CurrentUnitedHealthcarePolicy UB-04

REIMBURSEMENT POLICY UB-04

Governs completion and submission of UB-04 (CMS-1450) facility claims for UnitedHealthcare Community Plan Medicaid product, specifying required Patient Discharge Status codes and type-of-bill alignment for inpatient, outpatient, skilled nursing, hospice and home health claims.

Policy Summary

PayerUnitedHealthcare

PolicyREIMBURSEMENT POLICY UB-04

Policy CodePolicy UB-04

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionEnsure accurate UB-04 claim submission by assigning Patient Discharge Status codes that align with the type of bill (TOB); inconsistent pairings may result in claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

applies to UB-04claim form covered

4 categoriesclaim types listed

NUBC referencedbilling format authority

FL interimstate exception example

Coverage and Billing Applicability

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.

Coverage and billing criteria

Applicability and required coding associations for claims submitted on UB-04 forms.

Policy applies to UnitedHealthcare Community Plan Medicaid product and to services reported using the UB-04 form (or electronic equivalent/successor) for all products and all network and non-network facilities, including non-network authorized and percent-of-charge contract facilities.

Providers must assign a Patient Discharge Status code that aligns with the type of bill (TOB) submitted; UnitedHealthcare Community Plan will deny claims when the Patient Discharge Status is inconsistent with the TOB.

ALL of the following

Hospital Inpatient Claims (TOBs 11X and 12X)
Skilled Nursing Claims (TOBs 18X, 21X, 22X, 23X)
Outpatient Hospital Services (TOBs 13X, 14X, 71X, 73X, 74X, 76X, 85X)
Hospice and Home Health: All Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X, 82X)

Type of bill frequency (fourth digit of TOB) must align with the Patient Discharge Status: frequency codes indicating an ongoing stay (for example, interim bills) should be reported with a discharge status indicating the patient is still receiving care (e.g., status 30 where appropriate); final or discharge claims should reflect the patient’s disposition at the conclusion of the encounter or through date of the claim.

If multiple Patient Discharge Status codes apply, code the highest level of care known.

Example guidance: discharge status 30 (Still Patient) is not appropriate with a final inpatient nursing home admit-through-discharge claim (type of bill 211).

State exception (Florida): Per Florida state regulations, for inpatient stays greater than 100 days follow the interim billing sequence (TOB 112, then 113, then final 114) and replace/void previously billed claims as instructed.

Patient Discharge Status and Bill Frequency

Selected Patient Discharge Status codes and descriptionsmixed

01	Discharge to Home or Self Care / Hospice (codes 40-42; hospice claims only TOBs 81X & 82X)
02	Discharged/Transferred to Short-Term General Hospital / Federal Hospital (code 43)
03	Discharged/Transferred to Skilled Nursing Facility (SNF) with Medicare Certification (codes 44-49)
06	Discharged/Transferred to Home Under Home Health (code 61) / Hospital-based Medicare approved swing bed
07	Left Against Medical Advice or Discontinued Care (code 62)
30	Still Patient or Expected to Return for Outpatient Services (code 30)

(additional referenced codes in surrounding guidance)mixed

No codes listed

Bill frequency alignment

RequirementType of bill frequency (fourth digit) must align with Patient Discharge Status; frequency indicates submission sequence (e.g., interim vs final)

GuidanceA bill with a frequency reflective of an ongoing stay should use a discharge status indicating the patient is still receiving care (e.g., status 30)

Interim billsBill types ending in 2 (Interim First Claim) or 3 (Interim - Continuing Claim) should be reported with Patient Discharge Status 30 (Still Patient)

Final/Discharge claimsA bill type reflective of a discharge or final claim must be reported with the Patient Discharge Status that identifies where the patient is at the conclusion of the encounter or the through date of the claim

Denial riskUnitedHealthcare Community Plan will deny claims when Patient Discharge Status is inconsistent with the type of bill reported

Billing Responsibilities and State Exceptions

Denial Risk

Provider billing responsibilities and denial risk — ensure accurate UB-04 submission and alignment of Patient Discharge Status with type of bill

You are responsible for submitting accurate UB-04 (or electronic equivalent) claims. Ensure the Patient Discharge Status code aligns with the Type of Bill (TOB) frequency and the clinical status of the member. UnitedHealthcare Community Plan requires Patient Discharge Status codes for hospital inpatient claims (TOBs 11X and 12X), skilled nursing claims (TOBs 18X, 21X, 22X and 23X), outpatient hospital services (TOBs 13X, 14X, 71X, 73X, 74X, 76X and 85X), and all hospice and home health claims (TOBs 32X, 33X, 34X, 81X and 82X). The TOB fourth digit (frequency) must reflect whether the claim is an interim/ongoing stay or a final/discharge claim and therefore must align with an appropriate discharge status. When two or more discharge status codes could apply, code the highest level of care known. Claims with Patient Discharge Status codes inconsistent with the TOB will be denied.

Patient Discharge Status required for TOBs: 11X, 12X, 18X, 21X, 22X, 23X, 13X, 14X, 71X, 73X, 74X, 76X, 85X, 32X, 33X, 34X, 81X, 82X
Select discharge status that matches TOB frequency: ongoing stays -> statuses indicating patient still receiving care; final claims -> discharge status indicating patient disposition at claim through date
If multiple statuses apply, report the highest level of care known
Example denial risk: discharge status 30 (Still Patient) is not appropriate with TOB 211 (Inpatient Nursing Home: Admit through discharge claim)

Billing Rule

Florida state exception: interim claims for long stays — procedure for inpatient stays >100 days, TOB 112/113/114 interim billing sequence and replace/void process

Florida-specific interim claim procedure for inpatient stays exceeding 100 days. Follow the TOB sequencing and void/replace process described below. This applies to inpatient hospitals in Florida, excluding Statewide Inpatient Psychiatric Program (SIPP) and SNF providers.

First 100 days: use TOB 112 (first interim claim); Discharge Status must indicate the member is still inpatient; Admission date = original admission date through current billing date
Additional days after initial billing: use TOB 113 (continuing claim); Discharge Status must indicate the member is still inpatient; Admission date = original admission date through current billing date; include billed amounts from previously billed claims through current billing dates; previously billed claims must be voided and replaced with the subsequent claim
Final claim at discharge: use TOB 114 (discharge TOB); Discharge Status must reflect member has been discharged; Admission date = original admission date through discharge date; include billed amounts from all previously billed claims through discharge billing date; previously billed claims must be voided and replaced with the Final claim
Providers may bill outpatient TOBs 75X and 77X in addition to the outpatient TOBs listed in Reimbursement Guidelines where applicable

OpenPayer

REIMBURSEMENT POLICY UB-04

Coverage and Billing Applicability

Patient Discharge Status and Bill Frequency

Billing Responsibilities and State Exceptions

Key Definitions