SV3 Dental Service

To specify the claim service detail for dental work

Position
Element
Name
Type
Requirement
Min
Max
Repeat
SV301
Composite Medical Procedure Identifier
Composite (composite)
Mandatory
01
Product/Service ID Qualifier
Identifier (ID)
Mandatory
2
2
-
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
02
Product/Service ID
String (AN)
Mandatory
1
48
-
Identifying number for a product or service
03
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-03 modifies the value in C003-02.
04
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-04 modifies the value in C003-02.
05
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-05 modifies the value in C003-02.
06
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-06 modifies the value in C003-02.
07
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content
C003-07 is the description of the procedure identified in C003-02.
SV302
Monetary Amount
Decimal number (R)
Optional
1
15
-
Monetary amount
SV302 is a submitted charge amount.
SV303
Facility Code Value
String (AN)
Optional
1
2
-
Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
SV303 is the place of service code representing the location where the dental treatment was rendered.
SV304
Oral Cavity Designation
Composite (composite)
Optional
01
Oral Cavity Designation Code
Identifier (ID)
Mandatory
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
02
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
03
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
04
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
05
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
SV305
Prosthesis, Crown or Inlay Code
Identifier (ID)
Optional
1
1
-
Code specifying the placement status for the dental work
SV306
Quantity
Decimal number (R)
Optional
1
15
-
Numeric value of quantity
SV306 is the number of procedures.
SV307
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content
SV307 is the reason for replacement.
SV308
Copay Status Code
Identifier (ID)
Optional
1
1
-
Code indicating whether or not co-payment requirements were met on a line by line basis
SV309
Provider Agreement Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of agreement under which the provider is submitting this claim
SV310
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response
SV310 is the predetermination of benefits indicator. A "Y" value indicates that this service is being submitted for predetermination of benefits.
SV311
Composite Diagnosis Code Pointer
Composite (composite)
Optional
01
Diagnosis Code Pointer
Numeric (N0)
Mandatory
1
2
-
A pointer to the claim diagnosis code in the order of importance to this service
C004-01 identifies the primary diagnosis code for this service line.
02
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
A pointer to the claim diagnosis code in the order of importance to this service
C004-02 identifies the second diagnosis code for this service line.
03
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
A pointer to the claim diagnosis code in the order of importance to this service
C004-03 identifies the third diagnosis code for this service line.
04
Diagnosis Code Pointer
Numeric (N0)
Optional
1
2
-
A pointer to the claim diagnosis code in the order of importance to this service
C004-04 identifies the fourth diagnosis code for this service line.

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