HCFA-1500 Box 7 - Insured's Address

On the HCFA-1500 form, box 7 is designated for the insured's street address, city, state, zip code and telephone number. This is the subscriber of the patient who the services were rendered to on the claim.

In our example below, we populated box 7 with the street address'123 Main Street', city 'Anytown', state 'NE', zip code '12345' and the telephone number '415-555-0132'.

Note: The full 9-digit zip code is optional and only the 5-digit zip code is required. If the last 4-digits of the full 9-digit zip code are unknown, it's often acceptable to use 0000 or 9999. Example: 12345-0000

So far, we talked about what the insured's address 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 address box in relation to the X12 837 format.

In the X12 837 format, the insured's address box information goes in the 2010BA Subscriber Name Loop - N3/N4 segments. More specifically, the HCFA box 7 insured's address data goes in the N301, N401, N402 and N403 segment/data elements. The 2010BA - N3/N4 segments are only required when the patient is the subscriber.

If the patient and subscriber are NOT the same, then you would populate the 2010CA Patient Name Loop - N3/N4 segments.

The example below shows the 2010BA Subscriber Name Loop for both 5010/4010 formats - N3/N4 segments. Remember you only send the 2010BA Subscriber Name Loop - N3/N4 segments when the patient is the same person as the subscriber.

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

Note: There is no 837 location for the insured telephone number.

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

Sample 837P (4010) - 2010BA - Subscriber 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
• HCFA-1500 Box 5 - Patient's Address
• HCFA-1500 Box 6 - Patient Relationship to Insured
• HCFA-1500 Box 7 - Insured's Address [You are Here]
• HCFA-1500 Box 8 - Reserved For NUCC Use

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