Connecticut Workers’ Compensation Fee Schedule Rates

The Connecticut workers’ compensation fee schedule sets the maximum amount medical providers can be paid for treating a workplace injury. It has two main parts: a practitioner fee schedule, most recently updated effective July 15, 2025, and a separate hospital and ambulatory surgery center schedule that is republished annually. Prescription drugs follow their own pricing formula. All three are maintained by the Workers’ Compensation Commission (WCC) and apply to every bill tied to a compensable claim.¹

Who and What the Schedule Covers

The practitioner schedule governs medical services delivered under the Workers’ Compensation Act, Title 31, Chapter 568 of the Connecticut General Statutes. It reaches licensed physicians, surgeons, physical therapists, chiropractors, and podiatrists. Any provider who treats a workplace injury is bound by the caps, whether the employee chose them or the employer designated them.²

Insurance carriers, self-insured employers, and third-party administrators all pay from the same schedule. Diagnostic, surgical, and rehabilitative services in non-hospital settings fall under it. Hospitals and ambulatory surgery centers follow a separate Medicare-based formula, and prescription drugs use their own AWP-based formula. Those pieces are covered below.

How Practitioner Rates Are Set

Connecticut does not use relative value units. Instead, the WCC caps each procedure’s maximum payment at the 74th percentile of what Connecticut providers actually charge for that service. In other words, the reimbursement ceiling lands at the level where 74% of providers in the state charge less.²

Every service is identified by its Current Procedural Terminology (CPT) code, and the schedule publishes a maximum dollar amount for each code. Annual updates are capped by the yearly percentage increase in the Consumer Price Index for All Urban Workers (CPI-U), a requirement carried over from Public Act 93-228.²

Non-Physician Providers

When a non-physician bills under the same CPT code as a physician, reimbursement is 70% of the physician rate. Physical medicine services are the exception. The rate follows the licensure of the person who actually performed the service, not the licensure of whoever the bill goes out under.² So a physician assistant or nurse practitioner delivering care in a physician-led practice is paid at the 70% rate even though the practice’s name is on the claim.

Negotiated Rates

The schedule is a ceiling, not a floor. Providers and payers are free to enter written agreements at different rates, including discounted rates through preferred provider networks. Without a written agreement, the published schedule is the maximum permissible payment.²

Hospital and Ambulatory Surgery Center Rates

Hospitals and ambulatory surgery centers (ASCs) are paid off a Medicare-based formula rather than the practitioner schedule. Under Section 31-294d(e), the WCC chairperson publishes these formulas each year after consulting with employers, insurers, hospitals, and ASCs.³ The 2025 rates, set in Memorandum No. 2024-10, are:

Hospital inpatient: 174% of the Medicare rate payable to that facility
Hospital outpatient and hospital-based ASC: 210% of the Medicare rate payable to that facility
Non-hospital-based ASC: 195% of the hospital-based outpatient Medicare rate in the same Core Based Statistical Area

Facility fees pay for the technical side of care: operating room time, nursing, equipment, and supplies. The surgeon’s professional fee is billed separately under the practitioner schedule.⁴ Hospitals and ASCs can also negotiate their own rates with employers or insurers. Absent that, the published Medicare-based formulas control.³

Prescription Drug Reimbursement

Prescription medications are paid at the Average Wholesale Price (AWP) plus a dispensing fee. The dispensing fee is $5.00 for brand-name drugs and $8.00 for generics. The higher generic fee is intentional, an incentive for pharmacies to stock and dispense the lower-cost option.

Over-the-counter medications dispensed directly in a provider’s office are reimbursed at the provider’s acquisition cost plus 30%. When a physician dispenses medication out of the office rather than sending a prescription to a pharmacy, reimbursement is the lower of the National Drug Code (NDC) price for the original manufacturer’s product or a therapeutic equivalent. If the original manufacturer information isn’t provided, the insurer picks the NDC and AWP used for the calculation.

Connecticut’s general pharmacy law also requires generic substitution unless the prescribing physician indicates that the brand-name drug is medically necessary. Where a generic is available and no valid override exists, reimbursement can be limited to the generic price.

Billing Rules and the Ban on Balance Billing

The fee schedule amount is the full permissible payment for an authorized service. Providers who accept workers’ compensation cases accept those caps as a condition of billing. Charging the injured worker the gap between the provider’s standard rate and the fee schedule amount is prohibited. Section 31-294d limits employer liability to charges prevailing in the community for comparable treatment, and the regulation makes the fee schedule the binding ceiling.² A worker who receives a balance bill can raise it with the Commission.

Claims go in on standardized forms: the CMS-1500 for practitioner services and the UB-04 for facility charges. Both require the CPT codes and modifiers matching what was actually done, the date of service, and the injury details. Insurers routinely reject claims where the codes don’t line up with the medical records.

Payment Deadlines and Late-Payment Interest

Insurers have 60 days from receiving proper documentation to pay a compensable medical bill. After day 60, unpaid bills accrue interest at 1.5% per month. That penalty runs automatically and doesn’t require a separate hearing.

For the broader claim, Connecticut law adds a stronger set of penalties for delay. If the employer or insurer is at fault for unduly delaying payments, an administrative law judge can add 12% annual interest and a reasonable attorney’s fee to the award. Payments that haven’t started within 35 days after the employee files a written notice of claim are presumed to be unduly delayed unless the employer has filed a notice to contest.⁵ Where the delay wasn’t the employer’s fault (for example, an appeal), the judge can still order interest at a lower rate the judge considers fair and reasonable.

Disputing a Medical Bill

An employer or insurer challenging liability for medical treatment files a Form 43, Notice of Intention to Contest Employee’s Right to Compensation Benefits, with the administrative law judge. When the dispute involves medical care, a copy also has to go to the medical provider. Service is by personal delivery or certified mail, and the employer should keep a dated copy as proof.⁶

If a bill is denied or underpaid, the first step is to request an informal hearing at the WCC district office handling the claim. Informal hearings resolve most billing disputes without a full proceeding. If the informal process doesn’t settle it, the case moves to a formal hearing before an administrative law judge, who can order payment and add interest for unjustified delay.

1
Connecticut Workers’ Compensation Commission. Memorandum No. 2025-03 – 2025 Official Connecticut Practitioner Fee Schedule
2
Cornell Law School. Connecticut Agencies Regulations 31-280-3 – Practitioner Fee Schedule
3
Justia. Connecticut Code 31-294d – Medical and Surgical Aid, Hospital, Ambulatory Surgical Center and Nursing Service
4
Connecticut Workers’ Compensation Commission. Memorandum No. 2024-10 – 2025 WCC Hospital and Ambulatory Surgical Center Fee Schedule
5
Justia. Connecticut Code 31-300 – Award as Judgment, Interest, Attorney Fee, Procedure on Discontinuance or Reduction
6
Workers’ Compensation Commission. Notice of Intention to Contest Employee’s Right to Compensation Benefits – Form 43