HCFA-1500 Box 4 - Insured's Name

On the HCFA-1500 form, box 4 is designated for the insured's name (Last, First, Middle). This is the subscriber of the patient who the services were rendered to for the claim. The name should be entered exactly as it appears on the subscriber's card.

In our example below, we populated box 4 with the name 'Smith, Jane'. The name should be in the order of (Last, First, Middle). Use a comma to separate the Last and First Names.

Note: Follow the name order if there is one designated on the form, otherwise use general naming order conventions. You want to keep the order consistent on every claim to help ensure any name translation mapping is successful.

So far, we talked about what the insured's name box on the HCFA form is and the information used to populate this location. In the next section, we'll briefly discuss the insured's name box in relation to the X12 837 format.

In the X12 837 format, the insured's name box information goes in the 2010BA Subscriber Name Loop - NM1 segment. More specifically, the HCFA box 4 insured's name data goes in the NM103, NM104, NM105 and NM107 segment/data elements. If the subscriber is the same person as the patient, then you only send the subscriber name loop. You can pull the data from box 2 as it's common for the box 4 subscriber info to be blank when the patient is the subscriber - in this event the 2010CA Patient Loop isn't required.

The example below shows the 2010BA Subscriber Name Loop and the 2010CA Patient Name Loop - NM1 segment. Remember that you only send the 2010CA Patient Name Loop if the patient is not the same person as the subscriber.

Please refer to the HCFA box 2 Patient's Name article for more details on the 2010BA - Patient Name loop.

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

Note: When the Patient (box 2) and Insured (box 4) are the same person, send only the 2010BA Subscriber Name Loop with box 2. When they are different, populate the 2010BA Subscriber Name Loop with box 4 and 2010CA Patient Name Loop with box 2.

Sample 837P (5010) - 2010BA - Subscriber Name

Sample 837P (5010) - 2010CA - Patient Name

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 [You are Here]
• 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

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