EDI 148 Report of Injury or Illness

Functional Group IJ

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Report of Injury or Illness Transaction Set (148) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used to report information pertaining to an injury or illness to entities interested in the information for statistical, legal, and claims processing requirements.

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Heading

Position

Segment

Name

Max use

010Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
020Beginning SegmentMandatory->Max 1
To indicate the beginning of a transaction set.
022CurrencyOptional->Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
024QuantityOptional->Max 1
To specify quantity information.
NM1 Loop Optional
Repeat >1
1. 030Individual or Organizational NameMandatory->Max 1
  To supply the full name of an individual or organizational entity
  The NM1 loop is used to identify the submitter and receiver of the report.
2. 040Additional Name InformationOptional->Max 1
  To specify additional names or those longer than 35 characters in length
3. 050Address InformationOptional->Max 2
  To specify the location of the named party
4. 060Geographic LocationOptional->Max 1
  To specify the geographic place of the named party
5. 070Administrative Communications ContactOptional->Max 3
  To identify a person or office to whom administrative communications should be directed
6. 080Account IdentificationOptional->Max 9
  To specify account information.
7. 090Date or Time or PeriodOptional->Max 9
  To specify any or all of a date, a time, or a time period
8. 100Demographic InformationOptional->Max 1
  To supply demographic information
9. 110Reference NumbersOptional->Max 9
  To specify identifying numbers.

Detail

Position

Segment

Name

Max use

HL Loop Mandatory
Repeat 99999
1. 010Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments.
  HL identifies the appropriate hierachical level: Reporting Agency (RA), Primary Claim Administrator (PA), Secondary Claim Administrator (SA), Contractholder (CH), Contractholder Branch (CB), and Claimant (CL). All levels are optional.
2. 020Account IdentificationOptional->Max 2
  To specify account information.
3. 030Date or Time or PeriodOptional->Max 9
  To specify any or all of a date, a time, or a time period
4. 040CurrencyOptional->Max 1
  To specify the currency (dollars, pounds, francs, etc.) used in a transaction
5. 050Monetary AmountOptional->Max 2
  To indicate the total monetary amount.
6. 060Financial ContributionOptional->Max 2
  To specify the financial contribution information
7. 070Reference NumbersOptional->Max 9
  To specify identifying numbers.
8. 080Demographic InformationOptional->Max 1
  To supply demographic information
9. 090QuantityOptional->Max 9
  To specify quantity information.
10. 100Claim Report InformationOptional->Max 1
  To specify information about the claim being reported
11. 110EmploymentOptional->Max 1
  To specify employment information
12. 120Conditions IndicatorOptional->Max >1
  To supply information on conditions
13. NM1 Loop Mandatory
  Repeat 99
  1. 130Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    NM1 segment designates the names of the entities represented at that hierarchical level.
  2. 140Additional Name InformationOptional->Max 1
    To specify additional names or those longer than 35 characters in length
  3. 150Address InformationOptional->Max 2
    To specify the location of the named party
  4. 160Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  5. 170Administrative Communications ContactOptional->Max 3
    To identify a person or office to whom administrative communications should be directed
  6. 172Account IdentificationOptional->Max 9
    To specify account information.
  7. 174Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
  8. 176Demographic InformationOptional->Max 1
    To supply demographic information
  9. 178Reference NumbersOptional->Max 9
    To specify identifying numbers.
14. ESI Loop Optional
  Repeat 9
  1. 180Employment Status InformationMandatory->Max 1
    To specify status of employment
    The ESI segment identifies pre and post injury information, including income and work schedules.
  2. 190Date or Time or PeriodOptional->Max 3
    To specify any or all of a date, a time, or a time period
  3. 200QuantityOptional->Max 4
    To specify quantity information.
  4. 202Conditions IndicatorOptional->Max 9
    To supply information on conditions
  5. AIN Loop Optional
    Repeat 9
    210IncomeMandatory->Max 1
    To provide type and amount of income obtained
    220CurrencyOptional->Max 1
    To specify the currency (dollars, pounds, francs, etc.) used in a transaction
    230Tax InformationOptional->Max 9
    To specify tax information.
    240Work ScheduleOptional->Max 99
    To specify an individual's work schedule
    250Date or Time or PeriodOptional->Max 1
    To specify any or all of a date, a time, or a time period
    The time period applies to all income and work schedules specified within the loop.
    260QuantityOptional->Max 9
    To specify quantity information.
15. LN Loop Optional
  Repeat 99
  1. 270Loan InformationMandatory->Max 1
    To specify information about the loan
    LN segment specifies loan information for determination of benefits, and is used for credit disability only.
  2. 280Reference NumbersOptional->Max 2
    To specify identifying numbers.
  3. AMT Loop Optional
    Repeat 9
    290Monetary AmountMandatory->Max 1
    To indicate the total monetary amount.
    300Date or Time or PeriodOptional->Max 1
    To specify any or all of a date, a time, or a time period
16. INJ Loop Optional
  Repeat 9
  1. 310Injury or Illness DetailMandatory->Max 1
    To specify information about the injury or illness
  2. 320InformationOptional->Max 9
    To report optionally codified information
    The III segment contains information about the accident or injury or illness.
  3. 330Impairment DetailOptional->Max 6
    To specify impairment to a body part
  4. 340Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
  5. 342Conditions IndicatorOptional->Max 9
    To supply information on conditions
  6. NM1 Loop Optional
    Repeat 99
    350Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    The NM1 loop specifies medical provider and witness information.
    360Additional Name InformationOptional->Max 1
    To specify additional names or those longer than 35 characters in length
    370Address InformationOptional->Max 2
    To specify the location of the named party
    380Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    390Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    392Account IdentificationOptional->Max 9
    To specify account information.
    394Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    396Demographic InformationOptional->Max 1
    To supply demographic information
    398Reference NumbersOptional->Max 9
    To specify identifying numbers.
17. AD1 Loop Optional
  Repeat 99
  1. 400Adjustment AmountMandatory->Max 1
    To specify the characteristics of an adjustment
    The AD1 segment specifies benefit adjustments, payments and offset information.
  2. 410CurrencyOptional->Max 1
    To specify the currency (dollars, pounds, francs, etc.) used in a transaction
  3. 420Date or Time or PeriodOptional->Max 3
    To specify any or all of a date, a time, or a time period
  4. 430QuantityOptional->Max 2
    To specify quantity information.
  5. 440RelationshipOptional->Max 30
    To specify relationship and birth order of entity
    The REL segment is used to identify beneficiaries' relationship to benefit payments and/or legal benefit compensability and distribution decisions.
  6. NM1 Loop Optional
    Repeat 99
    450Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    The NM1 segment specifies information about the offset benefits provider.
    460Additional Name InformationOptional->Max 1
    To specify additional names or those longer than 35 characters in length
    470Address InformationOptional->Max 2
    To specify the location of the named party
    480Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    490Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    492Account IdentificationOptional->Max 9
    To specify account information.
    494Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    496Demographic InformationOptional->Max 1
    To supply demographic information
    498Reference NumbersOptional->Max 9
    To specify identifying numbers.
500Transaction Set TrailerMandatory->Max 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).