EDI 148 Report of Injury, Illness or Incident

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, Illness or Incident 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, illness or incident to entities interested in the information for statistical, legal, and claims and risk management 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 IdentificationOptional->Max 9
  To specify identifying information

Detail

Position

Segment

Name

Max use

HL Loop Mandatory
Repeat 999999
1. 010Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments
  HL identifies the appropriate hierarchical level: Reporting Agency (RA), Primary Administrator (PA), Secondary Administrator (SA), Contractholder (CH), Contractholder Branch Office (CB), Claimant (CL), Cause of Injury (CI), Source of Injury (SI), Body Part (BP), Nature of Injury (NI), and Payment Detail (PY). All levels are optional.
2. 020Account IdentificationOptional->Max 2
  To specify account information
3. 030Date or Time or PeriodOptional->Max >1
  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 >1
  To indicate the total monetary amount
6. 060Financial ContributionOptional->Max 2
  To specify the financial contribution information
7. 070Reference IdentificationOptional->Max >1
  To specify identifying information
8. 080Demographic InformationOptional->Max 1
  To supply demographic information
9. 090QuantityOptional->Max >1
  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. 125Vehicle InformationOptional->Max >1
  To provide descriptions that identify a specific vehicle
14. NM1 Loop Mandatory
  Repeat 999
  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 IdentificationOptional->Max >1
    To specify identifying information
15. ESI Loop Optional
  Repeat 99
  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 >1
    To specify any or all of a date, a time, or a time period
  3. 200QuantityOptional->Max >1
    To specify quantity information
  4. 202Conditions IndicatorOptional->Max 9
    To supply information on conditions
  5. AIN Loop Optional
    Repeat 99
    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
16. LN Loop Optional
  Repeat 999
  1. 270Loan InformationMandatory->Max 1
    To specify information about the loan
    The LN segment is used primarily by Credit Insurance. Other business lines may also utilize this segment in determining coverage and claim processing.
  2. 280Reference IdentificationOptional->Max >1
    To specify identifying information
  3. VEH Loop Optional
    Repeat >1
    282Vehicle InformationMandatory->Max 1
    To provide descriptions that identify a specific vehicle
    284Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    286Product/Item DescriptionOptional->Max >1
    To describe a product or process in coded or free-form format
  4. AMT Loop Optional
    Repeat 99
    290Monetary AmountMandatory->Max 1
    To indicate the total monetary amount
    295Percent AmountsOptional->Max 1
    To qualify percent amounts and supply percent amounts
    300Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
  5. NM1 Loop Optional
    Repeat >1
    305Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    307Demographic InformationOptional->Max 1
    To supply demographic information
    309Address InformationOptional->Max 1
    To specify the location of the named party
    312Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    314Administrative Communications ContactOptional->Max 1
    To identify a person or office to whom administrative communications should be directed
    316Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
    318Reference IdentificationOptional->Max >1
    To specify identifying information
17. III Loop Optional
  Repeat >1
  1. 320InformationMandatory->Max 1
    To report information
    The III segment contains information about the accident or injury or illness or incident.
  2. 330Impairment DetailOptional->Max 6
    To specify impairment to a body part
  3. 340Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
  4. 342Conditions IndicatorOptional->Max 9
    To supply information on conditions
  5. LM Loop Optional
    Repeat >1
    345Code Source InformationMandatory->Max 1
    To transmit standard code list identification information
    The LM loop specifies the code(s) and code source(s) for Cause of Injury, Source of Injury, Body Part, and Nature of Injury represented at that hierarchical level.
    346Industry CodeMandatory->Max >1
    Code to transmit standard industry codes
  6. NM1 Loop Optional
    Repeat 999
    350Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    The NM1 Loop specifies medical provider, witness, supervisor, place of occurrence, third party, and other entities pertaining to Injury, Illness, or Incident detail.
    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 >1
    To specify any or all of a date, a time, or a time period
    396Demographic InformationOptional->Max 1
    To supply demographic information
    398Reference IdentificationOptional->Max >1
    To specify identifying information
18. AD1 Loop Optional
  Repeat 999
  1. 400Adjustment AmountMandatory->Max 1
    To specify the characteristics of an adjustment
    The AD1 segment specifies benefit adjustments, payments, offset, recovery, and reserve information represented at that hierarchical level.
  2. 410CurrencyOptional->Max 1
    To specify the currency (dollars, pounds, francs, etc.) used in a transaction
  3. 420Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
  4. 430QuantityOptional->Max >1
    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 999
    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 IdentificationOptional->Max 9
    To specify identifying information

Summary

Position

Segment

Name

Max use

LX Loop Optional
Repeat 1
1. 010Assigned NumberMandatory->Max 1
  To reference a line number in a transaction set
2. 020QuantityOptional->Max 99
  To specify quantity information
030Transaction 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)