CurrentUnitedHealthcarePolicy N/A

UB-04 (UBO4) facility claim form reimbursement guidelines

Governs how UnitedHealthcare Individual Exchange reimburses facility outpatient claims billed on the UB-04 (UBO4/CMS-1450) form or electronic equivalent for Individual Exchange products; affects outpatient facilities including ASCs and other outpatient surgical centers submitting UB-04 claims.

Policy Summary

PayerUnitedHealthcare

PolicyUB-04 (UBO4) facility claim form reimbursement guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate UB-04 (UBO4/CMS-1450) claims with complete and valid Form Locator data to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

nationalgeographic applicability

UB-04 FLstopics addressed

enumerateddenial triggers

MCE/NUBCexternal sources

UB-04 Reimbursement Criteria

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Applies to UnitedHealthcare Individual Exchange products for services reported using the UB-04 (UBO4/CMS-1450) claim form or electronic equivalent; applies to all network and non-network outpatient facility claims including Ambulatory Surgical Centers (ASC) and Outpatient Surgical Centers (OSC).

Claims must include valid UB-04 Form Locator (FL) data; missing, incomplete, or invalid FL information will result in denial.

Examples of required UB-04 fields include discharge status, bill type, principal diagnosis, source of admission, condition code, type of admission, patient gender, and patient age.

Claims with incorrect UB-04 information that may cause denial include, but are not limited to: gender-to-procedure or diagnosis conflicts; age-to-procedure or diagnosis conflicts; procedure or diagnosis codes requiring additional digit(s); services provided after the discharge date; use of an E-code as a primary diagnosis; and mismatched ICD-10-PCS codes.

Providers should follow applicable facility edit sources (e.g., NUBC-determined FLs and industry/CMS edits) when preparing UB-04 submissions.

Referenced Code Sets, Edits, and Claim Completeness

Referenced code sets and editsmixed

ICD-10-PCS	Procedure coding system referenced for UB-04 mismatch checks
ICD-10-CM	Diagnosis coding referenced (including E codes not allowed as primary)
CPT	CPT referenced for definitional purposes

External edit sourcesmixed

CMS Medical Code Edits (MCE)	External source of facility edits used for adjudication
NUBC	National Uniform Billing Committee - UB-04 form locators and requirements
OptumInsight UB Editor	Editing tool referenced for facility claim validation

Claim completeness — denial conditions

Claim denial for missing/incomplete/invalid UB-04 fieldsClaims with missing, incomplete, or invalid UB-04 Form Locator (FL) data will be denied.

Examples of FLs that may trigger denialDischarge status; Bill type; Principal diagnosis; Source of admission; Condition code; Type of admission; Patient gender; Patient age.

Additional denial scenariosGender-to-procedure or diagnosis conflict; Age-to-procedure or diagnosis conflict; Procedure or diagnosis codes requiring additional digits; Services after the discharge date; Use of an E-code as primary diagnosis; Mismatched ICD-10-PCS codes.

Provider Claim Submission Responsibilities

Documentation Required

Submit complete and accurate UB-04 (CMS-1450) claims

Submit accurate UB-04 (UBO4/CMS-1450) claims with complete and valid Form Locator (FL) data; missing, incomplete, or invalid UB-04 field information may result in claim denial.

Ensure required FLs are populated (examples: discharge status, bill type, principal diagnosis, source of admission, condition code, type of admission, patient gender, patient age).
Avoid common errors that cause denials such as gender-to-procedure/diagnosis conflicts, age-to-procedure/diagnosis conflicts, use of an E-code as the primary diagnosis, services dated after discharge, and mismatched ICD-10-PCS codes.

Form and Locator Definitions

Uniform bill and required form locators (FLs)

Uniform bill formUB-04 (CMS-1450) — the uniform bill used for facility services billing.

Form locator (FL) authorityUB-04 data elements and design are determined by the National Uniform Billing Committee (NUBC); FLs are required data elements for Medicare billing.

Use and flexibilityThe UB-04 form and EDI format accommodate most third-party payers and hospitals and include unassigned codes/spaces for future reporting and payer-specific requirements.

Claims with missing, incomplete, or invalid FL data elements

Denial triggers — specific FLsDischarge status; Bill type; Principal diagnosis; Source of admission; Condition code; Type of admission; Patient gender; Patient age — missing, incomplete, or invalid entries may result in denial.

Coding/edit conflicts that cause denialGender-to-procedure/diagnosis conflict; Age-to-procedure/diagnosis conflict; Procedure/diagnosis requiring additional digits; Use of E-code as primary diagnosis; Mismatched ICD-10-PCS codes.

Scope of fields listedThe policy lists these fields and scenarios as examples and notes the list is not exhaustive — other incorrect required information may also cause denials.