Conn. Gen. Stat. § 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.