CurrentUnitedHealthcarePolicy 2025F7007A

UB-04 (CMS-1450) facility claim form billing and edits

This policy governs completion and validation of UB-04 (CMS-1450) claim form locators for UnitedHealthcare Individual Exchange products and applies to outpatient facility claims, ASCs, and related outpatient surgical centers for both network and non-network facilities.

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 (CMS-1450) facility claim form billing and edits

Policy CodePolicy 2025F7007A

Change TypeNon-material revisions to reimbursement guidelinestemplate updates

Effective Date

Next Review Date

Key ActionSubmit complete and valid UB-04 form locators; missing, incomplete, or invalid information may result in claim denial.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Guidelines updated

Updated Application Language & Logo Updated in Template.

UB04form covered

Individual Exchangeproduct applicability

Outpatient, ASC, OSCfacility types

Claim denieddenial consequence

UB-04 Claim Validation Criteria

Claims must include valid, complete UB-04 form locators. The following issues will cause denials or edits:

ALL of the following

Missing or invalid UB-04 fields
- Missing, incomplete, or invalid form locator information => claim denial
- Bill Type
- Discharge Status
- Principal diagnosis

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 (CMS-1450) facility claim form billing and edits

Policy CodePolicy 2025F7007A

Change TypeNon-material revisions to reimbursement guidelinestemplate updates

Effective Date

Next Review Date

Key ActionSubmit complete and valid UB-04 form locators; missing, incomplete, or invalid information may result in claim denial.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Required Fields

Claim coding issues referencedmixed

ICD-10-PCS	Procedure coding system; mismatched codes may cause denials
E-code	Use of E code as primary diagnosis is not allowed

Required UB-04 fields — Claim validation (high priority)

Bill TypeRequired UB-04 field; missing or invalid Bill Type may cause claim denial

Discharge StatusRequired UB-04 field; incorrect Discharge Status may cause claim denial

Principal diagnosisRequired UB-04 field; use of an E code as primary diagnosis is not allowed and may cause denial

Source of AdmissionRequired UB-04 field; missing or invalid Source of Admission may cause claim denial

Condition codeRequired UB-04 field; incorrect Condition code may cause claim denial

Type of AdmissionRequired UB-04 field; missing or invalid Type of Admission may cause claim denial

Patient age and genderRequired UB-04 fields; age-to-procedure/diagnosis or gender-to-procedure/diagnosis conflicts will cause denials

Submission and Billing Actions

Documentation Required

UB-04 submission requirements

Submit complete and valid UB-04 (CMS-1450) form locators. If any required Form Locator information is missing, incomplete, or invalid, the claim will be denied.

Required fields include Bill Type; Discharge Status; Principal diagnosis; Source of Admission; Condition code; Type of Admission; Patient age; Patient gender.
Other errors that may cause denials: age-to-procedure or age-to-diagnosis conflicts; gender-to-procedure or gender-to-diagnosis conflicts; procedure/diagnosis codes requiring additional digits; use of an E code as the primary diagnosis; services billed after the discharge date range; mismatched ICD-10-PCS codes.

Key Terms

UB-04 (CMS-1450)

Uniform bill nameUB-04 (CMS-1450) — standard facility billing form used by Medicare and many major third-party payers

Form purposeUsed for billing facility services including outpatient facility, ASC, and related outpatient surgical centers

Form flexibilityForm and EDI format are flexible to accommodate third-party payers and hospitals

National Uniform Billing Committee (NUBC)

Determining bodyNational Uniform Billing Committee (NUBC) — determines data elements and design of UB-04 billing formats

Stakeholder requestsNUBC acts at the request of CMS, state uniform billing committees (SUBC), provider and payer associations

Maintenance roleNUBC revises Form Locator requirements, revenue codes and subcategory codes on an ongoing basis