UB04 Patient's Relation to Insured Code 20: Employee

Overview

Code 20 in UB-04 Field 59 (Patient Relationship to Insured) signifies that the patient is an Employee of the insured individual. This code is part of the standard set of relationship codes used by payers to identify how the patient is connected to the policyholder. According to the Novitas Solutions UB-04 Form Locator, Field 59 includes codes such as 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 Field 59 is used to report the patient’s relationship to the insured, though it does not list specific code values ^[2]. Code 20 is distinct from family or dependent relationships; it applies only when the patient is an employee of the person or entity that holds the insurance policy. This code is commonly seen in employer-sponsored group health plans where the employee is covered under the employer’s policy but is not the policyholder (e.g., when the employer is the insured group and the employee is a covered member). Proper use of code 20 ensures accurate claims processing and correct application of benefits, deductibles, and coordination of benefits rules.

When to Use

Use code 20 in Field 59 when the patient receiving services is an employee of the insured individual or entity. The insured is typically the employer or the group policyholder, and the patient is a covered employee under that policy ^[1]. This scenario most often arises in employer-sponsored health plans where the employer is the named insured and the employee is a beneficiary. For example, if a company’s health plan covers its workers, each employee patient would be reported with code 20. Do not use code 20 for the employee’s spouse or children; those relationships require codes 01 (Spouse) or 19 (Child) respectively ^[1]. Similarly, if the patient is the policyholder themselves, code 18 (Self) should be used ^[1]. Code 20 is also inappropriate for retirees, former employees, or dependents of employees unless they are actively employed and covered under the employer’s policy. When the patient’s relationship is unknown, use code 21 (Unknown) ^[1]. Accurate use of code 20 is critical for payers to determine benefit eligibility, coordination of benefits, and correct application of employer-specific plan provisions. Providers should verify the patient’s employment status and the policyholder’s identity before selecting this code.

Step-by-Step Claim Example

Consider a scenario: ABC Manufacturing holds a group health insurance policy. John Smith is an employee of ABC Manufacturing and receives medical treatment at a hospital. The hospital submits a UB-04 claim for John Smith. In Field 59 (Patient Relationship to Insured), the biller must enter 20 to indicate that the patient is an employee of the insured (the employer) ^[1]. The insured’s name (ABC Manufacturing) is entered in Field 58 (Insured’s Name). The patient’s name (John Smith) is in Field 8a. The biller ensures that no other relationship code applies: John is not the insured himself (so not code 18), not a spouse (not code 01), not a child (not code 19), and not an organ donor (not code 39 or 40) ^[1]. The claim is then submitted with code 20 in Field 59. The payer processes the claim using the employer’s group number and verifies John’s eligibility as an employee. If John were also the policyholder (e.g., a sole proprietor), code 18 would be correct instead. This example illustrates the direct application of code 20 when the patient is an employee of the insured entity.

Common Mistakes & Audit Red Flags

Several errors can occur when using code 20, leading to claim denials or audits. A frequent mistake is using code 20 for a patient who is the insured themselves; the correct code in that case is 18 (Self) ^[1]. Another error is applying code 20 to a patient who is a spouse or child of an employee; those relationships require codes 01 or 19 respectively ^[1]. Using code 20 for retirees or former employees is also incorrect, as they are no longer active employees. Payers may flag claims where the patient’s relationship seems inconsistent with the insured’s name (e.g., same last name but code 20 instead of 01 or 19). Additionally, if the insured is an individual (not an employer), code 20 should rarely be used; it is primarily for group plans. Audit red flags include: frequent use of code 20 with no corresponding employer identification in Field 50 (Payer Name) or Field 58; claims where the patient’s age or employment status contradicts the code (e.g., a minor child coded as employee); and claims where code 20 is used alongside other relationship codes on the same claim. Providers should verify employment status and policyholder details before submitting code 20 to avoid unnecessary denials and compliance issues.

Related Codes/Fields

The following table lists other relationship codes available in UB-04 Field 59, as provided by Novitas Solutions ^[1]. These codes are used to indicate the patient’s connection to the insured individual.

Code	Meaning	Notes
01	Spouse	Patient is married to the insured.
18	Self	Patient is the insured individual.
19	Child	Patient is a child (natural, adopted, step, or foster) of the insured.
20	Employee	Patient is an employee of the insured (employer).
21	Unknown	Relationship is not known or not specified.
39	Organ Donor	Patient is an organ donor.
40	Cadaver Donor	Patient is a cadaver donor.
53	Life Partner	Patient is a domestic partner or life partner of the insured.
G8	Other Relationship	Any relationship not covered by the other codes.

These codes are used in Field 59 of the UB-04 claim form. The MassHealth UB-04 Billing Guide references Field 59 but does not list specific code values ^[2]. Providers should refer to payer-specific instructions for any additional codes or modifiers.

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References

[1] Novitas FL59 — https://www.novitas.com

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