HCFA-1500 Box 20 - Outside Lab Charges

On the HCFA-1500 form, Box 20 is used to indicate whether laboratory work was performed by an outside laboratory. If the box is checked “Yes,” the provider must also include the total charge for the lab work.

Tip: If the provider performed the lab work in-house, select “No.” If an outside laboratory was used, check “Yes” and report the associated charge.

In our example below, the provider checked “Yes” and reported an amount of $75.00.

In the X12 837P 5010 transaction, Box 20 maps to the PS1 segment within the 2400 Service Line Loop. This segment is used to report the identification of the provider that performed the purchased service (e.g., the lab), along with the total charge amount.

Sample 837P (5010) – 2400 PS1 Segment

Segment Breakdown:

• PS101: The Purchased Service Provider Identifier – typically the NPI or other ID of the lab or external provider that performed the service.
• PS102: The charge amount for the outside lab service (e.g., 75).

Note: The PS1 segment is only required when Box 20 is marked “Yes.” If no outside lab was used, do not include the PS1 segment in the 837P 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
• 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 [You are Here]

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