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

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. To indicate the beginning of a transaction set.

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

  4. To specify quantity information.

  5. NM1 Loop Optional
    Repeat >1
    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. To specify additional names or those longer than 35 characters in length

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

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

    6. To specify account information.

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

    8. To supply demographic information

    9. To specify identifying numbers.

Detail

Position
Segment
Name
Max use
  1. HL Loop Mandatory
    Repeat 999999
    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. To specify account information.

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

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

    5. To indicate the total monetary amount.

    6. To specify the financial contribution information

    7. To specify identifying numbers.

    8. To supply demographic information

    9. To specify quantity information.

    10. To specify information about the claim being reported

    11. To specify employment information

    12. To supply information on conditions

    13. NM1 Loop Mandatory
      Repeat 999
      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. To specify additional names or those longer than 35 characters in length

      3. To specify the location of the named party

      4. To specify the geographic place of the named party

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

      6. To specify account information.

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

      8. To supply demographic information

      9. To specify identifying numbers.

    14. ESI Loop Optional
      Repeat 99
      1. To specify status of employment

        The ESI segment identifies pre and post injury information, including income and work schedules.
      2. To specify any or all of a date, a time, or a time period

      3. To specify quantity information.

      4. To supply information on conditions

      5. AIN Loop Optional
        Repeat 99
        1. To provide type and amount of income obtained

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

        3. To specify tax information.

        4. To specify an individual's work schedule

        5. 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. To specify quantity information.

    15. LN Loop Optional
      Repeat 999
      1. To specify information about the loan

        LN segment specifies loan information for determination of benefits, and is used for credit disability only.
      2. To specify identifying numbers.

      3. AMT Loop Optional
        Repeat 99
        1. To indicate the total monetary amount.

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

    16. INJ Loop Optional
      Repeat 99
      1. To specify information about the injury or illness

      2. To report information

        The III segment contains information about the accident or injury or illness.
      3. To specify impairment to a body part

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

      5. To supply information on conditions

      6. NM1 Loop Optional
        Repeat 999
        1. To supply the full name of an individual or organizational entity

          The NM1 loop specifies medical provider and witness information.
        2. To specify additional names or those longer than 35 characters in length

        3. To specify the location of the named party

        4. To specify the geographic place of the named party

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

        6. To specify account information.

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

        8. To supply demographic information

        9. To specify identifying numbers.

    17. AD1 Loop Optional
      Repeat 999
      1. To specify the characteristics of an adjustment

        The AD1 segment specifies benefit adjustments, payments and offset information.
      2. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

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

      4. To specify quantity information.

      5. 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. To supply the full name of an individual or organizational entity

          The NM1 segment specifies information about the offset benefits provider.
        2. To specify additional names or those longer than 35 characters in length

        3. To specify the location of the named party

        4. To specify the geographic place of the named party

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

        6. To specify account information.

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

        8. To supply demographic information

        9. To specify identifying numbers.

Summary

Position
Segment
Name
Max use
  1. LX Loop Optional
    Repeat 1
    1. To reference a line number in a transaction set.

    2. To specify quantity information.

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

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