148 Report of Injury or Illness
148 Report of Injury or Illness
Function Group IJ
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.
Position
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
CurrencyOptional
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
024
QuantityOptional
Max 1
To specify quantity information.
NM1Loop
Optional
Repeat >1
030
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
040
Additional Name InformationOptional
Max 1
To specify additional names or those longer than 35 characters in length
050
Address InformationOptional
Max 2
To specify the location of the named party
060
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
070
Administrative Communications ContactOptional
Max 3
To identify a person or office to whom administrative communications should be directed
080
Account IdentificationOptional
Max 9
To specify account information.
090
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
100
Demographic InformationOptional
Max 1
To supply demographic information
110
Reference NumbersOptional
Max 9
To specify identifying numbers.
Position
Segment
Name
Max Use
HLLoop
Mandatory
Repeat 99999
010
Hierarchical LevelMandatory
Max 1
To identify dependencies among and the content of hierarchically related groups of data segments.
020
Account IdentificationOptional
Max 2
To specify account information.
030
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
040
CurrencyOptional
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
050
Monetary AmountOptional
Max 2
To indicate the total monetary amount.
060
Financial ContributionOptional
Max 2
To specify the financial contribution information
070
Reference NumbersOptional
Max 9
To specify identifying numbers.
080
Demographic InformationOptional
Max 1
To supply demographic information
090
QuantityOptional
Max 9
To specify quantity information.
100
Claim Report InformationOptional
Max 1
To specify information about the claim being reported
110
EmploymentOptional
Max 1
To specify employment information
120
Conditions IndicatorOptional
Max >1
To supply information on conditions
NM1Loop
Mandatory
Repeat 99
130
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
140
Additional Name InformationOptional
Max 1
To specify additional names or those longer than 35 characters in length
150
Address InformationOptional
Max 2
To specify the location of the named party
160
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
170
Administrative Communications ContactOptional
Max 3
To identify a person or office to whom administrative communications should be directed
172
Account IdentificationOptional
Max 9
To specify account information.
174
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
176
Demographic InformationOptional
Max 1
To supply demographic information
178
Reference NumbersOptional
Max 9
To specify identifying numbers.
ESILoop
Optional
Repeat 9
180
Employment Status InformationMandatory
Max 1
To specify status of employment
190
Date or Time or PeriodOptional
Max 3
To specify any or all of a date, a time, or a time period
200
QuantityOptional
Max 4
To specify quantity information.
202
Conditions IndicatorOptional
Max 9
To supply information on conditions
AINLoop
Optional
Repeat 9
210
IncomeMandatory
Max 1
To provide type and amount of income obtained
220
CurrencyOptional
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
230
Tax InformationOptional
Max 9
To specify tax information.
240
Work ScheduleOptional
Max 99
To specify an individual's work schedule
250
Date or Time or PeriodOptional
Max 1
To specify any or all of a date, a time, or a time period
260
QuantityOptional
Max 9
To specify quantity information.
LNLoop
Optional
Repeat 99
270
Loan InformationMandatory
Max 1
To specify information about the loan
280
Reference NumbersOptional
Max 2
To specify identifying numbers.
AMTLoop
Optional
Repeat 9
290
Monetary AmountMandatory
Max 1
To indicate the total monetary amount.
300
Date or Time or PeriodOptional
Max 1
To specify any or all of a date, a time, or a time period
INJLoop
Optional
Repeat 9
310
Injury or Illness DetailMandatory
Max 1
To specify information about the injury or illness
320
InformationOptional
Max 9
To report optionally codified information
330
Impairment DetailOptional
Max 6
To specify impairment to a body part
340
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
342
Conditions IndicatorOptional
Max 9
To supply information on conditions
NM1Loop
Optional
Repeat 99
350
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
360
Additional Name InformationOptional
Max 1
To specify additional names or those longer than 35 characters in length
370
Address InformationOptional
Max 2
To specify the location of the named party
380
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
390
Administrative Communications ContactOptional
Max 2
To identify a person or office to whom administrative communications should be directed
392
Account IdentificationOptional
Max 9
To specify account information.
394
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
396
Demographic InformationOptional
Max 1
To supply demographic information
398
Reference NumbersOptional
Max 9
To specify identifying numbers.
AD1Loop
Optional
Repeat 99
400
Adjustment AmountMandatory
Max 1
To specify the characteristics of an adjustment
410
CurrencyOptional
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
420
Date or Time or PeriodOptional
Max 3
To specify any or all of a date, a time, or a time period
430
QuantityOptional
Max 2
To specify quantity information.
440
RelationshipOptional
Max 30
To specify relationship and birth order of entity
NM1Loop
Optional
Repeat 99
450
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
460
Additional Name InformationOptional
Max 1
To specify additional names or those longer than 35 characters in length
470
Address InformationOptional
Max 2
To specify the location of the named party
480
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
490
Administrative Communications ContactOptional
Max 2
To identify a person or office to whom administrative communications should be directed
492
Account IdentificationOptional
Max 9
To specify account information.
494
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
496
Demographic InformationOptional
Max 1
To supply demographic information
498
Reference NumbersOptional
Max 9
To specify identifying numbers.
500
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).