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.

Heading

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

  2. 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

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

  4. To specify quantity information

  5. To specify identifying information

  6. 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

    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 information

    10. To specify quantity information

    11. To supply information on conditions

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 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. To specify information about the claim being reported

    3. To specify account information

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

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

    6. To indicate the total monetary amount

    7. To specify the financial contribution information

    8. To specify identifying information

    9. To supply demographic information

    10. To specify quantity information

    11. To supply information on conditions

    12. To provide descriptions that identify a specific vehicle

    13. NM1 Loop Optional
      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

      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 information

      10. To specify quantity information

      11. To supply information on conditions

    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 employment information

      3. To identify title of an individual within a company

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

      5. To specify identifying information

      6. To specify quantity information

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

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

      9. To supply information on conditions

      10. LX Loop Optional
        Repeat 99
        1. To reference a line number in a transaction set

        2. To provide type and amount of income obtained

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

        4. To specify tax information

        5. To specify an individual's work schedule

        6. 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.
        7. To specify quantity information

        8. To specify identifying information

    15. LN Loop Optional
      Repeat 999
      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. To specify identifying information

      3. VEH Loop Optional
        Repeat >1
        1. To provide descriptions that identify a specific vehicle

        2. To specify the geographic place of the named party

        3. To describe a product or process in coded or free-form format

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

        2. To qualify percent amounts and supply percent amounts

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

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

        2. To supply demographic information

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

        7. To specify identifying information

    16. To indicate that the next segment begins a loop

    17. LX Loop Optional
      Repeat >1
      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
        1. To report information

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

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

        4. To supply information on conditions

        5. To specify quantity information

        6. To specify identifying information

        7. LM Loop Optional
          Repeat >1
          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.
          2. Code to transmit standard industry codes

      3. NM1 Loop Optional
        Repeat 999
        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.
        2. To specify additional names

        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 information

        10. To supply information on conditions

    18. To indicate that the loop immediately preceding this segment is complete

    19. CFI Loop Optional
      Repeat 999
      1. To report compensation and or claim financial information

        The CFI segment specifies benefit payment, recovery, and reserve information at that hierarchical level.
      2. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

      3. To indicate the total monetary amount

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

      5. To specify quantity information

      6. 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. To specify identifying information

      8. To supply information on conditions

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

          The AD1 segment specifies benefit adjustments and offsets represented at that hierarchical level.
        2. To specify any or all of a date, a time, or a time period

        3. To specify identifying information

      10. 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, payee, or dependent.
        2. To specify additional names

        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 information

Summary

Position
Segment
Name
Max use
  1. To respond to a specific government reporting requirement

  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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