2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-478r - Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage.
(a) Each provider, as defined in section 38a-478, shall code for the presenting symptoms of all emergency claims and each hospital shall record such code for such claims on locator 76 on the UB92 form or its successor.
(b) The presenting symptoms, as coded by the provider and recorded by the hospital on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates an emergency medical condition, shall be the basis for reimbursement or coverage, provided such symptoms reasonably indicated an emergency medical condition.
(c) For the purposes of this section, in accordance with the National Committee for Quality Assurance, an emergency medical condition is a condition such that a prudent layperson, acting reasonably, would have believed that emergency medical treatment is needed.
(d) The Insurance Commissioner may develop and disseminate to hospitals in this state a claims form system that will ensure that all hospitals consistently code for the presenting and diagnosis symptoms on all emergency claims.
(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88; P.A. 11-58, S. 73; P.A. 15-118, S. 49.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re “the final diagnosis, whichever reasonably indicates an emergency medical condition,” effective July 1, 1997; P.A. 11-58 amended Subsec. (d) to delete provision re consultation with working group convened pursuant to Sec. 38a-478p, effective July 1, 2011; P.A. 15-118 made a technical change in Subsec. (c).
