HCFA-1500 Box 11c - Insurance Plan Name or Program Name

On the HCFA-1500 form, Box 11c is designated for the “Insurance Plan Name or Program Name.” This field is used to report the name of the insurance plan or program that covers the insured individual. It typically reflects the name of the group health plan, commercial insurer, or government program providing coverage.

Tip: Enter the official name of the insured’s health plan or program as it appears on the ID card, such as “BLUE CROSS BLUE SHIELD.” Some payers may use this field for routing or eligibility matching.

In our example below, we populated Box 11c with the name 'BLUE CROSS BLUE SHIELD'.

So far, we've discussed how the insurance plan name 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 11c maps to the SBR04 element in the 2000B Subscriber Information Loop. This element captures the name of the insurance plan or program covering the subscriber.

The example below illustrates how Box 11c maps to the 837 5010 and 4010 formats, specifically within Loop 2000B:

5010 & 4010 Versions:
  SBR04 (Subscriber/Insured Group Name): 'BLUE CROSS BLUE SHIELD'

Sample 837P (5010/4010) - 2000B - Subscriber Information

Note: HCFA Box 11c maps to the SBR04 data element in Loop 2000B of the X12 837 format. It carries the name of the insurance plan that provides coverage for the insured individual. This value is used by payers for validation, routing, and matching eligibility.

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
• HCFA-1500 Box 11c - Insurance Plan Name or Program Name [You are Here]
• 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