SV3 Dental Service

To specify the claim service detail for dental work

Position

Element

Name

Type

Requirement

Min

Max

Repeat

SV3-01 C003 Composite Medical Procedure Identifier Composite (composite) Mandatory

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).

02 · 234 · Product/Service ID · String (AN) · Mandatory · 1 · 30 · -

Identifying number for a product or service.

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.

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.

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.

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.

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.

SV3-02 · 782 · Monetary Amount · Decimal number (R) · Mandatory · 1 · 15 · -

Monetary amount.

SV302 is submitted charge amount.

SV3-03 · 1331 · Facility Code Value · String (AN) · Optional · 1 · 2 · -

Code identifying the type of facility where services were performed; the first and second 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

SV303 is place of service or treatment.

SV3-04 · 127 · Reference Number · String (AN) · Optional · 1 · 30 · -

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

SV304 is tooth number

SV3-05 · 1369 · Tooth Surface Code · Identifier (ID) · Optional · 1 · 2 · -

Code identifying the area of the tooth that was treated

SV3-06 · 1361 · Dental Quadrant Code · Identifier (ID) · Optional · 1 · 3 · -

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

SV3-07 · 1358 · Prosthesis, Crown or Inlay Code · Identifier (ID) · Optional · 1 · 1 · -

Code specifying the placement status for the dental work

SV3-08 · 380 · Quantity · Decimal number (R) · Optional · 1 · 15 · -

Numeric value of quantity.

SV308 is number of procedures.

SV3-09 · 352 · Description · String (AN) · Optional · 1 · 80 · -

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

SV309 is reason for replacement.

SV3-10 · 1327 · Copay Status Code · Identifier (ID) · Optional · 1 · 1 · -

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

SV3-11 · 1360 · Provider Agreement Code · Identifier (ID) · Optional · 1 · 1 · -

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