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Bulletin HC-56


August 9, 2000

TO: ALL INSURERS LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE AND ALL HEALTH CARE CENTERS

RE: CONNECTICUT GENERAL STATUTE §38a-816(15) AS AMENDED BY PUBLIC ACT 99-284 §30 REGARDING PROMPT PAYMENT OF ACCIDENT AND HEALTH CLAIMS

Section 38a-816(15) of the Connecticut General Statutes, as amended by section 30 of Public Act 99-284, (hereinafter, the "statute") concerns, in part, claims filed by health care providers and the timeframe for payment by insurers. The statute requires insurers to pay interest if a claim containing all the information necessary for payment is not paid within 45 days of receipt. If a claim does not contain all the information necessary for payment, the insurer has 30 days to request additional information and 30 days after receiving the requested information to pay the claim without interest.

To implement the statute efficiently, a consensus on what constitutes a claim is needed. To this end, former Insurance Commissioner George M. Reider, Jr. organized members from Connecticut’s managed care industry, providers, and the State of Connecticut Insurance Department to discuss and propose criteria for determining what constitutes a claim for the purposes of C.G.S. §38a-816(15).

The criteria suggested by the members would NOT define what constitutes a "clean claim" or a claim containing all the information necessary for payment by an insurer. The criteria would simply establish when there is enough information on a piece of paper or bit of electronic media submitted to an insurer to be considered a claim. Once identified as a claim, the insurer would determine whether the claim should be paid, denied, or requires additional information.

After reviewing the member’s findings, Insurance Commissioner Susan F. Cogswell has determined that the Insurance Department shall use, and expects insurers and providers to use, the criteria set forth below to determine when information submitted to an insurer constitutes a claim and the 45 and 30-day time periods set forth in the statute begin. This bulletin is intended to define the minimum criteria for the acceptance of a claim; it does not guarantee payment. The best way to ensure prompt payment is to file a fully completed claim in accordance with an insurer’s practices and procedures.

For information submitted on a HCFA 1500 form, as periodically updated and revised, the following minimum requirements must be complete and received by the insurer before the form will be considered a claim.

Item Number Item Description
1a Insured’s ID 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 I.D. card)
11d Is there another health benefit plan?
17a I.D. number of referring physician (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 I.D. number
28 Total charge
31 Signature of physician or supplier with date
33 Physician’s, supplier’s billing name, address, zip code & phone

For information submitted on a HCFA UB-92 form, as periodically updated and revised, the following minimum requirements must be complete and received by the insurer before the form will be considered a claim.

Item Number Item Description
1 Provider name and address
5 Federal tax I.D. number
6 Statement covers period
12 Patient name
14 Patient’s birthdate
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 I.D.
51 Provider number
58 Insured’s name
60 Patient’s I.D. number (policy number and/or social security number)
62 Insurance group number (if on I.D. card)
67 Principal diagnosis code
76 Admitting diagnosis code
80 Principal procedure code and date
81 Other procedures code and date
82 Attending physician’s I.D. number

For the purpose of this bulletin, the terms "claim for payment," "reimbursement to health care providers," "claim for reimbursement," "claim," "request," and "request for payment" used in the statute shall be collectively referred to as a "claim" or "claims."

Susan F. Cogswell
Insurance Commissioner