SV3 Dental Service

To specify the claim service detail for dental work

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Position

Element

Name

Type

Requirement

Min

Max

Repeat

SV3-01

Composite Medical Procedure Identifier

Composite (composite)

Mandatory

Product/Service ID Qualifier

Identifier (ID)

Mandatory

2

2

-

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

Product/Service ID

String (AN)

Mandatory

1

40

-

Identifying number for a product or service

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.

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.

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.

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.

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.

Monetary Amount

Decimal number (R)

Optional

1

15

-

Monetary amount

SV302 is a submitted charge amount.

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 the place of service code representing the location where the dental treatment was rendered.

SV3-04

Oral Cavity Designation

Composite (composite)

Optional

Oral Cavity Designation Code

Identifier (ID)

Mandatory

1

3

-

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

Oral Cavity Designation Code

Identifier (ID)

Optional

1

3

-

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

Oral Cavity Designation Code

Identifier (ID)

Optional

1

3

-

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

Oral Cavity Designation Code

Identifier (ID)

Optional

1

3

-

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

Oral Cavity Designation Code

Identifier (ID)

Optional

1

3

-

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

Prosthesis, Crown or Inlay Code

Identifier (ID)

Optional

1

1

-

Code specifying the placement status for the dental work

Quantity

Decimal number (R)

Optional

1

15

-

Numeric value of quantity

SV306 is the number of procedures.

Description

String (AN)

Optional

1

80

-

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

SV307 is the reason for replacement.

Copay Status Code

Identifier (ID)

Optional

1

1

-

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

Provider Agreement Code

Identifier (ID)

Optional

1

1

-

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

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.

SV3-11

Composite Diagnosis Code Pointer

Composite (composite)

Optional

Diagnosis Code Pointer

Numeric (N0)

Mandatory

1

2

-

A pointer to the claim diagnosis code in the order of importance to this service

C004-01 identifies the primary diagnosis code for this service line.

Diagnosis Code Pointer

Numeric (N0)

Optional

1

2

-

A pointer to the claim diagnosis code in the order of importance to this service

C004-02 identifies the second diagnosis code for this service line.

Diagnosis Code Pointer

Numeric (N0)

Optional

1

2

-

A pointer to the claim diagnosis code in the order of importance to this service

C004-03 identifies the third diagnosis code for this service line.

Diagnosis Code Pointer

Numeric (N0)

Optional

1

2

-

A pointer to the claim diagnosis code in the order of importance to this service

C004-04 identifies the fourth diagnosis code for this service line.