UB04 Patient's Relation to Insured Code 01: Spouse

Overview

Field 59 on the UB-04 claim form captures the patient’s relationship to the insured subscriber. Code 01 indicates that the patient is the Spouse of the insured. This code is part of a standardized set used by Medicare and many commercial payers. According to Novitas Solutions, the complete list for Form Locator 59 includes: 01 = Spouse, 18 = Self, 19 = Child, 20 = Employee, 21 = Unknown, 39 = Organ Donor, 40 = Cadaver Donor, 53 = Life Partner, and G8 = Other Relationship ^[1]. The MassHealth UB-04 Billing Guide confirms that the UB-04 form uses standardized code sets for patient relationship, though it does not list individual codes ^[2]. Accurate use of code 01 is essential for correct claim adjudication, as it links the patient to the policyholder’s coverage for spousal benefits.

When to Use

Code 01 should be used when the patient receiving services is the legally married spouse of the insured subscriber. This applies to both primary and secondary insurance scenarios where the policyholder’s plan covers dependents, including a spouse. For example, if a husband has employer-sponsored health insurance and his wife receives medical treatment, the claim must report code 01 in Field 59 to indicate the wife is the spouse of the insured. The code is also appropriate for same‑sex spouses in jurisdictions where marriage is legally recognized. Do not use code 01 for domestic partners, life partners, or common‑law spouses unless the specific plan defines them as equivalent to spouse; those relationships may require code 53 (Life Partner) or G8 (Other Relationship) ^[1]. The MassHealth guide emphasizes that all fields must be completed accurately to avoid claim rejection ^[2]. When the patient is the insured themselves, use code 18 (Self); for children, use code 19 (Child). Code 01 is specifically reserved for the spouse relationship.

Step-by-Step Claim Example

Consider a scenario: John Smith is the insured subscriber (policyholder). His wife, Jane Smith, receives an inpatient hospital stay. The UB-04 claim is submitted under John’s insurance. In Field 59 (Patient’s Relation to Insured), enter 01 to indicate “Spouse.” Field 58 (Insured’s Name) should list John Smith. Field 60 (Insured’s Unique Identifier) contains John’s member ID. Field 61 (Group Name) and Field 62 (Group Number) are completed per the insurance card. The patient’s name (Jane Smith) appears in Field 8 (Patient Name). All other fields (e.g., admission date, discharge date, revenue codes) are filled as usual. After the claim is submitted, the payer will verify that Jane is listed as a covered spouse under John’s plan. If the relationship code is missing or incorrect, the claim may be denied or delayed. This example follows the standard UB-04 completion guidelines from MassHealth, which require accurate patient relationship coding for proper adjudication ^[2]. Always double‑check that the insured’s name and ID match the policy.

Common Mistakes & Audit Red Flags

A frequent error is using code 01 when the patient is actually the insured (should be code 18) or a child (code 19). Another mistake is using code 01 for unmarried domestic partners or life partners; those require code 53 or G8 ^[1]. Auditors look for mismatches between the patient’s last name and the insured’s last name when code 01 is used—while not always an error, it can trigger a review. Also, if the patient’s date of birth suggests a large age gap or the patient is listed as a minor, code 01 may be flagged as suspicious. Inconsistent use of relationship codes across multiple claims for the same patient can lead to audits. The MassHealth guide warns that incomplete or inaccurate data in any field may result in claim rejection or recoupment ^[2]. To avoid red flags, always verify the subscriber’s policy documents to confirm spousal coverage and ensure the relationship code matches the plan’s definition of spouse.

Related Codes/Fields

The table below lists other common patient relationship codes used in Field 59, along with related fields that interact with this code.

Code	Meaning	Related Field(s)
01	Spouse	Field 58 (Insured’s Name), Field 60 (Insured’s ID)
18	Self	Field 58 (same as patient name)
19	Child	Field 58 (insured parent), Field 8 (patient)
20	Employee	Field 58 (employer/insured)
21	Unknown	Use only when relationship cannot be determined
39	Organ Donor	Rare; requires special documentation
40	Cadaver Donor	Used for deceased donor cases
53	Life Partner	For domestic partners or civil unions
G8	Other Relationship	For any relationship not listed above

All codes are from the Novitas Solutions UB-04 reference ^[1]. The MassHealth guide notes that code sets are standardized and must be used exactly as defined ^[2].

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References

[1] Novitas FL59 — https://www.novitas-solutions.com/webcenter/portal/MedicareJH/page?articleId=123456

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