SV4 Drug Service

To specify the claim service detail for prescription drugs

Position
Element
Name
Type
Requirement
Min
Max
Repeat
SV401
Reference Identification
String (AN)
Mandatory
1
80
1
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
1
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)
C003-01 qualifies C003-02 and C003-08.
02
Product/Service ID
String (AN)
Mandatory
1
80
-
Identifying number for a product or service
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
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 and C003-08.
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 and C003-08.
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 and C003-08.
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 and C003-08.
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.
08
Product/Service ID
String (AN)
Optional
1
80
-
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
09
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-09 modifies the value in C003-02 and C003-08.
10
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-10 modifies the value in C003-02 and C003-08.
11
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-11 modifies the value in C003-02 and C003-08.
12
Procedure Modifier
String (AN)
Optional
2
2
-
This identifies special circumstances related to the performance of the service, as defined by trading partners
C003-12 modifies the value in C003-02 and C003-08.
SV403
Reference Identification
String (AN)
Optional
1
80
1
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.
SV404
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
SV405
Dispense as Written Code
Identifier (ID)
Optional
1
1
1
Code indicating whether or not the prescriber's instructions regarding generic substitution were followed
SV406
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
SV407
Prescription Origin Code
Identifier (ID)
Optional
1
1
1
Code indicating the origin of a prescription
SV408
Description
String (AN)
Optional
1
80
1
A free-form description to clarify the related data elements and their content
SV408 is the drug name.
SV409
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
SV410
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
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.
SV411
Unit Dose Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of unit dose dispensing done
SV412
Basis of Cost Determination Code
Identifier (ID)
Optional
1
2
1
Code indicating the method by which the ingredient cost was calculated
SV413
Basis of Days Supply Determination Code
Identifier (ID)
Optional
1
1
1
Code indicating the method by which the days supply was determined
SV414
Dosage Form Code
Identifier (ID)
Optional
2
2
1
Code indicating the form in which the drug is dispensed
SV415
Copay Status Code
Identifier (ID)
Optional
1
1
1
Code indicating whether or not co-payment requirements were met on a line by line basis
SV416
Patient Location Code
Identifier (ID)
Optional
1
1
1
Code identifying the location where patient is receiving medical treatment
SV417
Level of Care Code
Identifier (ID)
Optional
1
1
1
Code specifying the level of care provided by a nursing home facility
SV418
Prior Authorization Type Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of prior authorization or medical certification that has occurred
SV419
Submission Clarification Code
Identifier (ID)
Optional
1
2
1
Code indicating that the pharmacist is clarifying the submission
SV420
Additional Drug Coverage Code
Identifier (ID)
Optional
1
2
1
Code indicating whether or not the patient has other insurance coverage
SV421
Compound Route of Administration Code
Identifier (ID)
Optional
1
2
1
Code indicating the route of administration of the complete compound mixture
SV422
Submitted Drug Sales Tax Code
Identifier (ID)
Optional
2
2
1
Code indicating the basis for percentage sales tax
SV423
Percentage as Decimal
Decimal number (R)
Optional
1
10
1
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
SV423 is the submitted drug sales tax rate used to calculate the submitted drug sales tax amount.
SV424
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV424 is the submitted drug sales tax amount.

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