Claim Submission For Unlisted Procedure Code Or Service Code Special Report Form - Connecticut Claims Department
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1Claim Submission for
Unlisted Procedure Code or Service Code Special Report
In accordance with American Medical Association Current Procedural Terminology (CPT)/Healthcare Common
Procedure Coding System (HCPCS) reporting guidelines, please complete the following form to support the use of an
unlisted procedure or service code. This information will be used to determine appropriate payment and claim
adjudication in conjunction with the member's benefit plan.
Member Name:______________________________________________________________________________________
Member ID #:____________________________________________ Member Date of Birth: ________________________
Member address (street, city, state, zip): ___________________________________________________________________
__________________________________________________________________________________________________
Date of Service: _____________________________________________________________________________________
Submitting Provider Name: ____________________________________________________________________________
License #: _____________________________________ Specialty type: ________________________________________
Indicate the unlisted procedure or service code number:______________________________________________________
Indicate the RVU value associate with this service: __________________________________________________________
Indicate the specific CPT/HCPCS code that is most closely related to this service: _________________________________
Describe the unlisted service or procedure and explain why the service does not meet the definition of the standard defined
CPT-HCPCS code listed above. Please be certain to include an adequate definition or description of the nature, extent and
need for the unlisted procedure and the time, effort and equipment necessary to provide the service. Additional items, which
may be included, are complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic/therapeutic procedures,
concurrent problems and follow-up care.
Description: _______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Indicate the name of the individual who may be contacted should there be questions regarding this form.
Name:_______________________________________________________ Phone: ______________________________
Providers should mail the completed form to:
ConnectiCare, P.O. Box 4000, Farmington, CT 06034-4000, Attn: Claims Department
Please Do Not Write Below This Line
Medical Director:________________________________________ Review Date: _____________________________
Report acceptable:_______________________________ Requires additional information: _______________________
Determination: __________________________________________________________________________________
______________________________________________________________________________________________
Prepared by: _________________________________________________ Date: ______________________________
Print
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