(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 complete
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(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.