SV4 Drug Service
To specify the claim service detail for prescription drugs
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
SV401 is a prescription number.
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
C003-01 qualifies C003-02 and C003-08.
Codes (544)
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.
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.
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.
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.
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.
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.
Identifying number for a product or service
C003-08 represents the ending value in the range in which the code occurs.
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.
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.
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.
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.
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
SV403 indicates whether the prescription is an original or a refill. A value of
zero indicates a new prescription; any other value is the subsequent fill
number of an existing prescription
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.
Codes (9)
Code indicating whether or not the prescriber's instructions regarding generic
substitution were followed
Codes (10)
Code specifying the level of service rendered
Codes (19)
Code indicating the origin of a prescription
Codes (4)
A free-form description to clarify the related data elements and their content
SV408 is the drug name.
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.
Codes (9)
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.
Codes (9)
Code indicating the type of unit dose dispensing done
Codes (15)
Code indicating the method by which the ingredient cost was calculated
Codes (11)
Code indicating the method by which the days supply was determined
Codes (4)
Code indicating the form in which the drug is dispensed
Codes (72)
Code indicating whether or not co-payment requirements were met on a line by
line basis
Codes (4)
Code identifying the location where patient is receiving medical treatment
Codes (15)
Code specifying the level of care provided by a nursing home facility
Codes (8)
Code indicating the type of prior authorization or medical certification that
has occurred
Codes (9)
Code indicating that the pharmacist is clarifying the submission
Code indicating whether or not the patient has other insurance coverage
Code indicating the route of administration of the complete compound mixture
Code indicating the basis for percentage tax
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through
100%)
SV423 is the submitted drug tax rate used to calculate the submitted drug tax
amount.
Monetary amount
SV424 is the submitted drug tax amount.