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 · 40 · -

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) · Optional · 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 positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format

SV303 is Place of Service code representing the location where the Dental treatment was rendered.

SV3-04 C006 Oral Cavity Designation Composite (composite) Optional

01 · 1361 · Oral Cavity Designation Code · Identifier (ID) · Mandatory · 1 · 3 · -

Code Identifying the area of the oral cavity in which service is rendered

02 · 1361 · Oral Cavity Designation Code · Identifier (ID) · Optional · 1 · 3 · -

Code Identifying the area of the oral cavity in which service is rendered

03 · 1361 · Oral Cavity Designation Code · Identifier (ID) · Optional · 1 · 3 · -

Code Identifying the area of the oral cavity in which service is rendered

04 · 1361 · Oral Cavity Designation Code · Identifier (ID) · Optional · 1 · 3 · -

Code Identifying the area of the oral cavity in which service is rendered

05 · 1361 · Oral Cavity Designation Code · Identifier (ID) · Optional · 1 · 3 · -

Code Identifying the area of the oral cavity in which service is rendered

SV3-05 · 1358 · Prosthesis, Crown or Inlay Code · Identifier (ID) · Optional · 1 · 1 · -

Code specifying the placement status for the dental work

SV3-06 · 380 · Quantity · Decimal number (R) · Optional · 1 · 15 · -

Numeric value of quantity.

SV306 is number of procedures.

SV3-07 · 352 · Description · String (AN) · Optional · 1 · 80 · -

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

SV307 is reason for replacement.

SV3-08 · 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

SV3-09 · 1360 · Provider Agreement Code · Identifier (ID) · Optional · 1 · 1 · -

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

SV3-10 · 1073 · Yes/No Condition or Response Code · Identifier (ID) · Optional · 1 · 1 · -

Code indicating a Yes or No condition or response.

SV310 is the predetermination of benefits indicator. A ``Y'' value indicates that this service is being submitted for predetermination of benefits.