CurrentColorado Rocky Mountain Health PlansPolicy N/A

UB-04 (CMS-1450) facility billing and form locator reimbursement policy

Governs reimbursement rules and required UB-04 form locator data for UnitedHealthcare Community Plan Medicaid products and applies to facility claims billed on UB-04 or electronic equivalent across network and non‑network facilities.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUB-04 (CMS-1450) facility billing and form locator reimbursement policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims with complete and valid UB-04 form locator data to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04billing form governed

Community Plan Medicaidproducts affected

Fields listedrequired form locators

KY, FL, MD, MO, TX, WIstate exceptions noted

Claims denieddenial consequence

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Required UB-04 Form Locator Data & Validation

Required UB-04 form locator data

Claims must include complete and valid UB-04 form locator information. Missing, incomplete, or invalid information will result in denial.

ALL of the following

Required example fields include: Bill Type; Discharge Status; Principal diagnosis; Source of Admission; Condition code; Type of Admission; Patient age; Patient gender.
Other required data elements include those necessary for correct claim adjudication (Form Locators as defined by NUBC/CMS).

Claims submission must use complete and valid codes and data in the appropriate FLs; failure to do so will result in denial or return of the claim.

Common facility edits and validation rules

Additional validation rules and edits that commonly trigger denials or edits on facility claims.

Age-to-procedure and/or age-to-diagnosis conflicts will trigger edits or denial.

Validate patient age against procedure and diagnosis codes to avoid denial.

Gender-to-procedure and/or gender-to-diagnosis conflicts will trigger edits or denial.

Validate patient gender against procedure and diagnosis codes to avoid denial.

Procedure and/or diagnosis codes missing required digits (digit completeness) will trigger edits or denial.

Ensure ICD-10 and other codes have the required number of characters/digits.

Use of an external cause (E) code as the primary diagnosis will be denied.

External cause codes must not be reported as the principal diagnosis unless permitted by state guidance.

Services dated after the discharge date range will be denied.

Ensure service dates fall within the patient's admission/discharge span.

State exceptions and special billing instructions

State-specific submission requirements and exceptions (examples) that override or supplement general FL requirements.

KY example: Kentucky: Claims billing with external cause codes must be billed within field 72 on the UB-04 form or the electronic equivalent.

FL example: Florida: Statement covered dates must equal the sum of value codes 80 and 81.

MD example: Maryland: Inpatient admission date must be between the 'From' and 'Through' dates and cannot be more than 3 calendar days from the 'From' date, with exceptions for certain Type of Bill Frequency Codes.

MO example: Missouri: The statement from date cannot be before the admission date for inpatient claims.

Referenced Code Systems, Edits, and Digit Completeness

Referenced code systems and common edit triggersmixed

ICD-10-PCS / ICD-10-CM	Diagnosis and procedure coding systems referenced; mismatched or incorrect digit counts may cause denials.
CPT / HCPCS	CPT and HCPCS coding guidance referenced for definitional purposes.

Digit completeness (inv-05)

RequirementProcedure and/or diagnosis codes must contain the required number of digits; codes missing required digits can trigger claim denials or edits.

ConsequenceClaims with procedure or diagnosis codes that lack required digits will be denied or returned for correction.

Common triggersPolicy explicitly lists 'Procedure &/or diagnosis code requires additional digit(s)' as an edit that will cause denials.

Related editsMismatched ICD-10-PCS codes and use of E-code as primary diagnosis are listed alongside digit-completeness as denial triggers.

Submission Requirements and Applicability

Billing Rule

Claims submission and accuracy — include complete UB-04 form locator data

Submit accurate claims using the code(s) that correctly describe the services provided and include complete and valid UB-04 form locator (FL) data; if information submitted is missing, incomplete, or invalid, the claim will be denied.

Include required FLs such as Bill Type, Discharge Status, Principal diagnosis, Source of Admission, Condition code, Type of Admission, Patient age, and Patient gender.
Avoid common validation errors: age-to-procedure/diagnosis conflicts, gender-to-procedure/diagnosis conflicts, procedure/diagnosis codes missing required digits, use of E code as primary diagnosis, services outside discharge date range, and mismatched ICD-10-PCS codes.

Note

Applicability — UB-04/electronic equivalent for Community Plan Medicaid

This policy applies to services reported using the UB-04 form or its electronic equivalent for UnitedHealthcare Community Plan Medicaid products across all network and non‑network facilities.

Key Terms

UB-04 definition (inv-08)

Form nameUB-04 (CMS-1450)

PurposeUniform institutional billing form used by Medicare and many third-party payers for facility services billing.

GovernanceData elements and format determined by the National Uniform Billing Committee (NUBC) and CMS; FL requirements revised ongoing by NUBC.

UseForm and EDI format accommodate third-party payers and hospitals to promote uniform claim submission.

Form Locator (FL) (inv-09)

DefinitionForm Locator (FL): specific data field on the UB-04 (examples: Bill Type, Discharge Status, Principal diagnosis) required for claim adjudication.