UB04 Assignment of Benefit Certification Code Y: Yes, the provider has a signed form on file authorizing the release of information and assignment of benefits.

Overview

This field is maintained as part of the National Uniform Billing Committee (NUBC) code set, which is referenced by Medicare contractors for processing institutional claims ^[1]. The UB-04 form, also known as Form CMS-1450, is designed for uniform billing across multiple third-party payers, and each payer may define its own requirements for this field ^[1]. MassHealth also provides instructions for completing the UB-04, including the code sets used in each field ^[2].

When to Use

The code is applicable for all claim types—inpatient, outpatient, and other institutional services—when the provider will bill for assigned benefits. If the provider does not have a signed authorization on file, a different code (such as “N”) must be used. Using “Y” without a signed form is a compliance risk and may result in claim denial or recoupment.

Step-by-Step Claim Example

A hospital submits a paper UB-04 claim for a Medicare inpatient stay. The provider has already obtained a signed Medicare Assignment of Benefits form from the patient at admission.

Step 1: Locate Field 53 on the UB-04 form (labeled “Assignment of Benefit Certification” in some versions). The field accepts a single alphanumeric code.
Step 2: Verify that the signed form is present in the patient’s record. The form must authorize both release of information and assignment of benefits.
Step 3: Enter the code “Y” in Field 53. No other characters or spaces should be included.
Step 4: Complete the remaining form locators according to Medicare instructions (e.g., FL04 Type of Bill, FL06 Statement Covers Period, FL08 Patient Name, etc.). The A/B MAC processes the claim as described in CMS guidance ^[1].
Step 5: Retain the provider copy of the form and the signed authorization in the patient’s record for audit purposes. The signed form must be available upon request by the Medicare Administrative Contractor (MAC) or MassHealth ^[2].

Common Mistakes & Audit Red Flags

• Missing Signed Form: Entering code “Y” when no signed assignment/authorization is on file. This is a frequent cause of overpayment recoveries and can trigger fraud audits. Medicare requires that the provider maintain the signed form in its records ^[1].
• Using Code “Y” for Non-Assigned Claims: Providers sometimes mistakenly use “Y” when the patient has not assigned benefits. The code should only be used when assignment of benefits and release of information are both authorized.
• Inconsistent Documentation: The patient’s signature must clearly authorize both the release of information and the assignment of benefits. A general consent for treatment does not suffice.
• Paper Claim Errors: On paper UB-04 forms, Field 53 is often misread or incorrectly transcribed due to poor handwriting. Use of a typed or printed code is recommended. MassHealth’s all-electronic claims policy means paper submissions require special approval, so the code must match the electronic equivalent ^[2].
• Audit Trails: A/B MACs are required to capture all NUBC-approved input data for audit trail purposes ^[1]. Any discrepancy between Field 53 and the provider’s records will be flagged during medical review or post-payment audit.

Related Codes/Fields

The table below lists codes and fields that interact with or are related to Field 53 on the UB-04 claim form.

Field / Code	Description	Source
Field 53 Code Y	Yes – signed form on file for release of information and assignment of benefits	[1] (NUBC coding referenced)
Field 53 Code N	No – provider does not have a signed authorization on file	[1]
Field 53 Code Blank	May be used when the field is not required by the payer; check specific payer guidance	[1]
Field 38 (Responsible Party Name/Address)	Identifies the party responsible for the bill; used in coordination with assignment of benefits	[1]
Field 39 (Value Codes/Amounts)	Captures dollar amounts related to patient responsibility and third‑party liability, which may be affected by assignment status	[1]
Field 50 (Payer Identification)	Identifies the primary payer; assignment of benefits is typically given to the payer listed here	[2]
Occurrence Code 50	Indicates date of assignment of benefits (used in some payer systems)	[1] (NUBC code)

Note: All codes and fields listed are based on the NUBC standards referenced by Medicare and adopted by MassHealth. For the most current list, providers should consult the official NUBC manual and payer‑specific instructions.

---

References

[1] CMS Chapter 25 — https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c25.pdf

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