HCFA-1500 Box 15 - Other Date

On the HCFA-1500 form, Box 15 is used to report another relevant date associated with the patient's condition or treatment. This could include the initial treatment date, the date of a prior similar illness, or other contextually important dates depending on the nature of the services rendered.

Tip: Enter the date in MMDDYYYY format and include a qualifier to specify the type of date being reported—such as the initial treatment date (454) or the date of acute manifestation of a chronic condition (453).

In our example below, we populated Box 15 with the date '03/05/2025' and used the qualifier '454', which indicates the initial treatment date.

So far, we've discussed how additional clinically relevant dates can be reported on the HCFA-1500 form. Now let’s look at how this information is represented in the X12 837 electronic format.

In the X12 837 transaction, Box 15 also maps to the DTP segment in the 2300 Claim Information Loop, using a different qualifier to indicate the specific nature of the date.

Key X12 837 Details:
  • DTP01: Date Qualifier (e.g., 454 for initial treatment date, 453 for acute manifestation of chronic condition, etc.)
  • DTP02: Date Format Qualifier (typically D8 for CCYYMMDD)
  • DTP03: Date Value (e.g., 20250305)

Sample 837P (5010/4010) – 2300 Claim Information

Note: Box 15 maps to the DTP segment in Loop 2300 of the 837 transaction. Qualifiers such as 454 (initial treatment) or 453 (acute manifestation of a chronic condition) are used based on the nature of the service.

Comparison: Box 14 reports the onset date of the current condition (e.g., illness, injury, pregnancy), while Box 15 is used to report other clinically relevant dates such as the initial treatment date. The two fields may contain different dates depending on the patient’s history.

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
• 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 [You are Here]
• 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