EDI 148 Report of Injury, Illness or Incident

Functional Group IJ

X12N Insurance Subcommittee

This X12 Transaction Set 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

0100Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
0200Beginning of Hierarchical TransactionMandatory->Max 1
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
0220CurrencyOptional->Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
0240QuantityOptional->Max 1
To specify quantity information
0260Reference IdentificationOptional->Max 9
To specify identifying information
NM1 Loop Optional
Repeat >1
1. 0300Individual 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. 0400Additional Name InformationOptional->Max 1
  To specify additional names
3. 0500Address InformationOptional->Max 2
  To specify the location of the named party
4. 0600Geographic LocationOptional->Max 1
  To specify the geographic place of the named party
5. 0700Administrative Communications ContactOptional->Max 3
  To identify a person or office to whom administrative communications should be directed
6. 0800Account IdentificationOptional->Max 9
  To specify account information
7. 0900Date or Time or PeriodOptional->Max 9
  To specify any or all of a date, a time, or a time period
8. 1000Demographic InformationOptional->Max 1
  To supply demographic information
9. 1100Reference IdentificationOptional->Max 9
  To specify identifying information
10. 1200QuantityOptional->Max >1
  To specify quantity information
11. 1300Conditions IndicatorOptional->Max >1
  To supply information on conditions

Detail

Position

Segment

Name

Max use

HL Loop Mandatory
Repeat 999999
1. 0100Hierarchical 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), Claim Administrator (AB), Primary Claim Administrator (PA), Secondary Claim Administrator (SA), Insurer (AA), Insured (AC), Contract Holder (CH), Contract Holder Branch (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. 0150Claim Report InformationOptional->Max >1
  To specify information about the claim being reported
3. 0200Account IdentificationOptional->Max 2
  To specify account information
4. 0300Date or Time or PeriodOptional->Max >1
  To specify any or all of a date, a time, or a time period
5. 0400CurrencyOptional->Max 1
  To specify the currency (dollars, pounds, francs, etc.) used in a transaction
6. 0500Monetary AmountOptional->Max >1
  To indicate the total monetary amount
7. 0600Financial ContributionOptional->Max 2
  To specify the financial contribution information
8. 0700Reference IdentificationOptional->Max >1
  To specify identifying information
9. 0800Demographic InformationOptional->Max 1
  To supply demographic information
10. 0900QuantityOptional->Max >1
  To specify quantity information
11. 1200Conditions IndicatorOptional->Max >1
  To supply information on conditions
12. 1250Vehicle InformationOptional->Max >1
  To provide descriptions that identify a specific vehicle
13. NM1 Loop Optional
  Repeat 999
  1. 1300Individual 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. 1400Additional Name InformationOptional->Max 1
    To specify additional names
  3. 1500Address InformationOptional->Max 2
    To specify the location of the named party
  4. 1600Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  5. 1700Administrative Communications ContactOptional->Max 3
    To identify a person or office to whom administrative communications should be directed
  6. 1720Account IdentificationOptional->Max 9
    To specify account information
  7. 1740Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
  8. 1760Demographic InformationOptional->Max 1
    To supply demographic information
  9. 1780Reference IdentificationOptional->Max >1
    To specify identifying information
  10. 1790QuantityOptional->Max >1
    To specify quantity information
  11. 1800Conditions IndicatorOptional->Max >1
    To supply information on conditions
14. ESI Loop Optional
  Repeat 99
  1. 1830Employment Status InformationMandatory->Max 1
    To specify status of employment
    The ESI segment identifies pre and post injury information, including income and work schedules.
  2. 1850EmploymentOptional->Max 1
    To specify employment information
  3. 1870Business Professional TitleOptional->Max 1
    To identify title of an individual within a company
  4. 1900Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
  5. 1930Reference IdentificationOptional->Max >1
    To specify identifying information
  6. 1950QuantityOptional->Max >1
    To specify quantity information
  7. 2000Individual or Organizational NameOptional->Max 1
    To supply the full name of an individual or organizational entity
  8. 2010Administrative Communications ContactOptional->Max >1
    To identify a person or office to whom administrative communications should be directed
  9. 2020Conditions IndicatorOptional->Max 9
    To supply information on conditions
  10. LX Loop Optional
    Repeat 99
    2050Assigned NumberMandatory->Max 1
    To reference a line number in a transaction set
    2100IncomeOptional->Max 1
    To provide type and amount of income obtained
    2200CurrencyOptional->Max 1
    To specify the currency (dollars, pounds, francs, etc.) used in a transaction
    2300Tax InformationOptional->Max 9
    To specify tax information
    2400Work ScheduleOptional->Max 99
    To specify an individual's work schedule
    2500Date 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.
    2600QuantityOptional->Max 9
    To specify quantity information
    2650Reference IdentificationOptional->Max >1
    To specify identifying information
15. LN Loop Optional
  Repeat 999
  1. 2700Loan 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. 2800Reference IdentificationOptional->Max >1
    To specify identifying information
  3. VEH Loop Optional
    Repeat >1
    2820Vehicle InformationMandatory->Max 1
    To provide descriptions that identify a specific vehicle
    2840Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    2860Product/Item DescriptionOptional->Max >1
    To describe a product or process in coded or free-form format
  4. AMT Loop Optional
    Repeat 99
    2900Monetary AmountMandatory->Max 1
    To indicate the total monetary amount
    2950Percent AmountsOptional->Max 1
    To qualify percent amounts and supply percent amounts
    3000Date 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
    3050Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    3070Demographic InformationOptional->Max 1
    To supply demographic information
    3090Address InformationOptional->Max 1
    To specify the location of the named party
    3120Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    3140Administrative Communications ContactOptional->Max 1
    To identify a person or office to whom administrative communications should be directed
    3160Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
    3180Reference IdentificationOptional->Max >1
    To specify identifying information
16. 3190Loop HeaderOptional->Max 1
  To indicate that the next segment begins a loop
17. LX Loop Optional
  Repeat >1
  1. 3200Assigned NumberMandatory->Max 1
    To reference a line number in a transaction set
    The LX loop allows III Loop at position 3250 or NM1 Loop at position 3500 to be used independently, or represent a "1 to 1", "1 to Many" or "Many to 1" relationship between their respective information.
  2. III Loop Optional
    Repeat >1
    3250InformationMandatory->Max 1
    To report information
    The III segment contains information about the accident or injury or illness or incident.
    3300Impairment DetailOptional->Max 6
    To specify impairment to a body part
    3400Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
    3420Conditions IndicatorOptional->Max 9
    To supply information on conditions
    3430QuantityOptional->Max >1
    To specify quantity information
    3440Reference IdentificationOptional->Max >1
    To specify identifying information
    LM Loop Optional
    Repeat >1
    3450Code 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 Illness, and or Diagnosis, Occupation Code, or similar coded data consistent with injury, illness, or incident reporting represented at the Claimant or other hierarchical level as appropriate.
    3460Industry CodeMandatory->Max >1
    Code to transmit standard industry codes
  3. NM1 Loop Optional
    Repeat 999
    3500Individual 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.
    3600Additional Name InformationOptional->Max 1
    To specify additional names
    3700Address InformationOptional->Max 2
    To specify the location of the named party
    3800Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    3900Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    3920Account IdentificationOptional->Max 9
    To specify account information
    3940Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
    3960Demographic InformationOptional->Max 1
    To supply demographic information
    3970Reference IdentificationOptional->Max >1
    To specify identifying information
    3980Conditions IndicatorOptional->Max >1
    To supply information on conditions
18. 3990Loop TrailerOptional->Max 1
  To indicate that the loop immediately preceding this segment is complete
19. CFI Loop Optional
  Repeat 999
  1. 4000Compensation Financial InformationMandatory->Max 1
    To report compensation and or claim financial information
    The CFI segment specifies benefit payment, recovery, and reserve information at that hierarchical level.
  2. 4100CurrencyOptional->Max 1
    To specify the currency (dollars, pounds, francs, etc.) used in a transaction
  3. 4150Monetary AmountOptional->Max 9
    To indicate the total monetary amount
  4. 4200Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
  5. 4300QuantityOptional->Max >1
    To specify quantity information
  6. 4400RelationshipOptional->Max 30
    To specify relationship and birth order of entity
    The REL segment is used to identify beneficiaries' relationship to the benefit payments or legal benefit compensability and distribution decisions.
  7. 4420Reference IdentificationOptional->Max 9
    To specify identifying information
  8. 4440Conditions IndicatorOptional->Max >1
    To supply information on conditions
  9. AD1 Loop Optional
    Repeat 999
    4460Adjustment AmountMandatory->Max 1
    To specify the characteristics of an adjustment
    The AD1 segment specifies benefit adjustments and offsets represented at that hierarchical level.
    4480Date or Time or PeriodOptional->Max >1
    To specify any or all of a date, a time, or a time period
    4490Reference IdentificationOptional->Max >1
    To specify identifying information
  10. NM1 Loop Optional
    Repeat 999
    4500Individual 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, payee, or dependent.
    4600Additional Name InformationOptional->Max 1
    To specify additional names
    4700Address InformationOptional->Max 2
    To specify the location of the named party
    4800Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    4900Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    4920Account IdentificationOptional->Max 9
    To specify account information
    4940Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    4960Demographic InformationOptional->Max 1
    To supply demographic information
    4980Reference IdentificationOptional->Max 9
    To specify identifying information

Summary

Position

Segment

Name

Max use

0100Statistical Government InformationOptional->Max 99
To respond to a specific government reporting requirement
0300Transaction 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)