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.

Heading

1. 010 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 020 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set.

3. 022 · CUR · Currency · Max 1 · Optional

   To specify the currency (dollars, pounds, francs, etc.) used in a transaction

4. 024 · QTY · Quantity · Max 1 · Optional

   To specify quantity information.

5. NM1 Loop Optional Repeat >1

   1. 030 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

      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. 040 · N2 · Additional Name Information · Max 1 · Optional

      To specify additional names or those longer than 35 characters in length

   3. 050 · N3 · Address Information · Max 2 · Optional

      To specify the location of the named party

   4. 060 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 070 · PER · Administrative Communications Contact · Max 3 · Optional

      To identify a person or office to whom administrative communications should be directed

   6. 080 · ACT · Account Identification · Max 9 · Optional

      To specify account information.

   7. 090 · DTP · Date or Time or Period · Max 9 · Optional

      To specify any or all of a date, a time, or a time period

   8. 100 · DMG · Demographic Information · Max 1 · Optional

      To supply demographic information

   9. 110 · REF · Reference Numbers · Max 9 · Optional

      To specify identifying numbers.

Detail

1. HL Loop Mandatory Repeat 999999

   1. 010 · HL · Hierarchical Level · Max 1 · Mandatory

      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. 020 · ACT · Account Identification · Max 2 · Optional

      To specify account information.

   3. 030 · DTP · Date or Time or Period · Max >1 · Optional

      To specify any or all of a date, a time, or a time period

   4. 040 · CUR · Currency · Max 1 · Optional

      To specify the currency (dollars, pounds, francs, etc.) used in a transaction

   5. 050 · AMT · Monetary Amount · Max >1 · Optional

      To indicate the total monetary amount.

   6. 060 · FC · Financial Contribution · Max 2 · Optional

      To specify the financial contribution information

   7. 070 · REF · Reference Numbers · Max >1 · Optional

      To specify identifying numbers.

   8. 080 · DMG · Demographic Information · Max 1 · Optional

      To supply demographic information

   9. 090 · QTY · Quantity · Max >1 · Optional

      To specify quantity information.

   10. 100 · CRI · Claim Report Information · Max >1 · Optional

       To specify information about the claim being reported

   11. 110 · EMT · Employment · Max 1 · Optional

       To specify employment information

   12. 120 · CRC · Conditions Indicator · Max >1 · Optional

       To supply information on conditions

   13. NM1 Loop Mandatory Repeat 999

       1. 130 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

          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. 140 · N2 · Additional Name Information · Max 1 · Optional

          To specify additional names or those longer than 35 characters in length

       3. 150 · N3 · Address Information · Max 2 · Optional

          To specify the location of the named party

       4. 160 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

       5. 170 · PER · Administrative Communications Contact · Max 3 · Optional

          To identify a person or office to whom administrative communications should be directed

       6. 172 · ACT · Account Identification · Max 9 · Optional

          To specify account information.

       7. 174 · DTP · Date or Time or Period · Max 9 · Optional

          To specify any or all of a date, a time, or a time period

       8. 176 · DMG · Demographic Information · Max 1 · Optional

          To supply demographic information

       9. 178 · REF · Reference Numbers · Max >1 · Optional

          To specify identifying numbers.

   14. ESI Loop Optional Repeat 99

       1. 180 · ESI · Employment Status Information · Max 1 · Mandatory

          To specify status of employment

          The ESI segment identifies pre and post injury information, including income and work schedules.

       2. 190 · DTP · Date or Time or Period · Max >1 · Optional

          To specify any or all of a date, a time, or a time period

       3. 200 · QTY · Quantity · Max >1 · Optional

          To specify quantity information.

       4. 202 · CRC · Conditions Indicator · Max 9 · Optional

          To supply information on conditions

       5. AIN Loop Optional Repeat 99

          1. 210 · AIN · Income · Max 1 · Mandatory

             To provide type and amount of income obtained

          2. 220 · CUR · Currency · Max 1 · Optional

             To specify the currency (dollars, pounds, francs, etc.) used in a transaction

          3. 230 · TXI · Tax Information · Max 9 · Optional

             To specify tax information.

          4. 240 · WS · Work Schedule · Max 99 · Optional

             To specify an individual's work schedule

          5. 250 · DTP · Date or Time or Period · Max >1 · Optional

             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.

          6. 260 · QTY · Quantity · Max 9 · Optional

             To specify quantity information.

   15. LN Loop Optional Repeat 999

       1. 270 · LN · Loan Information · Max 1 · Mandatory

          To specify information about the loan

          LN segment specifies loan information for determination of benefits, and is used for credit disability only.

       2. 280 · REF · Reference Numbers · Max 2 · Optional

          To specify identifying numbers.

       3. AMT Loop Optional Repeat 99

          1. 290 · AMT · Monetary Amount · Max 1 · Mandatory

             To indicate the total monetary amount.

          2. 300 · DTP · Date or Time or Period · Max >1 · Optional

             To specify any or all of a date, a time, or a time period

   16. INJ Loop Optional Repeat 99

       1. 310 · INJ · Injury or Illness Detail · Max 1 · Mandatory

          To specify information about the injury or illness

       2. 320 · III · Information · Max 9 · Optional

          To report information

          The III segment contains information about the accident or injury or illness.

       3. 330 · IMP · Impairment Detail · Max 6 · Optional

          To specify impairment to a body part

       4. 340 · DTP · Date or Time or Period · Max >1 · Optional

          To specify any or all of a date, a time, or a time period

       5. 342 · CRC · Conditions Indicator · Max 9 · Optional

          To supply information on conditions

       6. NM1 Loop Optional Repeat 999

          1. 350 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

             To supply the full name of an individual or organizational entity

             The NM1 loop specifies medical provider and witness information.

          2. 360 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          3. 370 · N3 · Address Information · Max 2 · Optional

             To specify the location of the named party

          4. 380 · N4 · Geographic Location · Max 1 · Optional

             To specify the geographic place of the named party

          5. 390 · PER · Administrative Communications Contact · Max 2 · Optional

             To identify a person or office to whom administrative communications should be directed

          6. 392 · ACT · Account Identification · Max 9 · Optional

             To specify account information.

          7. 394 · DTP · Date or Time or Period · Max >1 · Optional

             To specify any or all of a date, a time, or a time period

          8. 396 · DMG · Demographic Information · Max 1 · Optional

             To supply demographic information

          9. 398 · REF · Reference Numbers · Max >1 · Optional

             To specify identifying numbers.

   17. AD1 Loop Optional Repeat 999

       1. 400 · AD1 · Adjustment Amount · Max 1 · Mandatory

          To specify the characteristics of an adjustment

          The AD1 segment specifies benefit adjustments, payments and offset information.

       2. 410 · CUR · Currency · Max 1 · Optional

          To specify the currency (dollars, pounds, francs, etc.) used in a transaction

       3. 420 · DTP · Date or Time or Period · Max >1 · Optional

          To specify any or all of a date, a time, or a time period

       4. 430 · QTY · Quantity · Max >1 · Optional

          To specify quantity information.

       5. 440 · REL · Relationship · Max 30 · Optional

          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 999

          1. 450 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

             To supply the full name of an individual or organizational entity

             The NM1 segment specifies information about the offset benefits provider.

          2. 460 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          3. 470 · N3 · Address Information · Max 2 · Optional

             To specify the location of the named party

          4. 480 · N4 · Geographic Location · Max 1 · Optional

             To specify the geographic place of the named party

          5. 490 · PER · Administrative Communications Contact · Max 2 · Optional

             To identify a person or office to whom administrative communications should be directed

          6. 492 · ACT · Account Identification · Max 9 · Optional

             To specify account information.

          7. 494 · DTP · Date or Time or Period · Max 9 · Optional

             To specify any or all of a date, a time, or a time period

          8. 496 · DMG · Demographic Information · Max 1 · Optional

             To supply demographic information

          9. 498 · REF · Reference Numbers · Max 9 · Optional

             To specify identifying numbers.

Summary

1. LX Loop Optional Repeat 1

   1. 010 · LX · Assigned Number · Max 1 · Mandatory

      To reference a line number in a transaction set.

   2. 020 · QTY · Quantity · Max 99 · Optional

      To specify quantity information.

2. 030 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).