(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.