HCFA-1500 Box 19 - Additional Claim Information

On the HCFA-1500 form, Box 19 is designated for "Additional Claim Information" and is used to report miscellaneous or situational details that don’t fit into other defined fields. It serves as a catch-all for payer-specific notes, clinical descriptions, provider information, and attachment references that may be required for proper claim adjudication.

Tip: Box 19 should only be populated when explicitly requested by a payer or required by situational rules. The content must be concise and comply with payer-specific formatting expectations.

Depending on the nature of the information, Box 19 content can map to one or more segments in the X12 837P 4010 or 5010 transaction. While the mapping logic is similar between versions, this example will focus on the 5010 implementation.

The most common mappings include:

• NTE*ADD – Additional claim-level notes (Loop 2300)
• PWK – Paperwork segment for attachments (Loop 2300)
• NM1 Segments – Referring, Rendering, or Supervising Provider (Loops 2310A, 2310B, 2310D)

Sample 837P (5010) – Box 19 Mappings

Explanation of Common Mappings:

• NTE*ADD – Use to transmit a free-text note about the service or situation.
• PWK – Indicates supplemental documentation such as operative reports or referrals, often referenced via Attachment Control Number.
• NM1*DN – Referring Provider (Loop 2310A, Qualifier DN)
• NM1*DQ – Supervising Provider (Loop 2310D, Qualifier DQ)

Important: There is no one-to-one mapping for Box 19. Instead, the claim content must be routed into the appropriate loop and segment depending on the payer's expectations and what the text in Box 19 represents.

Note: The content of Box 19 must be evaluated for proper mapping before submission. Incorrect usage may delay or deny claims.

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
• HCFA-1500 Box 17b - NPI
• HCFA-1500 Box 18 - Hospitalization Dates Related to Current Services
• HCFA-1500 Box 19 - Additional Claim Information [You are Here]
• HCFA-1500 Box 20 - Outside Lab Charges

Grab a sample of the HCFA-1500 claim form here - HCFA 02/12 Claim Form