HCFA-1500 Box 16 - Dates Patient Unable to Work in Current Occupation

On the HCFA-1500 form, Box 16 is used to report the dates during which the patient was unable to work in their current occupation due to illness or injury. If the patient is employed and unable to work, enter the date(s) reflecting that absence. An entry in this field may suggest that employment-related insurance coverage, such as Workers’ Compensation or employer disability benefits, could apply.

Tip: Enter the dates in MMDDYYYY format. If both a start and end date are known, include them. Otherwise, supply only the date that applies based on the patient's current disability status.

In our example below, we entered '05/02/2025' as the start date and '05/15/2025' as the end date.

In the X12 837 transaction, Box 16 maps to one of several DTP segments in the 2300 Claim Information Loop, depending on whether one or both dates are known:

• DTP*314 – Use when both start and end dates of disability are known. This segment uses format RD8 to represent a date range.
• DTP*360 – Use if the patient is currently disabled and only the start date is known.
• DTP*361 – Use if the patient is no longer disabled and only the end date is known.

Key X12 837 Details:
  • DTP01: Date Qualifier (314, 360, or 361)
  • DTP02: Date Format Qualifier (RD8 for ranges, D8 for single dates)
  • DTP03: Date or Date Range Value (e.g., 20250502-20250515)

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

Note: Use DTP*314 with RD8 format when both dates are available. Use DTP*360 (start only) or DTP*361 (end only) if only one date is known. These segments appear in Loop 2300 of the 837 transaction.

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
• HCFA-1500 Box 16 - Dates Patient Unable to Work in Current Occupation [You are Here]
• 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