State Codes and Statutes
Statutes > Connecticut > Title38a > Chap700c > Sec38a-477Sec. 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.
