UB04 Condition Codes Code 67: Special Requirement Indicator (State Specific)

Overview

Condition Code 67 on the UB‑04 claim form (located in Form Locators 18–28) carries two distinct meanings depending on the payer jurisdiction. Neither the Noridian list nor the MassHealth UB‑04 billing guide explicitly define this state‑specific meaning in the provided excerpts ^[1]. Therefore, providers should consult their individual state’s billing manual or health plan companion guide to confirm whether Code 67 is required for special certifications, waivers, or program‑specific reporting. Using Code 67 incorrectly can lead to claim denials or payer rejections.

When to Use

Use Condition Code 67 only when directed by a specific state Medicaid agency or commercial payer instruction. For Medicare Part A claims, Code 67 is used exclusively when a beneficiary has elected not to use LTR days during a qualifying inpatient stay—this election must be documented in the medical record and communicated to the provider ^[2]. Because the MassHealth UB‑04 guide does not list Code 67 in its condition code appendix, providers must obtain the most current state billing instructions or contact the agency directly ^[1]. Always verify the code’s applicability before submission.

Step-by-Step Claim Example

Scenario: A Massachusetts acute care hospital submits a UB‑04 claim for a Medicaid patient who is receiving a High‑Cost Therapy that requires a state‑issued “Special Requirement” certification.
2. Document the special requirement: A copy of the state certification notice is attached to the paper claim (or electronically linked).
3. Enter Code 67: On the UB‑04, in Form Locator 18 (Condition Codes), enter “67” as the first condition code. If other condition codes apply (e.g., Code 03 for other insurance), they follow in sequential order.
4. Complete other fields: Ensure all required patient, provider, and service line data are accurate.
5. Submit the claim: Mail to the MassHealth address or submit electronically under the waiver.
6. Follow up: Monitor remittance advice; Code 67 may trigger a special review processing delay but should not cause a denial if properly supported.

This example assumes state‑specific instruction; however, if the same claim were submitted to Medicare, Code 67 would be inappropriate for a therapy service—Medicare’s definition applies only to LTR days ^[2].

Common Mistakes & Audit Red Flags

• Using Code 67 instead of the correct Medicare code: If a Medicare beneficiary elects not to use LTR days, do not substitute any other code; Code 67 must be used exactly as defined. Misuse can trigger Medicare audit adjustment ^[2].
• Applying Code 67 without state authorization: Because MassHealth and other state plans do not publicly define Code 67 in the standard guide, using it without written confirmation from the payer is a red flag. Auditors will look for a supporting document (e.g., state approval letter, prior authorization number) ^[1].
• Omitting documentation: Condition Code 67 alone does not justify payment; the medical record must contain the “Special Requirement” notice or certification. Missing documentation can lead to recoupment.
• Conflicting use with other codes: Do not combine Code 67 with codes that indicate a different beneficiary election (e.g., Code 68 – Beneficiary elects to use LTR days) on the same claim. Noridian notes that Code 67 and 68 are mutually exclusive ^[2].
• Failing to update payer guidelines: State‑specific definitions can change; always consult the latest provider bulletin. The provided MassHealth guide is dated February 2021 and may not reflect current policy ^[1].

Related Codes/Fields

The following table lists condition codes often used alongside or in contrast to Code 67. These codes may appear in Form Locators 18–28.

Code	Meaning (Standard Medicare / State‑Specific)	Source
66	Operating cost outlier not reported by provider (payer only)	[2]
67	Special Requirement Indicator (state‑specific) / Beneficiary elects not to use LTR days (Medicare)	Combined from [2] and state guidance
68	Beneficiary elects to use LTR days (Medicare)	[2]
69	IME/DGME/N&AH payment only billing	[2]
01	Military service related; coordinate with VA	[2]
03	Patient covered by insurance not reflected here	[2]
21	Billing for denial notice	[2]

Note: The full list of condition codes is maintained by CMS and state agencies. Providers should always verify each code’s approved use with the applicable payer.

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References

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

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