Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 020 - INSURANCE DIVISION › Chapter 033 - RULE 93-4; UNIFORM CLAIM FORMS AND UNIFORM STANDARDS AND PROCEDURES FOR PROCESSING › Section 21 020 033 - RULE 93-4; UNIFORM CLAIM FORMS AND UNIFORM STANDARDS AND PROCEDURES FOR PROCESSING

Current through June, 2024
Section 1 Purpose
The purpose of this regulation is to promote efficiency and
				  cost savings in the payment of health insurance claims by the use of common
				  claim forms and procedures and to improve the availability and consistency of
				  health services information.
Section
				2 Authority
This regulation is issued pursuant to the authority vested in
				  the Commissioner of Banking, Insurance and Securities (Commissioner) under
				  Title
				  18 V.S.A.
				  9408.
Section 3 Applicability and Scope
Except as otherwise specifically provided, the requirements
				  of this regulation apply to all issuers of policies or contracts of insurance,
				  administrators of self-funded employee benefit plans, and other forms of
				  insurance involved in the reimbursement of health care expenses, and all
				  providers of health care licensed or certificated by this
				  state.
Section 4 Definitions
(a) "ADA claim form" means the uniform dental
				claim form approved by the American Dental Association for use by
				dentists.
(b) "CDT codes" means the
				current dental terminology published by the American Dental
				Association.
(c) "CPT-4 codes"
				means the current procedural terminology used by the American Medical
				Association.
(d) "DSM-III-R codes"
				means the American Psychiatric Association's codes for mental
				disorders.
(e) "Durable Medical
				Equipment" means equipment which (a) can withstand repeated use; (b) is
				primarily and customarily used to serve a medical purpose; (c) generally is not
				useful to a person in the absence of an illness or injury; and (d) is
				appropriate for use in the home. All requirements of the definition must be met
				before an item can be considered to be durable medical equipment.
(f) "HCFA" means the federal Health Care
				Financing Administration of the United States Department of Health and Human
				Services.
(g) "HCFA-1450" (UB-82 or
				UB-92) means the health insurance claims form published by HCFA for use by
				institutional providers.
(h)
				"HCFA-1500" means the health insurance claims form published by HCFA for use by
				health care professionals.
(i)
				"HCPCS codes" means HCFA's common procedure coding system which includes both
				of the following:
(1) Level 1 codes, which
				are CPT codes; and
(2) Level 2
				codes, which are procedure codes for which there are no CPT codes.
(j) "Health care facility" means
				all facilities and institutions, as defined in Title
				18 V.S.A. §
											9402.
(k) "Health care provider" means a person,
				partnership or corporation, other than a facility, as defined in Title
				18 V.S.A. §
											9402.
(l) "Health insurer" means any health
				insurance company, nonprofit hospital and medical services corporation, health
				maintenance organization, and, to the extent permitted under federal law, any
				administrator of an insured, partially insured, self-insured or publicly funded
				health care benefit plan offered by public or private entities.
(m) "ICD-9-CM codes" means the disease codes
				in the international classification of diseases, 9th revision, clinical
				modification published by the United States Department of Health and Human
				Services.
(n) "Local codes" means
				those codes approved for use by the State Uniform Claim Form
				Committee.
(o) "Medicare" means
				Title XVIII of the federal Social Security Act.
(p) "Pharmacy Products" means prescription
				drugs, durable medical equipment, surgical supplies and over-the-counter
				products when dispensed by a registered pharmacy.
(q) "State Uniform Claim Form Committee"
				means the committee described in Section 10 of this regulation.