EDI
API DocsTerminal

SV7 Drug Adjudication

To specify the claim service detail for drug services that have been adjudicated

Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
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
SV701 is an internal processing identification number.
02
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
SV702 is the number assigned to the doctor who wrote the prescription.
03
Prescription Denial Override Code
Identifier (ID)
Optional
2
2
1
Code indicating that a pharmacist has overridden the denial of a prescription
Codes (8)
04
Coverage Level Code
Identifier (ID)
Mandatory
3
3
1
Code indicating the level of coverage being provided for this insured
This code is used to indicate or verify the patient's benefit coverage level at the time the claim was adjudicated.
Codes (25)
05
Product/Process Characteristic Code
Identifier (ID)
Mandatory
2
3
1
Code identifying the general class of a product or process characteristic
SV705 describes the legal status (characteristic) of the drug being dispensed.
Codes (289)
06
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
SV706 is the Drug Utilization Review (DUR) alert indicator. A "Y" indicates a DUR alert was issued; an "N" indicates DUR processing occurred but no alert was issued.
Codes (9)
07
Drug Use Review (DUR)
Composite (composite)
Optional
6
01
Reason for Service Code
Identifier (ID)
Mandatory
2
2
-
Code identifying the type of utilization conflict detected
C059-01 is a code identifying the type of utilization conflict detected.
02
Professional Service Code
Identifier (ID)
Mandatory
2
2
-
Code identifying pharmacist intervention when a conflict code has been identified
C059-02 is a code identifying the intervention when a conflict code has been identified.
03
Result of Service Code
Identifier (ID)
Mandatory
2
2
-
Code identifying action taken by a pharmacist in response to a conflict
C059-03 is a code identifying the action taken in response to a conflict.

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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.