider's specialty or subspecialty; and
(2) Access via the Internet or other electronic or digital format to the contracting health organization's policies and procedures regarding (A) payments to providers, (B) providers' duties and requirements under the participating provider contract, (C) inquiries and appeals from providers, including contact information for the office or offices responsible for responding to such inquiries or appeals and a description of the rights of a provider, enrollee and enrollee's dependents with respect to an appeal.
(c) The provisions of subdivision (1) of subsection (b) of this section shall not apply to any provider whose services are reimbursed in a manner that does not utilize current procedural terminology (CPT) or current dental terminology (CDT) codes.
(d) The fee information received by a provider pursuant to subdivision (1) of subsection (b) of this section is proprietary and shall be confidential, and the procedure adopted pursuant to this section may contain penalties for the unauthorized distribution of fee information, which may include termination of the participating provider contract.
(P.A. 06-178, S. 1; P.A. 07-54, S. 2; P.A. 09-204, S. 1; P.A. 11-132, S. 1; P.A. 19-155, S. 1.)
History: P.A. 07-54 made a technical change in Subsec. (c), effective May 22, 2007; P.A. 09-204 amended Subsec. (a) by deleting former Subdiv. (2) defining “physician” and adding new Subdiv. (2) defining “provider”, amended Subsec. (b) by revising fee schedules and other information contracting health organizations are required to provide to providers and specifying access methodology, deleted former Subsec. (c) re procedure, redesignated existing Subsecs. (d) and (e) as Subsecs. (c) and (d) and made conforming and technical changes, effective January 1, 2010; P.A. 11-132 made a technical change in Subsec. (a)(2); P.A. 19-155 amended Subsec. (a)(2) by redefining “provider” and amended Subsecs. (b)(1) and (c) by adding references to current dental terminology codes, effective January 1, 2020.
See Sec. 38a-193 for additional provisions re contracts between health care centers and participating providers.
See Secs. 42-490 to 42-493, inclusive, for provisions re the selling, leasing, renting, assigning or granting of access to a contract or terms of a contract between health care providers and contracting entities.