CurrentConnecticut Insurance DepartmentPolicy HC-131

Connecticut Legitimate Disputes Pertaining to Accident and Health Claims

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy HC-131 alerts

Get alerted when Policy HC-131 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs when Connecticut health insurers and other claim-paying entities may reasonably delay accident and health claim payments while investigating specified legitimate disputes; establishes payment deadlines, investigation limits, notice requirements, and approval procedures.

Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Legitimate Disputes Pertaining to Accident and Health Claims

Policy CodePolicy HC-131

Change TypeAdministrative revisionreplaces HC-69

Effective DateFebruary 1, 2024

Next Review DateN/A

Key ActionProcess complete claims within the applicable statutory timeframe unless a qualifying deficiency or Commissioner-determined legitimate dispute applies.

SourceLink

POLICY UPDATE CHANGES

This bulletin rescinds and replaces Bulletin HC-69.

60 daysPaper claim payment period

20 daysElectronic claim payment period

15%/yearUntimely-payment interest

30 days

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentConnecticut Insurance DepartmentPolicy HC-131

Connecticut Legitimate Disputes Pertaining to Accident and Health Claims

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy HC-131 alerts

Get alerted when Policy HC-131 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Legitimate Disputes Pertaining to Accident and Health Claims

Policy CodePolicy HC-131

Change TypeAdministrative revisionreplaces HC-69

Effective DateFebruary 1, 2024

Next Review DateN/A

Key ActionProcess complete claims within the applicable statutory timeframe unless a qualifying deficiency or Commissioner-determined legitimate dispute applies.

SourceLink

POLICY UPDATE CHANGES

This bulletin rescinds and replaces Bulletin HC-69.

60 daysPaper claim payment period

20 daysElectronic claim payment period

15%/yearUntimely-payment interest

30 days

Paper claim period after needed information

10 daysElectronic claim period after needed information

YearlyRoutine subsequent COB investigation frequency

Legitimate Disputes and Claim-Payment Delay Limits

Commissioner-Recognized Legitimate Disputes

The Commissioner has determined that the following questions are legitimate disputes for which an insurer or other claim-paying entity may delay payment for a reasonable period while resolving the dispute. Investigations must remain limited to the conditions and purposes described below, and all reviews and investigations should be concluded promptly.

Whether the claim or condition that is the subject of a new claim is preexisting.

Any investigation must be consistent with Connecticut Insurance Department Bulletin HC-66 (September 24, 2007), limited to issues directly related to the alleged preexisting claim or condition, and may otherwise be deemed post-claim underwriting.

Whether the services rendered are medically necessary.

The investigation must apply the definition of medically necessary established by Conn. Gen. Stat. §§ 38a-482a and 38a-513c.

Whether the services are consistent with emergency medical treatment.

An emergency medical condition is one in which a prudent layperson, acting reasonably, would have believed that emergency medical treatment was needed. The provider must code the presenting symptoms of each emergency claim, and the hospital must record the code in locator 76 of the UB92 form or its successor. The presenting symptoms recorded on the form, or the final diagnosis, whichever reasonably indicates an emergency medical condition, must be the basis for reimbursement or coverage. Investigation is permitted only when the UB92 claim form is not completed as required; when the required information is present, the claim is complete and must be processed without further investigation.

Whether there is potential for dual coverage and, if so, the applicable coordination of benefits (COB).

COB information should be investigated when the initial claim indicates dual coverage. Subsequent claims may not be investigated more frequently than once yearly unless changed circumstances are indicated. Investigation is permitted to determine payment priority; when another insurer is determined to be primary, the secondary carrier may withhold payment until receiving notice of the primary payment needed to determine secondary liability, but must notify the claimant that payment is being withheld pending proof of the primary payer's determination. Group-contract COB determinations must comply with Conn. Agencies Regs. §§ 38a-480-1 through 38a-480-7. Investigation may also verify whether a child or stepchild continues to qualify for coverage under Conn. Gen. Stat. §§ 38a-497 and 38a-512b, or verify marital status when information varies from the records on file.

Whether a dependent remains eligible for coverage when the issue involves verification of dependent status beyond routine enrollment information.

For mentally or physically handicapped dependents, under Conn. Gen. Stat. §§ 38a-489 and 38a-515, proof of incapacity and dependency must be furnished within 31 days after the child reaches the limiting age. The insurer or health care center may require proof of continuing incapacity and dependency at any time; after two years following attainment of the limiting age, periodic proof may be required no more frequently than once annually.

Whether a claim submitted by a foreign provider requires additional processing because bills are in a foreign language or payment is requested in a foreign currency.

A claim may be reasonably delayed in extraordinary circumstances to obtain date-of-service currency conversion rates or translate bills into English. Absent extraordinary circumstances, the claim must be processed within the timeframes established by Conn. Gen. Stat. § 38a-816(15)(B)(i) and (ii).

Whether information concerning an accident is sufficient to evaluate a claim for health care services rendered in response to an accidental injury.

Investigation is permitted when information about the nature of the accident and how the injuries were sustained is missing or incomplete, and must be limited to issues directly related to the accident.

Whether there is a reasonable basis to suspect that a claim is fraudulent.

A carrier may investigate when the claim submission provides a reasonable basis to suspect fraudulent activity by the enrollee, member, subscriber, or provider. The carrier should be prepared to provide the Commissioner with evidence supporting the basis for the suspected fraud.

Limits on Claim-Payment Delays

The Department expects insurers, health care centers, and other claim-paying entities to promptly conclude reviews and investigations. A claim-payment delay based on missing information or an unlisted dispute is permitted only under the requirements below.

When information needed to process the claim is deficient

Claim filing format
- Paper claims
  - Send prompt written notice to the claimant and health care provider describing the alleged deficiencies before expiration of the 60-day period specified by Conn. Gen. Stat. § 38a-816(15)(B)(i).
  - Follow up within 30 days when the necessary requested information has not been received.
  - Process the claim within 30 days after receipt of the necessary information.
- Electronic claims

Payment Deadlines and Claim-Processing Parameters

Emergency claim presenting-symptom reportingRevenueCovered

UB92 locator 76

Record the provider-coded presenting symptoms for emergency claims on locator 76 or its successor.

Paper Claim Payment

Paper claim deadlinePay no later than 60 days after receipt of the claimant’s proof of loss form or the health care provider’s payment request.

Applies toClaims filed in paper format.

Payment entityThe insurer or other entity responsible for payment to the health care provider under the insurance policy.

Electronic Claim Payment

Electronic claim deadlinePay no later than 20 days after receipt of the claimant’s proof of loss form or the health care provider’s payment request.

Applies toClaims filed in electronic format.

Claim Handling and Investigation Requirements

Billing Rule

Process Complete Claims on Time

Process complete accident and health claims within the statutory deadline: 60 days after receipt of a paper claim and 20 days after receipt of an electronic claim. A claim submitted with the information required by Conn. Gen. Stat. §38a-477 is complete and ripe for processing unless the Commissioner has determined that a legitimate dispute exists.

The deadline may be extended when information needed to process the claim is deficient, or when the Commissioner determines that a legitimate dispute exists concerning coverage, liability, damages, or fraudulent causation of the loss.
For a deficient claim, send written notice of all alleged deficiencies no later than 30 days after receipt and pay the claim no later than 30 days after receiving the requested information.
Failure to pay within the applicable statutory period may require payment of the claim plus interest at 15% per annum, in addition to other applicable penalties.

Key Claim-Processing Terms

Complete Claim

DefinitionA claim submitted with the information required by Conn. Gen. Stat. §38a-477 is a complete claim ripe for processing.

Processing conditionThe claim is considered complete unless the Insurance Commissioner has determined that a legitimate dispute exists.

Applicable standardThe information required by Conn. Gen. Stat. §38a-477 determines whether the claim is deficient or complete.

Legitimate Dispute

DefinitionA legitimate dispute is a dispute identified by the Commissioner that permits an insurer or other claim-paying entity to delay payment for a reasonable period while attempting in good faith to resolve the dispute.

Recognized issuesThe dispute may concern coverage, liability, damages, or whether the claimant fraudulently caused or contributed to the loss.

Policy Summary

PayerConnecticut Insurance Department

PolicyConnecticut Legitimate Disputes Pertaining to Accident and Health Claims

Policy CodePolicy HC-131

Change TypeAdministrative revisionreplaces HC-69

Effective DateFebruary 1, 2024

Next Review DateN/A

Key ActionProcess complete claims within the applicable statutory timeframe unless a qualifying deficiency or Commissioner-determined legitimate dispute applies.

SourceLink

On This Page

Promptly notify the claimant and health care provider of the alleged deficiencies before expiration of the 20-day period specified by Conn. Gen. Stat. § 38a-816(15)(B)(ii).

Follow up within 10 days when the necessary requested information has not been received.

Process the claim within 10 days after receipt of the necessary information.

When the dispute is not included in the Commissioner's legitimate-dispute listing

The claim-paying entity must obtain the Commissioner's prior approval for legitimate-dispute status for the specific claim before delaying settlement on the basis of the investigation or inquiry.
The request must include a complete description of the claim, the specific information lacking from the claim submission, and why that information is necessary to consider the claim.
The required information and a complete copy of the claim file must be submitted to the Department's Consumer Affairs Division for consideration.
Any claim-settlement delay not deemed a legitimate dispute by the Department under this Bulletin is treated as a per se violation of CUIPA and is subject to applicable penalties.

Payment entityThe insurer or other entity responsible for payment to the health care provider under the insurance policy.

Claim Deficiency Notice

Notice deadlineSend written notice of all alleged deficiencies in the information needed to process the claim no later than 30 days after receipt of the claim.

Notice recipientThe claimant or health care provider, as applicable.

Complete claim standardA claim containing the information required by Conn. Gen. Stat. §38a-477 is considered complete and ripe for processing unless the Commissioner has determined that a legitimate dispute exists.

Coordination of Benefits Investigation

Initial claimInvestigate coordination of benefits when the initial claim indicates dual coverage.

Subsequent claimsDo not investigate coordination of benefits more frequently than once yearly.

ExceptionMore frequent investigation is permitted when there is an indication of changed circumstances.

Handicapped-Dependent Proof

Proof requiredProof of the handicapped dependent’s continuing incapacity and dependency may be required.

Two-year ruleAfter two years have elapsed following the child’s attainment of the limiting age, periodic proof may be required.

Maximum frequencyPeriodic proof may not be required more frequently than once every year.

Denial Risk

Limit Preexisting-Condition Investigations

Limit any preexisting-condition investigation to issues having a direct relationship to the alleged preexisting claim or condition that is the subject of the new claim. Conduct the investigation consistently with Insurance Department Bulletin HC-66 (September 24, 2007); an inconsistent investigation may be deemed post-claim underwriting.

Documentation Required

Apply the Statutory Medical-Necessity Definition

When reviewing whether services are medically necessary, apply the definition of “medically necessary” established by Conn. Gen. Stat. §§38a-482a and 38a-513c.

Do not use a different or broader investigation standard to determine medical necessity.

Billing Rule

Code Emergency Claims by Presenting Symptoms

For every emergency claim, code the presenting symptoms. Each hospital must record the presenting-symptom code in locator 76 of the UB92 form or its successor. Reimbursement or coverage must be based on the presenting symptoms, as coded and recorded, or the final diagnosis, whichever reasonably indicates an emergency medical condition under the prudent-layperson standard.

An emergency medical condition is one for which a prudent layperson, acting reasonably, would have believed emergency medical treatment was needed.
An insurer or health care center may investigate only when the UB92 claim form or successor is not completed as required; a properly completed claim is complete under Conn. Gen. Stat. §§38a-477 and 38a-816(15)(B) and must be processed without further investigation.

Billing Rule

Coordinate Benefits Within the Annual Limit

Investigate coordination-of-benefits information with the initial claim when dual coverage is indicated. Do not investigate COB for subsequent claims more frequently than once each year unless changed circumstances are indicated.

Investigate to determine payment priority, or, when another insurer is primary, to determine secondary liability after receiving notice of the primary payment.
A secondary carrier may withhold payment pending proof of the primary payer’s determination, but must notify the claimant that payment is being withheld for that reason.
COB determinations for group contracts must comply with Conn. Agencies Regs. §§38a-480-1 through 38a-480-7.

Documentation Required

Verify Dependent Eligibility on the Required Schedule

For a mentally or physically handicapped dependent, the policyholder or subscriber must provide proof of incapacity and dependency within 31 days after the child reaches the limiting age. The insurer or health care center may require proof of continuing incapacity and dependency at any time.

After two years following attainment of the limiting age, recurring proof may be required, but not more frequently than once every year.
Eligibility verification for children or stepchildren must comply with Conn. Gen. Stat. §§38a-497, 38a-512b, 38a-489, and 38a-515, as applicable.

Billing Rule

Process Foreign-Provider Claims Without Unjustified Delay

Claims from foreign providers containing bills in a foreign language or requesting payment in a foreign currency may be reasonably delayed only in extraordinary circumstances to obtain translation or the currency-conversion rate for the date or dates of service. Absent extraordinary circumstances, process these claims within the paper or electronic deadlines in Conn. Gen. Stat. §38a-816(15)(B)(i) and (ii).

Obtain an English translation when needed.
Obtain the applicable foreign-currency conversion rate for the service date or dates.

Denial Risk

Limit Accident and Fraud Investigations

A claim for health care services resulting from an accidental injury may be investigated when information about the nature of the accident or how the injuries were sustained is missing or incomplete. Limit the investigation to issues directly related to the accident.

A claim submission providing a reasonable basis to suspect fraud by an enrollee, member, subscriber, or provider may be investigated.
Be prepared to provide the Commissioner with evidence supporting the basis for suspected fraud.

Documentation Required

Send Deficiency Notices and Follow Up

For deficient claims, promptly notify the claimant and health care provider in writing of the alleged deficiencies before the applicable complete-claim deadline expires. Follow up when requested information has not been received, and process the claim promptly after the information is supplied.

Paper claims: provide notice before expiration of the 60-day period, follow up within 30 days, and process within 30 days after receiving the necessary information.
Electronic claims: provide notice before expiration of the 20-day period, follow up within 10 days, and process within 10 days after receiving the necessary information.
The statutory rule requires notice of all alleged deficiencies no later than 30 days after receipt of the claim.

Prior Authorization

Request Commissioner Approval for an Unlisted Legitimate Dispute

Do not treat a claim-settlement delay based on an investigation or inquiry as a legitimate dispute unless the dispute falls within the identified categories or the Commissioner gives prior approval for the specific claim. Submit the request and a complete copy of the claim file to the Department’s Consumer Affairs Division.

Include a complete description of the claim.
Identify the specific information lacking from the claim submission.
Explain why the information is necessary to consider the claim.
A delay not deemed a legitimate dispute may be treated as a per se violation of CUIPA and subject to applicable penalties.

Other disputesA dispute not identified in the bulletin requires the Commissioner’s prior approval for the specific claim.

Emergency Medical Condition

DefinitionAn emergency medical condition is a condition such that a prudent layperson, acting reasonably, would have believed that emergency medical treatment was needed.

Emergency claim evidenceThe presenting symptoms coded by the provider and recorded by the hospital, or the final diagnosis, whichever reasonably indicates an emergency medical condition, is the basis for reimbursement or coverage.

Statutory authorityThe definition is provided under Conn. Gen. Stat. §38a-478r(c).

Medically Necessary

Definition standardThe statutory definition of medically necessary services governs investigations into whether rendered services were medically necessary.

Applicable statuteThe governing definition is established by Conn. Gen. Stat. §38a-482a.

Additional authorityThe governing definition is also established by Conn. Gen. Stat. §38a-513c.