HCFA-1500 Box 11b - Other Claim ID

On the HCFA-1500 form, Box 11b is designated for the “Other Claim ID.” This field is typically used to report a claim number assigned by a payer such as Workers’ Compensation or other liability insurers. It helps identify prior claims or associated cases.

Tip: If applicable, enter the prior claim ID assigned by the carrier, such as a Workers’ Compensation claim number. This field is often required when the claim is related to an accident or injury handled by another insurer.

In our example below, we populated Box 11b with the ID '112233'.

Visual Note: Box 11b includes a vertical bar separator. When applicable, a two-character qualifier (such as “Y4”) may appear to the left of the bar, while the claim number itself is entered to the right. This format is commonly used by some payers to indicate the type of reference ID being provided.

So far, we've discussed how the Other Claim ID is 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 11b maps to the REF segment in the 2010BA Subscriber Information Loop. The REF01 element identifies the reference type, and REF02 carries the Other Claim ID value.

The example below illustrates how Box 11b maps to the 837 5010 and 4010 formats, specifically within Loop 2010BA:

5010 & 4010 Versions:
  REF01 (Reference Identification Qualifier): 'Y4' for Agency Claim Number
  REF02 (Other Claim ID – for example, Workers’ Compensation or Property Casualty Claim Number): '112233'

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

Note: HCFA Box 11b maps to the REF segment in Loop 2010BA of the X12 837 format using qualifier Y4. This is most commonly used for Workers’ Compensation or other liability programs that assign a separate claim number.

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
• HCFA-1500 Box 11b - Other Claim ID [You are Here]
• 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