HCFA-1500 Box 11a - Insured's Date of Birth and Sex

On the HCFA-1500 form, Box 11a is designated for the insured’s date of birth and sex. This field captures key demographic information about the insured individual and is used by payers to validate eligibility and coverage.

Tip: Enter the insured’s date of birth in MMDDYYYY format and mark the appropriate box for male or female.

In our example below, we populated Box 11a with the date '01/01/1980' and selected 'Male'.

So far, we've discussed how the insured’s date of birth and sex are captured on the HCFA-1500 form. Now let’s look at how this information is reported in the X12 837 electronic format.

In the X12 837 transaction, Box 11a maps to the DMG segment in the 2010BA Subscriber Demographic Information Loop. The DMG02 element represents the date of birth, and DMG03 represents the gender code.

The examples below illustrate how Box 11a maps to the 837 5010 and 4010 formats, specifically within Loop 2010BA:

5010 & 4010 Versions:
  DMG01 (Date Time Period Format Qualifier): 'D8' for CCYYMMDD format
  DMG02 (Subscriber Birth Date): '19800101'
  DMG03 (Subscriber Gender Code): 'M' for Male

Sample 837P (5010/4010) - 2010BA - Subscriber Demographic Information

Note: HCFA Box 11a maps to the DMG segment in Loop 2010BA of the X12 837 format. This segment is used when the insured is the subscriber or treated as the subscriber on the claim.

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
• 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 [You are Here]
• 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