EDI
API DocsTerminal

SV4 Drug Service

To specify the claim service detail for prescription drugs

Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
127
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.
02
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.
Codes (544)
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.
03
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 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
04
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.
Codes (9)
05
Dispense as Written Code
Identifier (ID)
Optional
1
1
1
Code indicating whether or not the prescriber's instructions regarding generic substitution were followed
Codes (10)
06
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
Codes (19)
07
Prescription Origin Code
Identifier (ID)
Optional
1
1
1
Code indicating the origin of a prescription
Codes (4)
08
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.
09
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.
Codes (9)
10
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.
Codes (9)
11
Unit Dose Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of unit dose dispensing done
Codes (15)
12
Basis of Cost Determination Code
Identifier (ID)
Optional
1
2
1
Code indicating the method by which the ingredient cost was calculated
Codes (11)
13
Basis of Days Supply Determination Code
Identifier (ID)
Optional
1
1
1
Code indicating the method by which the days supply was determined
Codes (4)
14
Dosage Form Code
Identifier (ID)
Optional
2
2
1
Code indicating the form in which the drug is dispensed
Codes (72)
15
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
Codes (4)
16
Patient Location Code
Identifier (ID)
Optional
1
1
1
Code identifying the location where patient is receiving medical treatment
Codes (15)
17
Level of Care Code
Identifier (ID)
Optional
1
1
1
Code specifying the level of care provided by a nursing home facility
Codes (8)
18
Prior Authorization Type Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of prior authorization or medical certification that has occurred
Codes (9)
19
Submission Clarification Code
Identifier (ID)
Optional
1
2
1
Code indicating that the pharmacist is clarifying the submission
20
Additional Drug Coverage Code
Identifier (ID)
Optional
1
2
1
Code indicating whether or not the patient has other insurance coverage
21
Compound Route of Administration Code
Identifier (ID)
Optional
1
2
1
Code indicating the route of administration of the complete compound mixture
22
Submitted Drug Tax Code
Identifier (ID)
Optional
2
2
1
Code indicating the basis for percentage tax
23
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 tax rate used to calculate the submitted drug tax amount.
24
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV424 is the submitted drug tax amount.

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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.