Connecticut General Statutes|Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. Regulations.

                                                
Sec. 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.)