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Transaction Set
in
X12 Release 004010

148 Report of Injury, Illness or Incident

Functional Group IJ

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

Sequence
Segment
Name
Max use
010
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
020
Beginning SegmentMandatory
Max 1
To indicate the beginning of a transaction set
022
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
024
Quantity
Max 1
To specify quantity information
NM1 Loop
Repeat >1
030
Individual or Organizational Name
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.
040
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
050
Address Information
Max 2
To specify the location of the named party
060
Geographic Location
Max 1
To specify the geographic place of the named party
070
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
080
Account Identification
Max 9
To specify account information
090
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
100
Demographic Information
Max 1
To supply demographic information
110
Reference Identification
Max 9
To specify identifying information

Detail

Sequence
Segment
Name
Max use
HL Loop
Repeat 999999
010
Hierarchical 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.
020
Account Identification
Max 2
To specify account information
030
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
040
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
050
Monetary Amount
Max >1
To indicate the total monetary amount
060
Financial Contribution
Max 2
To specify the financial contribution information
070
Reference Identification
Max >1
To specify identifying information
080
Demographic Information
Max 1
To supply demographic information
090
Quantity
Max >1
To specify quantity information
100
Claim Report Information
Max >1
To specify information about the claim being reported
110
Employment
Max 1
To specify employment information
120
Conditions Indicator
Max >1
To supply information on conditions
125
Vehicle Information
Max >1
To provide descriptions that identify a specific vehicle
NM1 Loop
Repeat 999
130
Individual 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.
140
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
150
Address Information
Max 2
To specify the location of the named party
160
Geographic Location
Max 1
To specify the geographic place of the named party
170
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
172
Account Identification
Max 9
To specify account information
174
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
176
Demographic Information
Max 1
To supply demographic information
178
Reference Identification
Max >1
To specify identifying information
ESI Loop
Repeat 99
180
Employment Status Information
Max 1
To specify status of employment
The ESI segment identifies pre and post injury information, including income and work schedules.
190
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
200
Quantity
Max >1
To specify quantity information
202
Conditions Indicator
Max 9
To supply information on conditions
AIN Loop
Repeat 99
210
Income
Max 1
To provide type and amount of income obtained
220
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
230
Tax Information
Max 9
To specify tax information
240
Work Schedule
Max 99
To specify an individual's work schedule
250
Date or Time or Period
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.
260
Quantity
Max 9
To specify quantity information
LN Loop
Repeat 999
270
Loan Information
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.
280
Reference Identification
Max >1
To specify identifying information
VEH Loop
Repeat >1
282
Vehicle Information
Max 1
To provide descriptions that identify a specific vehicle
284
Geographic Location
Max 1
To specify the geographic place of the named party
286
Product/Item Description
Max >1
To describe a product or process in coded or free-form format
AMT Loop
Repeat 99
290
Monetary Amount
Max 1
To indicate the total monetary amount
295
Percent Amounts
Max 1
To qualify percent amounts and supply percent amounts
300
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
NM1 Loop
Repeat >1
305
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
307
Demographic Information
Max 1
To supply demographic information
309
Address Information
Max 1
To specify the location of the named party
312
Geographic Location
Max 1
To specify the geographic place of the named party
314
Administrative Communications Contact
Max 1
To identify a person or office to whom administrative communications should be directed
316
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
318
Reference Identification
Max >1
To specify identifying information
III Loop
Repeat >1
320
Information
Max 1
To report information
The III segment contains information about the accident or injury or illness or incident.
330
Impairment Detail
Max 6
To specify impairment to a body part
340
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
342
Conditions Indicator
Max 9
To supply information on conditions
LM Loop
Repeat >1
345
Code Source Information
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.
346
Industry CodeMandatory
Max >1
Code to transmit standard industry codes
NM1 Loop
Repeat 999
350
Individual or Organizational Name
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.
360
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
370
Address Information
Max 2
To specify the location of the named party
380
Geographic Location
Max 1
To specify the geographic place of the named party
390
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
392
Account Identification
Max 9
To specify account information
394
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
396
Demographic Information
Max 1
To supply demographic information
398
Reference Identification
Max >1
To specify identifying information
AD1 Loop
Repeat 999
400
Adjustment Amount
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.
410
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
420
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
430
Quantity
Max >1
To specify quantity information
440
Relationship
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.
NM1 Loop
Repeat 999
450
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
The NM1 segment specifies information about the offset benefits provider.
460
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
470
Address Information
Max 2
To specify the location of the named party
480
Geographic Location
Max 1
To specify the geographic place of the named party
490
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
492
Account Identification
Max 9
To specify account information
494
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
496
Demographic Information
Max 1
To supply demographic information
498
Reference Identification
Max 9
To specify identifying information

Summary

Sequence
Segment
Name
Max use
LX Loop
Repeat 1
010
Assigned Number
Max 1
To reference a line number in a transaction set
020
Quantity
Max 99
To specify quantity information
030
Transaction 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)
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.