SV4 Drug Service

To specify the claim service detail for prescription drugs

Position
Element
Name
Type
Requirement
Min
Max
Repeat
SV4-01
Reference Identification
String (AN)
Mandatory
1
30
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SV401 is a prescription number.
SV402
Composite Medical Procedure Identifier
Composite (composite)
Optional
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.
SV4-03
Reference Identification
String (AN)
Optional
1
30
-
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SV403 is a new or refill number. A value of zero indicates a new prescription, any other value is the refill number of an existing prescription.
SV4-04
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response
SV404 is the generic indicator. A "Y" value indicates a generic drug; an "N" value indicates a branded drug.
SV4-05
Dispense as Written Code
Identifier (ID)
Optional
1
1
-
Code indicating whether or not the prescriber's instructions regarding generic substitution were followed
SV4-06
Level of Service Code
Identifier (ID)
Optional
1
3
-
Code specifying the level of service rendered
SV4-07
Prescription Origin Code
Identifier (ID)
Optional
1
1
-
Code indicating the origin of a prescription
SV4-08
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content
SV408 is the drug name.
SV4-09
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response
SV409 is the multisource indicator. A "Y" indicates drug is available from more than one manufacturer; an "N" value indicates drug is available from one manufacturer.
SV4-10
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response
SV410 is the compound indicator. A "Y" indicates a compound drug; an "N" value indicates a noncompound drug. A "U" value indicates a nonspecified drug compound.
SV4-11
Unit Dose Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of unit dose dispensing done
SV4-12
Basis of Cost Determination Code
Identifier (ID)
Optional
1
2
-
Code indicating the method by which the ingredient cost was calculated
SV4-13
Basis of Days Supply Determination Code
Identifier (ID)
Optional
1
1
-
Code indicating the method by which the days supply was determined
SV4-14
Dosage Form Code
Identifier (ID)
Optional
2
2
-
Code indicating the form in which the drug is dispensed
SV4-15
Copay Status Code
Identifier (ID)
Optional
1
1
-
Code indicating whether or not co-payment requirements were met on a line by line basis
SV4-16
Patient Location Code
Identifier (ID)
Optional
1
1
-
Code identifying the location where patient is receiving medical treatment
SV4-17
Level of Care Code
Identifier (ID)
Optional
1
1
-
Code specifying the level of care provided by a nursing home facility
SV4-18
Prior Authorization Type Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of prior authorization or medical certification that has occurred

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