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X12 transaction guide · Healthcare and insurance

EDI 186 Insurance Underwriting Requirements Reporting

The X12 document information providers use to report results of services needed to complete the underwriting of individual insurance.

Sent by
Information provider, such as a paramedical examiner or laboratory
Received by
Insurance company
Standard
ANSI ASC X12

What is an EDI 186?

The EDI 186 Insurance Underwriting Requirements Reporting is the ANSI X12 transaction set information providers use to report the results of specific services to their trading partners, giving the information needed to complete the underwriting of individually underwritten insurance.

Life and disability underwriting often requires medical exams, lab tests, attending physician statements or motor vehicle records. Providers report results electronically so underwriters can decide quickly. The requests for these services travel in the 255. Results can be reported as each service is completed, so underwriters can start their review before every requirement is in.

How the EDI 186 worksDiagram of the EDI 186 Insurance Underwriting Requirements Reporting. Information provider, such as a paramedical examiner or laboratory sends it to insurance company. It usually follows 255. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BGN (Beginning Segment) and detail: the required 2000 loop with ACT (Account Identification) and the required 2050 loop with LX (Transaction Set Line Number), the required 2075 loop with NM1 (Individual or Organizational Name) and the required 2100 loop with BOR (Beginning of Report). 6 optional loops are listed by their first segment.How the EDI 186 worksInsurance Underwriting Requirements Reporting: who sends it, where it fits and what the standard marksrequired1 WHERE IT FITSUSUALLY FOLLOWS255Underwriting InformationServicesEDI 186SENDERInformation provider,such as a paramedicalexaminer or laboratoryRECEIVERInsurance company997 or 999 acknowledgment back, if the partners agreeUSUALLY FOLLOWED BY997FunctionalAcknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDsISA … IEAFunctional group, ID code UWGS … GETransaction set 186ST … SEHEADINGBGNBeginning Segment+ 1 optional loop, starting with:NM1DETAILRequired loop 2000 · repeats many timesACTAccount IdentificationRequired loop 2050 · repeats many timesLXTransaction Set Line NumberRequired loop 2075 · repeats many timesNM1Individual or Organizational NameRequired loop 2100 · repeats many timesBORBeginning of Report+ 5 optional loops, starting with:NM1SPKLTRUCUDBlue box: required loop. Optional loops are listed by the segment that starts them; when a loop is used, that first segment is required. Optional segmentsoutside loops are not drawn.Structure: required segments and loops in the X12 008010 listing for the 186. Your trading partner's implementation guide adds its own requirements.
How the EDI 186 worksDiagram of the EDI 186 Insurance Underwriting Requirements Reporting. Information provider, such as a paramedical examiner or laboratory sends it to insurance company. It usually follows 255. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BGN (Beginning Segment) and detail: the required 2000 loop with ACT (Account Identification) and the required 2050 loop with LX (Transaction Set Line Number), the required 2075 loop with NM1 (Individual or Organizational Name) and the required 2100 loop with BOR (Beginning of Report). 6 optional loops are listed by their first segment.How the EDI 186 worksInsurance Underwriting RequirementsReporting: who sends it, where it fits and whatthe standard marks required1 WHERE IT FITSUSUALLY FOLLOWS255Underwriting Information ServicesEDI 186SENDERInformationprovider, suchas aparamedicalexaminer orlaboratoryRECEIVERInsurancecompany997 or 999 acknowledgment back, if the partnersagreeUSUALLY FOLLOWED BY997Functional Acknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDs (ISA… IEA)Functional group, ID code UW (GS … GE)Transaction set 186 (ST … SE)HEADINGBGNBeginning Segment+ 1 optional loop, starting with:NM1DETAILRequired loop 2000 · repeatsmany timesACTAccount IdentificationRequired loop 2050 · repeatsmany timesLXTransaction Set LineNumberRequired loop 2075 ·repeats many timesNM1Individual orOrganizationalNameRequired loop 2100 ·repeats many timesBORBeginning of Report+ 5 optional loops, starting with:NM1SPKLTRUCUDBlue box: required loop. Optional loops are listedby the segment that starts them; when a loop isused, that first segment is required. Optionalsegments outside loops are not drawn.Structure: required segments and loops in the X12008010 listing for the 186. Your trading partner'simplementation guide adds its own requirements.

How to read this diagram: the top row shows who sends the 186, to whom, and which documents usually come before and after it. The lower part shows what X12 release 008010 itself requires: the envelopes around the 186 and the segments and loops the standard marks as required, area by area. Optional loops are listed by the segment that starts them rather than drawn in full. This is the standard's minimum, not a trading partner's requirement: each partner's implementation guide usually makes some optional loops mandatory, restricts the codes and may use a different release.

Expand diagram Download SVG

When it is used

  • Reporting paramedical exam results
  • Reporting laboratory test results
  • Reporting other underwriting information

Where it fits in the document flow

Usually follows 255 Underwriting Information Services
This document 186 Insurance Underwriting Requirements Reporting
Usually followed by 997 Functional Acknowledgment

Structure

Mandatory segments in the 186 (X12 release 008010)

The segments X12 release 008010 marks as mandatory at their level, in order. Segments inside optional loops are needed only when the loop is used. This is the standard's requirement, not your trading partner's: each partner's implementation guide names the release it uses, adds the optional segments it requires and restricts the values. The requirement status comes from one published X12 reference listing and has not been checked against a second source.

  • ST
  • BGN
  • NM1
  • ACT
  • LX
  • BOR
  • SPK
  • LTR
  • UC
  • HL
  • EFI
  • BIN
  • UD
  • SE

Practical example

The 186 in practice

An insurer orders a paramedical exam and blood test for a life insurance applicant. After the exam, the provider sends the insurer a 186 with the measurements and the lab results. The underwriter reviews them with the application and decides on the rating.

Implementation

Implementation considerations for the 186

  • Protect applicants' personal and health data.
  • Match results to the requirement orders.
  • Use the result codes that insurers expect.
  • Report results promptly to avoid underwriting delays.

How ECOM helps

Automate the 186 with ECOM

Industry

Financial Services

Secure file transfer and B2B integration for banks and financial institutions.

Industry

Healthcare

Secure B2B integration and file transfer for providers, suppliers, distributors and healthcare partners.

Solution

EDI Integration

Exchange X12 and EDIFACT documents with partners and integrate them directly with your ERP.

More general questions about EDI are answered in the EDI FAQ.

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