HCFA-1500 Box 9d - Insurance Plan Name or Program Name

On the HCFA-1500 form, box 9d is designated for the other insured's plan name or program name. This field identifies the name of the insurance plan, program, or carrier that provides secondary coverage for the patient, such as Blue Cross Blue Shield, Medicare, or a union health fund. Other common examples include Aetna, Cigna, TRICARE, and Kaiser Permanente.

Completing this box provides details about the secondary insurance plan associated with the other insured listed in box 9.

Tip: If box 9 is populated, you must also mark box 11d ("Is there another health benefit plan?"), which in turn requires you to populate boxes 9, 9a, and 9d.

In our example below, we populated box 9d with the plan name 'Aetna'.

So far, we've discussed the other insured’s plan name or program name as it appears on the HCFA-1500 form. In this section, we’ll briefly explore how that same information is represented in the X12 837 format.

In the X12 837 transaction, the other insured’s plan or program name is reported in the 2320 Other Subscriber Information Loop, specifically within the SBR (Subscriber Information) segment. HCFA Box 9d maps directly to the SBR04 data element (Other Insured Group Name) in this loop.

The 2320 SBR segment is required when Box 11d on the HCFA-1500 form is checked to indicate that the patient has additional health coverage.

The examples below illustrate how Box 9d information maps to the 837 5010 and 4010 formats, specifically within the 2320 Other Subscriber Information Loop – SBR segment.

5010 Version:
  SBR01 (Payer Responsibility Sequence Number Code): 'S' for Secondary
  SBR02 (Individual Relationship Code): '01' for Spouse
  SBR04 (Other Insured Group Name): 'Aetna'
  SBR09 (Claim Filing Indicator Code): 'CI' for Commercial Insurance

4010 Version:
  SBR01 (Payer Responsibility Sequence Number Code): 'S' for Secondary
  SBR02 (Individual Relationship Code): '01' for Spouse
  SBR03 (Insured Group or Policy Number): 'B123456'
  SBR04 (Other Insured Group Name): 'Aetna'
  SBR05 (Insurance Type Code): 'CI' for Commercial Insurance
  SBR09 (Claim Filing Indicator Code): 'CI'

Sample 837P (5010) - 2320 - Other Subscriber Information

Sample 837P (4010) - 2320 - Other Subscriber Information

Note: HCFA Box 9d maps to the SBR04 data element (Other Insured Group Name) in Loop 2320 of the X12 837 format for both the 4010 and 5010 versions.

For additional information on the X12 837 format, we strongly recommend consulting the official X12 materials.

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 [You are Here]
• 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

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