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Transaction Set
in
X12 Release 008020

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.

Heading

Sequence
Segment
Name
Max use
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
Beginning 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
0220
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
0240
Quantity Information
Max 1
To specify quantity information
0260
Reference Information
Max 9
To specify identifying information
NM1 Loop
Repeat >1
0300
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.
0400
Additional Name Information
Max 1
To specify additional names
0500
Party Location
Max 2
To specify the location of the named party
0600
Geographic Location
Max 1
To specify the geographic place of the named party
0700
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
0800
Account Identification
Max 9
To specify account information
0900
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
1000
Demographic Information
Max 1
To supply demographic information
1100
Reference Information
Max 9
To specify identifying information
1200
Quantity Information
Max >1
To specify quantity information
1300
Conditions Indicator
Max >1
To supply information on conditions

Detail

Sequence
Segment
Name
Max use
HL Loop
Repeat 999999
0100
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), 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.
0150
Claim Report Information
Max >1
To specify information about the claim being reported
0200
Account Identification
Max 2
To specify account information
0300
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
0400
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
0500
Monetary Amount Information
Max >1
To indicate the total monetary amount
0600
Financial Contribution
Max 2
To specify the financial contribution information
0700
Reference Information
Max >1
To specify identifying information
0800
Demographic Information
Max 1
To supply demographic information
0900
Quantity Information
Max >1
To specify quantity information
1200
Conditions Indicator
Max >1
To supply information on conditions
1250
Vehicle Information
Max >1
To provide descriptions that identify a specific vehicle
NM1 Loop
Repeat 999
1300
Individual or Organizational Name
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.
1400
Additional Name Information
Max 1
To specify additional names
1500
Party Location
Max 2
To specify the location of the named party
1600
Geographic Location
Max 1
To specify the geographic place of the named party
1700
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
1720
Account Identification
Max 9
To specify account information
1740
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
1760
Demographic Information
Max 1
To supply demographic information
1780
Reference Information
Max >1
To specify identifying information
1790
Quantity Information
Max >1
To specify quantity information
1800
Conditions Indicator
Max >1
To supply information on conditions
ESI Loop
Repeat 99
1830
Employment Status Information
Max 1
To specify status of employment
The ESI segment identifies pre and post injury information, including income and work schedules.
1850
Employment
Max 1
To specify employment information
1870
Business Professional Title
Max 1
To identify title of an individual within a company
1900
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
1930
Reference Information
Max >1
To specify identifying information
1950
Quantity Information
Max >1
To specify quantity information
2000
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
2010
Administrative Communications Contact
Max >1
To identify a person or office to whom administrative communications should be directed
2020
Conditions Indicator
Max 9
To supply information on conditions
LX Loop
Repeat 99
2050
Transaction Set Line Number
Max 1
To reference a line number in a transaction set
2100
Income
Max 1
To provide type and amount of income obtained
2200
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
2300
Tax Information
Max 9
To specify tax information
2400
Work Schedule
Max 99
To specify an individual's work schedule
2500
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.
2600
Quantity Information
Max 9
To specify quantity information
2650
Reference Information
Max >1
To specify identifying information
LN Loop
Repeat 999
2700
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.
2800
Reference Information
Max >1
To specify identifying information
VEH Loop
Repeat >1
2820
Vehicle Information
Max 1
To provide descriptions that identify a specific vehicle
2840
Geographic Location
Max 1
To specify the geographic place of the named party
2860
Product/Item Description
Max >1
To describe a product or process in coded or free-form format
AMT Loop
Repeat 99
2900
Monetary Amount Information
Max 1
To indicate the total monetary amount
2950
Percent Amounts
Max 1
To qualify percent amounts and supply percent amounts
3000
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
3050
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
3070
Demographic Information
Max 1
To supply demographic information
3090
Party Location
Max 1
To specify the location of the named party
3120
Geographic Location
Max 1
To specify the geographic place of the named party
3140
Administrative Communications Contact
Max 1
To identify a person or office to whom administrative communications should be directed
3160
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3180
Reference Information
Max >1
To specify identifying information
3190
Loop Header
Max 1
To indicate that the next segment begins a loop
LX Loop
Repeat >1
3200
Transaction Set Line Number
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.
III Loop
Repeat >1
3250
Information
Max 1
To report information
The III segment contains information about the accident or injury or illness or incident.
3300
Impairment Detail
Max 6
To specify impairment to a body part
3400
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3420
Conditions Indicator
Max 9
To supply information on conditions
3430
Quantity Information
Max >1
To specify quantity information
3440
Reference Information
Max >1
To specify identifying information
LM Loop
Repeat >1
3450
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 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.
3460
Industry Code IdentificationMandatory
Max >1
To identify standard industry codes
NM1 Loop
Repeat 999
3500
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.
3600
Additional Name Information
Max 1
To specify additional names
3700
Party Location
Max 2
To specify the location of the named party
3800
Geographic Location
Max 1
To specify the geographic place of the named party
3900
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
3920
Account Identification
Max 9
To specify account information
3940
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
3960
Demographic Information
Max 1
To supply demographic information
3970
Reference Information
Max >1
To specify identifying information
3980
Conditions Indicator
Max >1
To supply information on conditions
3990
Loop Trailer
Max 1
To indicate that the loop immediately preceding this segment is complete
CFI Loop
Repeat 999
4000
Compensation Financial Information
Max 1
To report compensation and or claim financial information
The CFI segment specifies benefit payment, recovery, and reserve information at that hierarchical level.
4100
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
4150
Monetary Amount Information
Max 9
To indicate the total monetary amount
4200
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
4300
Quantity Information
Max >1
To specify quantity information
4400
Relationship
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.
4420
Reference Information
Max 9
To specify identifying information
4440
Conditions Indicator
Max >1
To supply information on conditions
AD1 Loop
Repeat 999
4460
Adjustment Amount
Max 1
To specify the characteristics of an adjustment
The AD1 segment specifies benefit adjustments and offsets represented at that hierarchical level.
4480
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
4490
Reference Information
Max >1
To specify identifying information
NM1 Loop
Repeat 999
4500
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, payee, or dependent.
4600
Additional Name Information
Max 1
To specify additional names
4700
Party Location
Max 2
To specify the location of the named party
4800
Geographic Location
Max 1
To specify the geographic place of the named party
4900
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
4920
Account Identification
Max 9
To specify account information
4940
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
4960
Demographic Information
Max 1
To supply demographic information
4980
Reference Information
Max 9
To specify identifying information

Summary

Sequence
Segment
Name
Max use
0100
Statistical Government Information
Max 99
To respond to a specific government reporting requirement
0300
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.