UB04 Condition Codes Code 03: Patient Covered by Insurance Not Reflected Here

Overview

Condition code 03 is defined as “Patient is covered by an insurance not reflected here” ^[1]. This code is used on the UB-04 claim form to signal that the patient has health insurance coverage that is not already listed in the other insurance fields of the claim, such as the primary payer information or value code entries ^[1]. Condition code 03 exists within a broader set of codes intended to communicate special circumstances about a patient’s coverage or billing situation ^[1]. Providers should consult their specific payer contracts and billing manuals, such as the MassHealth UB-04 guide, to confirm acceptance and proper usage ^[2].

When to Use

Condition code 03 should be used when the patient has insurance coverage that is not already reflected elsewhere on the UB-04 claim form ^[1]. Another common use is when a patient indicates they have coverage from a source such as a union plan, a specific commercial policy, or a state program that is not captured in the claim’s other insurance segments ^[1]. The code is distinct from other condition codes that address specific insurance types, such as workers’ compensation (code 02) or military service (code 01) ^[1]. Providers should apply code 03 only when the insurance in question is genuinely not represented elsewhere on the claim; using it to duplicate coverage already listed would be incorrect ^[1]. The MassHealth UB-04 guide emphasizes the importance of accurately reporting third-party liability to prevent overpayment and ensure correct coordination of benefits ^[2]. Therefore, when a patient discloses an insurance policy that is not already entered in fields such as Form Locators 50–66 or 39–41, condition code 03 should be appended ^[2]. It is also appropriate to use this code when billing a secondary payer and the primary payer information is present but the secondary coverage is not detailed elsewhere ^[1]. In summary, condition code 03 acts as a catch‑all indicator that additional insurance exists beyond what is shown in the claim’s standard insurance fields ^[1].

Step-by-Step Claim Example

Consider a patient who has Medicare Part A as primary coverage and also carries a private supplemental policy from a commercial insurer that the provider has not yet added to the claim’s payer hierarchy ^[1]. The billing staff complete the UB-04 form with Medicare entered in the primary payer field (e.g., Form Locator 50). No secondary payer information is provided because the hospital does not have the commercial policy on file ^[1]. During the patient registration interview, the patient mentions they have a secondary plan from ABC Insurance. The staff record this note but do not yet have the payer ID or group number to complete Form Locator 51 (secondary payer) ^[1]. To document the existence of this unreported coverage, the billing team enters condition code 03 in the Condition Code field (Form Locator 18–28) ^[1]. They do not enter code 02 (workers’ compensation) or code 01 (military) because those do not apply ^[1]. The claim is submitted with condition code 03, alerting the payer that the patient has insurance that is not reflected in the claim’s other insurance fields ^[1]. Upon receipt, the payer notes the condition code and may request additional information from the provider or coordinate benefits with the unreported plan ^[2]. The provider then follows up by obtaining the secondary payer details and submits a corrected claim or a secondary billing after receipt of the primary payment ^[2]. This example illustrates how condition code 03 serves as a temporary flag when insurance information is incomplete but known, helping avoid premature denial or loss of reimbursement ^[1].

Common Mistakes & Audit Red Flags

One frequent mistake is using condition code 03 when the patient’s additional insurance is actually already reflected on the claim in another field, such as a secondary payer entry or a value code indicating other coverage ^[1]. This duplication can cause confusion and lead to claim rejections or requests for clarification from the payer ^[1]. Another error is substituting code 03 for more specific codes, such as using it for workers’ compensation cases (code 02) or military‑related situations (code 01) ^[1]. Medicare and other payers expect the most precise condition code to be reported; using a generic code like 03 when a more specific code exists can trigger audits and recoupments ^[1]. Providers also sometimes omit condition code 03 entirely when the patient has an unreported policy, resulting in the claim being processed without coordination of benefits ^[1]. This omission can lead to overpayment by the primary payer, which may later be identified during a routine audit and require refunds ^[1]. Similarly, using code 03 for a patient who denies having any other insurance but later is found to have coverage can be flagged as a billing integrity issue ^[1]. The MassHealth UB-04 guide stresses the importance of accurate third-party liability reporting, and failure to adhere to these standards can result in claim denials and payment adjustments ^[2]. To avoid red flags, billing staff should always verify any reported insurance during patient intake and carefully compare the claim’s insurance fields against the condition codes entered ^[1]. Regular internal audits of claims with condition code 03 can help identify patterns of misuse, such as applying the code to all claims with any secondary insurance instead of only when the insurance is not reflected elsewhere ^[1]. Finally, providers should note that some payers may require supporting documentation or a note in the remarks field when using condition code 03, and omission of such documentation can be a red flag during post‑payment review ^[1].

Related Codes/Fields

The table below lists condition codes from the Noridian set that are closely related to insurance coverage and coordination of benefits. These codes may be used in similar situations or as alternatives to code 03.

Code	Meaning	Source
01	Military service related; coordinate with the Department of Veterans Affairs (VA).	[1]
02	Patient alleges the medical condition or injury causing this episode of care is due to the employment environment or events (e.g., workers compensation, black lung).	[1]
03	Patient is covered by an insurance not reflected here.	[1]
04	Bill is submitted for informational purposes only.	[1]
05	Lien has been filed.	[1]
06	ESRD patient in the first 30 months of entitlement covered by employer group health insurance.	[1]
07	Treatment of a non‑terminal condition for a hospice patient.	[1]
08	Beneficiary would not provide information concerning other insurance coverage.	[1]
09	Neither the patient nor the spouse is employed.	[1]
10	Patient and/or spouse is employed but no EGHP coverage exists.	[1]
28	Patients and/or spouses EGHP is secondary to Medicare.	[1]
29	Disabled beneficiary and/or family members LGHP is secondary to Medicare.	[1]

These codes are all found in the same condition code list provided by Noridian and are relevant when dealing with multiple payers, special coverage situations, or patient‑provided insurance information ^[1]. The MassHealth UB-04 guide also references the use of code sets on the UB-04, confirming that condition codes form an integral part of claim submission ^[2].

---

References

[1] Noridian Condition Codes — https://med.noridianmedicare.com/web/jea/topics/claim-submission/condition-codes

[2] MassHealth UB-04 Guide — https://www.mass.gov/doc/ub-04-billing-guide-0/download