2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › 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.
(P.A. 93-109; P.A. 03-57, S. 2; P.A. 12-197, S. 41.)
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; P.A. 12-197 amended Subsec. (b) by adding references to advanced practice registered nurse in items 17a, 31 and 33 and amended Subsec. (c) by adding reference to advanced practice registered nurse and making a technical change in item 82.