SV3 Dental Service

To specify the claim service detail for dental work

Position: SV3-01 · Element: 235 · Name: Product/Service ID Qualifier · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 2 · Repeat: -

Code identifying the type/source of the descriptive number used in Product/Service ID (234).

Position: SV3-02 · Element: 234 · Name: Product/Service ID · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 30 · Repeat: -

Identifying number for a product or service.

Position: SV3-03 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

Monetary amount.

SV303 is submitted charge amount.

Position: SV3-04 · Element: 1331 · Name: Facility Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility where services were performed; the first position of the uniform bill type or place of service from health care financing administration claim form or place of treatment from the dental claim form

SV304 is place of service or treatment.

Position: SV3-05 · Element: 127 · Name: Reference Number · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 30 · Repeat: -

Reference number or identification number as defined for a particular Transaction Set, or as specified by the Reference Number Qualifier.

SV305 is tooth number.

Position: SV3-06 · Element: 1369 · Name: Tooth Surface Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the area of the tooth that was treated

Position: SV3-07 · Element: 1361 · Name: Dental Quadrant Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: -

Code identifying the dental quadrant of the mouth in which service is rendered

Position: SV3-08 · Element: 1358 · Name: Prosthesis, Crown or Inlay Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code specifying the placement status for the dental work

Position: SV3-09 · Element: 380 · Name: Quantity · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

Numeric value of quantity.

SV309 is number of procedures.

Position: SV3-10 · Element: 352 · Name: Description · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 80 · Repeat: -

A free-form description to clarify the related data elements and their content.

SV310 is reason for replacement.

Position: SV3-11 · Element: 1327 · Name: Copay Status Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating whether or not co-payment requirements were met on a line by line basis

Position: SV3-12 · Element: 1360 · Name: Provider Agreement Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code indicating the type of agreement under which the provider is submitting this claim