HCFA-1500 Box 10 - Is Patient's Condition Related To

On the HCFA-1500 form, Boxes 10a, 10b, and 10c are used to indicate whether the patient’s condition is related to specific types of incidents: employment, auto accident, or another type of accident. These fields help determine whether another entity (such as a workers' compensation or auto insurance carrier) may be responsible for paying the claim.

These boxes are typically marked “Yes” or “No” by checking the corresponding field:

• Box 10a: Is the patient's condition related to employment (current or previous)?
• Box 10b: Is the patient's condition related to an auto accident? (If marked Yes, a 2-letter state code must also be provided.)
• Box 10c: Is the patient's condition related to another accident?

In our example below, Box 10a is checked “Yes” to indicate the condition is employment-related, while Boxes 10b and 10c are marked “No.”

The information from Boxes 10a–10c is represented in the X12 837 format in the CLM11 composite data element of the 2300 CLM (Claim Information) segment.

• CLM11-1: First “Yes” condition from Box 10a, 10b, or 10c
• CLM11-2: Second “Yes” condition from Box 10a, 10b, or 10c (if applicable)
• CLM11-3: Third “Yes” condition from Box 10a, 10b, or 10c (if applicable)
• CLM11-4: 2-character state code for Box 10b (auto accident), if marked “Yes”

Important: The order of CLM11-1 through CLM11-3 reflects the sequence in which Boxes 10a–10c are marked “Yes.” If only one box is marked, only CLM11-1 is sent. If two boxes are marked, CLM11-1 and CLM11-2 are sent, and so on.

Each “Yes” response is translated to a qualifier code as defined in the X12 837 standard:

• EM = Employment related
• AA = Auto accident
• OA = Other accident
• AB = 4010 only: Abuse
• AP = 4010 only: Another Party Responsible

Sample 837P (5010 ONLY) - 2300 - Claim Information

Note: HCFA-1500 Boxes 10a, 10b, and 10c map to the CLM11 composite data element in Loop 2300 of the X12 837 format. The first, second, and third indicators correspond to CLM11-1, CLM11-2, and CLM11-3 depending on how many boxes are checked “Yes.” If Box 10b is marked “Yes,” the state code is reported in CLM11-4.

For additional information on the X12 837 standard, please refer to the official implementation guides published by X12.

HCFA-1500 Form Box Locations

• HCFA-1500 Box 0 - Carrier Block
• HCFA-1500 Box 1 - Insurance Type
• HCFA-1500 Box 1a - Insured's ID Number
• HCFA-1500 Box 2 - Patient's Name
• HCFA-1500 Box 3 - Patient's Birth Date and Sex
• HCFA-1500 Box 4 - Insured's Name
• HCFA-1500 Box 5 - Patient's Address
• HCFA-1500 Box 6 - Patient Relationship to Insured
• HCFA-1500 Box 7 - Insured's Address
• HCFA-1500 Box 8 - Reserved For NUCC Use
• HCFA-1500 Box 9 - Other Insured's Name
• HCFA-1500 Box 9a - Other Insured's Policy or Group Number
• HCFA-1500 Box 9b - Reserved For NUCC Use
• HCFA-1500 Box 9c - Reserved For NUCC Use
• HCFA-1500 Box 9d - Insurance Plan Name or Program Name
• HCFA-1500 Box 10 - Is Patient's Condition Related To [You are Here]
• HCFA-1500 Box 10d - Claim Codes
• HCFA-1500 Box 11 - Insured's Policy Group or FECA Number
• HCFA-1500 Box 11a - Insured's Date of Birth and Sex
• HCFA-1500 Box 11b - Other Claim ID
• HCFA-1500 Box 11c - Insurance Plan Name or Program Name
• HCFA-1500 Box 11d - Is There Another Health Plan
• HCFA-1500 Box 12 - Patient's or Authorized Person's Signature
• HCFA-1500 Box 13 - Insured's or Authorized Person's Signature
• HCFA-1500 Box 14 - Date of Current Illness, Injury, Pregnancy (LMP)
• HCFA-1500 Box 15 - Other Date
• HCFA-1500 Box 16 - Dates Patient Unable to Work in Current Occupation
• HCFA-1500 Box 17 - Name of Referring Provider or Other Source
• HCFA-1500 Box 17a - Other ID
• HCFA-1500 Box 17b - NPI
• HCFA-1500 Box 18 - Hospitalization Dates Related to Current Services
• HCFA-1500 Box 19 - Additional Claim Information
• HCFA-1500 Box 20 - Outside Lab Charges

Grab a sample of the HCFA-1500 claim form here - HCFA 02/12 Claim Form