HCFA-1500 Box 17a - Other ID

On the HCFA-1500 form, Box 17a is used to report the referring, ordering, or supervising provider’s non-NPI identifier when required by a payer. This field sits above Box 17b and must include a qualifier followed by the appropriate ID number.

Tip: Use the correct qualifier in the shaded portion of Box 17a, followed by the provider's secondary ID. Do not use an NPI here—that goes in Box 17b. Common qualifiers include:

• 0B – State License Number
• 1G – Provider UPIN Number
• G2 – Provider Commercial Number
• LU – Location Number
• SY – Social Security Number
• ZZ – Mutually Defined Identifier

Note that not all payers accept all qualifiers. For example, G2 is commonly used but may be disallowed by some commercial payers.

In our example below, we used 'G2' as the qualifier and '54321' as the provider's commercial number.

In the X12 837 electronic claim, this data appears in the REF segment within the appropriate provider loop—typically alongside the NM1 segment for that provider.

• 2310A – Referring Provider
• 2420E – Ordering Provider
• 2310D – Supervising Provider

Key X12 837 Details:
  • REF01: Reference ID Qualifier (e.g., G2)
  • REF02: Provider Secondary Identifier (e.g., 54321)

Sample 837P (5010/4010) – 2310A Referring Provider

Note: Box 17a should only be used if a payer requires a secondary ID. The qualifier must match the type of ID being reported. This data is transmitted in the REF segment alongside the provider loop (2310A, 2420E, or 2310D).

Important: Not all payers require Box 17a. Always consult the X12 implementation guides and the payer-specific companion guides for detailed requirements regarding secondary identifiers.

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
• HCFA-1500 Box 17 - Name of Referring Provider or Other Source
• HCFA-1500 Box 17a - Other ID [You are Here]
• 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