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 NumberItem Description
1aInsured's identification number
2Patient's name
3Patient's birth date and sex
4Insured's name
10aPatient's condition - employment
10bPatient's condition - auto accident
10cPatient's condition - other accident
11Insured's policy group number (if provided on identification card)
11dIs there another health benefit plan?
17aIdentification number of referring physician (if required by insurer)
21Diagnosis
24ADates of service
24BPlace of service
24DProcedures, services or supplies
24EDiagnosis code
24FCharges
25Federal tax identification number
28Total charge
31Signature of physician or supplier with date
33Physician's, 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 NumberItem Description
1Provider name and address
5Federal tax identification number
6Statement covers period
12Patient name
14Patient's birth date
15Patient's sex
17Admission date
18Admission hour
19Type of admission
21Discharge hour
42Revenue codes
43Revenue description
44HCPCS/CPT4 codes
45Service date
46Service units
47Total charges by revenue code
50Payer identification
51Provider number
58Insured's name
60Patient's identification number (policy number and/or Social Security number)
62Insurance group number (if on identification card)
67Principal diagnosis code
76Admitting diagnosis code
80Principle procedure code and date
81Other procedures code and date
82Attending physician's identification number
(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.)
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.