UB04 Condition Codes Code 11: Disabled Beneficiary But No LGHP Coverage Exists

Overview

Condition code 11 is used on the UB-04 claim form to indicate a disabled beneficiary but no Large Group Health Plan (LGHP) coverage exists. The official meaning from the Noridian Condition Codes list is: “Disabled beneficiary but no LGHP” ^[1]. This code applies when a patient is entitled to Medicare due to disability (typically under age 65) and does not have any coverage under a large group health plan—meaning there is no employer-sponsored LGHP that would serve as primary payer. The code is part of a series of condition codes that address employment-based insurance coverage. For example, code 10 covers employed patients without EGHP, and code 29 covers disabled beneficiaries whose LGHP is secondary to Medicare ^[1] This code is essential for accurate coordination of benefits and helps prevent incorrect claims processinge., the patient has Medicare Part A and/or Part B due to meeting Social Security disability criteria); and (2) there is no large group health plan (LGHP) covering the beneficiary. The code is not to be used if the beneficiary has any LGHP coverage—even if that coverage is secondary to Medicare. In that situation, code 29 (“Disabled beneficiary and/or family members LGHP is secondary to Medicare”) should be used instead ^[1]. Likewise, code 10 (“Patient and/or spouse is employed but no EGHP coverage exists”) applies to non-disabled patients, not disabled beneficiaries. Code 11 is specifically reserved for disabled individualsg., code 29) may still be relevant. Proper use of code 11 ensures that the Medicare contractor correctly processes the claim as primary payer and avoids unnecessary development requests.

Step-by-Step Claim Example

Scenario: A 54‑year‑old patient is hospitalized for a knee replacement. The patient is entitled to Medicare Part A and Part B due to a disability (Social Security Disability Insurance). The patient is not employed and has no coverage under a large group health plan through any employer or family member. The provider bills a UB‑04 claim for the inpatient stay.

Steps:

1. Complete the header information (e.g., provider name, NPI, patient demographics).
2. In Form Locators 18–28 (Condition Codes), enter 11 in the first available condition code field (FL 18). No other LGHP-related condition code is needed because there is no LGHP. 3g., “Medicare Part A” with the appropriate payer ID). Since no other insurance is present, no secondary payer information is required.
3. In Form Locator 39 (Value Codes) and other applicable fields, report charges and patient liability as usual.

The claim should process with Medicare as primary, and no coordination of benefits issues should arise because condition code 11 clearly indicates the absence of a large group health plan. All other fields are completed according to standard UB‑04 instructions. The source for the code meaning and its appropriate use is the Noridian Condition Codes page ^[1].

Common Mistakes & Audit Red Flags

• Using code 11 when an LGHP exists – even as secondary payer: This is a frequent error. If the disabled beneficiary has an LGHP (e.g., through a spouse’s employer), code 29 must be used instead of code 11 ^[1]. Using code 11 in this situation can cause the claim to be rejected or processed incorrectly.
• Using code 11 for non‑disabled patients: The code is explicitly for disabled beneficiaries. For employed patients without employer group health coverage, code 10 is correct. Auditors will check coordination of benefits against patient entitlement information.
• Omitting code 11 when required: Failure to include code 11 for a disabled beneficiary with no LGHP may lead the payer to assume LGHP exists and either deny the claim or request additional information, delaying payment.
• Confusing code 11 with code 06: Code 06 is for ESRD patients in the first 30 months of entitlement covered by employer group health insurance—a completely different situation ^[1].
• Audit red flags: Medicare contractors often review claims for disabled beneficiaries for proper use of condition codes 11 and 29. Inconsistent use (e.g., using code 11 but also reporting a different primary payer) will trigger development and potential overpayment recovery. Providers should maintain documentation of the patient’s insurance status.

Related Codes/Fields

Code	Meaning	Source
10	Patient and/or spouse is employed but no EGHP coverage exists	[1]
11	Disabled beneficiary but no LGHP	[1]
29	Disabled beneficiary and/or family members LGHP is secondary to Medicare	[1]
06	ESRD patient in the first 30 months of entitlement covered by employer group health insurance	[1]
09	Neither the patient nor the spouse is employed	[1]

Field location: Condition codes are entered in UB‑04 Form Locators 18 through 28. Up to 10 condition codes can be reported, with code 11 typically placed in the first available field (FL 18) if it is the most applicable. Refer to the payer’s instructions for proper sequencing. The Noridian page confirms that these codes are used for Medicare Part A billing ^[1].

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References

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