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Senate Bill No. 351

Public Act No. 03-57

AN ACT CONCERNING DEFICIENCIES IN INSURANCE CLAIM INFORMATION.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Subdivision (15) of section 38a-816 of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2003):

(15) (A) Failure by an insurer, or any other entity responsible for providing payment to a health care provider pursuant to an insurance policy, to pay accident and health claims, including, but not limited to, claims for payment or reimbursement to health care providers, within the time periods set forth in subparagraph (B) of this subdivision, unless the Insurance Commissioner determines that a legitimate dispute exists as to coverage, liability or damages or that the claimant has fraudulently caused or contributed to the loss. Any insurer, or any other entity responsible for providing payment to a health care provider pursuant to an insurance policy, who fails to pay such a claim or request within the time periods set forth in subparagraph (B) of this subdivision shall pay the claimant or health care provider the amount of such claim plus interest at the rate of fifteen per cent per annum, in addition to any other penalties which may be imposed pursuant to sections 38a-11, 38a-25, 38a-41 to 38a-53, inclusive, 38a-57 to 38a-60, inclusive, 38a-62 to 38a-64, inclusive, 38a-76, 38a-83, 38a-84, 38a-117 to 38a-124, inclusive, 38a-129 to 38a-140, inclusive, 38a-146 to 38a-155, inclusive, 38a-283, 38a-288 to 38a-290, inclusive, 38a-319, 38a-320, 38a-459, 38a-464, 38a-815 to 38a-819, inclusive, 38a-824 to 38a-826, inclusive, and 38a-828 to 38a-830, inclusive. Whenever the interest due a claimant or health care provider pursuant to this section is less than one dollar, the insurer shall deposit such amount in a separate interest-bearing account in which all such amounts shall be deposited. At the end of each calendar year each such insurer shall donate such amount to The University of Connecticut Health Center.

(B) Each insurer, or other entity responsible for providing payment to a health care provider pursuant to an insurance policy subject to this section, shall pay claims not later than forty-five days after receipt by the insurer of the claimant's proof of loss form or the health care provider's request for payment filed in accordance with the insurer's practices or procedures, except that when there is a deficiency in the information needed for processing a claim, as determined in accordance with section 38a-477, as amended by this act, the insurer shall (i) send written notice to the claimant or health care provider, as the case may be, of all alleged deficiencies in information needed for processing a claim not later than thirty days after the insurer receives a claim for payment or reimbursement under the contract, and (ii) pay claims for payment or reimbursement under the contract not later than thirty days after the insurer receives the information requested.

(C) As used in this subdivision, "health care provider" means a person licensed to provide health care services under chapter 368v, chapters 370 to 373, inclusive, 375 to 383c, inclusive, 384a to 384c, inclusive, or chapter 400j.

Sec. 2. Section 38a-477 of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2003):

(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 [UB-82] 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, as amended by this act.

 

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

   

(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 or supplier with date

 

33

Physician'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, as amended by this act.

 

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

Attending physician's identification number

[(b)] (d) The commissioner may adopt regulations, in accordance with [the provisions of] chapter 54, to implement the provisions of [subsection (a) of] this section.

Approved June 3, 2003