Connecticut Insurance Department Specifies When Claims Payments May Be Delayed

June 18, 2024

On April 22, 2024, the Connecticut Insurance Department issued Bulletin HC-132 to all health insurers and healthcare centers authorized to do business in the state. Bulletin HC-132 replaces prior Bulletin HC-131.

Connecticut law requires that an insurer or any other entity responsible for providing payment to a healthcare provider pursuant to an insurance policy pay accident and health claims not later than 60 days after request for payment for paper claims and not later than 20 days for claims filed in electronic format. These deadlines apply unless there is a deficiency in the information needed for processing a claim or when the commissioner determines that there is a “legitimate dispute as to coverage, liability or damages” or that the claimant has fraudulently caused or contributed to the loss.

This bulletin lists the questions and issues that the commissioner has determined to be “legitimate” for delaying payment. These issues include:

• Whether a claim or condition is preexisting.
• Whether the services rendered are medically necessary.
• Whether the services are consistent with emergency medical treatment.
• When there is a potential for dual coverage.
• When there are dependent eligibility issues.
• When there is a lack of information about the accident when there are accidental injuries.
• When there are suspected fraudulent claims.
• When services are provided by foreign providers.

If an insurer wants to delay payment for a reason other than for one of these listed reasons, it must have prior approval of the commissioner.

Although timeliness of claims payment is more of a procedural issue that doesn’t directly involve health plan sponsors, employers will need to be aware that procedures such as these exist in case an employee/participant questions the handling of their claims.

Bulletin HC-132 CT Unfair Insurance Practices