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

C003

Composite Medical Procedure Identifier

Composite (composite)

Optional

1

01

235

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

234

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

1339

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

1339

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

1339

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

1339

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

352

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

234

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

1339

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

1339

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

1339

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

1339

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

127

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

1073

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

1329

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

1338

Level of Service Code

Identifier (ID)

Optional

1

3

1

Code specifying the level of service rendered

Codes (19)

07

1356

Prescription Origin Code

Identifier (ID)

Optional

1

1

1

Code indicating the origin of a prescription

Codes (4)

08

352

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

1073

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

1073

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

1370

Unit Dose Code

Identifier (ID)

Optional

1

1

1

Code indicating the type of unit dose dispensing done

Codes (15)

12

1319

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

1320

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

1330

Dosage Form Code

Identifier (ID)

Optional

2

2

1

Code indicating the form in which the drug is dispensed

Codes (72)

15

1327

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

1384

Patient Location Code

Identifier (ID)

Optional

1

1

1

Code identifying the location where patient is receiving medical treatment

Codes (15)

17

1337

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

1357

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

1734

Submission Clarification Code

Identifier (ID)

Optional

1

2

1

Code indicating that the pharmacist is clarifying the submission

20

1735

Additional Drug Coverage Code

Identifier (ID)

Optional

1

2

1

Code indicating whether or not the patient has other insurance coverage

21

1736

Compound Route of Administration Code

Identifier (ID)

Optional

1

2

1

Code indicating the route of administration of the complete compound mixture

22

1737

Submitted Drug Tax Code

Identifier (ID)

Optional

2

2

1

Code indicating the basis for percentage tax

23

954

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

782

Monetary Amount

Decimal number (R)

Optional

1

18

1

Monetary amount

SV424 is the submitted drug tax amount.