SV4 Drug Service

To specify the claim service detail for prescription drugs

Position: SV4-01 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 80 · Repeat: 1

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SV401 is a prescription number.

SV4-02 C003 Composite Medical Procedure Identifier Composite (composite) Optional 1

Position: 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)

C003-01 qualifies C003-02 and C003-08.

Position: 02 · Element: 234 · Name: Product/Service ID · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 48 · Repeat: -

Identifying number for a product or service

If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.

Position: 03 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-03 modifies the value in C003-02 and C003-08.

Position: 04 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-04 modifies the value in C003-02 and C003-08.

Position: 05 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-05 modifies the value in C003-02 and C003-08.

Position: 06 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-06 modifies the value in C003-02 and C003-08.

Position: 07 · 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

C003-07 is the description of the procedure identified in C003-02.

Position: 08 · Element: 234 · Name: Product/Service ID · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 48 · Repeat: -

Identifying number for a product or service

C003-08 represents the ending value in the range in which the code occurs.

Position: 09 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-09 modifies the value in C003-02 and C003-08.

Position: 10 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-10 modifies the value in C003-02 and C003-08.

Position: 11 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-11 modifies the value in C003-02 and C003-08.

Position: 12 · Element: 1339 · Name: Procedure Modifier · Type: String (AN) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

This identifies special circumstances related to the performance of the service, as defined by trading partners

C003-12 modifies the value in C003-02 and C003-08.

Position: SV4-03 · Element: 127 · Name: Reference Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 80 · Repeat: 1

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SV403 is a new or refill number. A value of zero indicates a new prescription, any other value is the refill number of an existing prescription.

Position: SV4-04 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

SV404 is the generic indicator. A "Y" value indicates a generic drug; an "N" value indicates a branded drug.

Position: SV4-05 · Element: 1329 · Name: Dispense as Written Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating whether or not the prescriber's instructions regarding generic substitution were followed

Position: SV4-06 · Element: 1338 · Name: Level of Service Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: 1

Code specifying the level of service rendered

Position: SV4-07 · Element: 1356 · Name: Prescription Origin Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating the origin of a prescription

Position: SV4-08 · Element: 352 · Name: Description · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 80 · Repeat: 1

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

SV408 is the drug name.

Position: SV4-09 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

SV409 is the multisource indicator. A "Y" indicates drug is available from more than one manufacturer; an "N" value indicates drug is available from one manufacturer.

Position: SV4-10 · Element: 1073 · Name: Yes/No Condition or Response Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating a Yes or No condition or response

SV410 is the compound indicator. A "Y" indicates a compound drug; an "N" value indicates a noncompound drug. A "U" value indicates a nonspecified drug compound.

Position: SV4-11 · Element: 1370 · Name: Unit Dose Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating the type of unit dose dispensing done

Position: SV4-12 · Element: 1319 · Name: Basis of Cost Determination Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating the method by which the ingredient cost was calculated

Position: SV4-13 · Element: 1320 · Name: Basis of Days Supply Determination Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating the method by which the days supply was determined

Position: SV4-14 · Element: 1330 · Name: Dosage Form Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: 1

Code indicating the form in which the drug is dispensed

Position: SV4-15 · Element: 1327 · Name: Copay Status Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

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

Position: SV4-16 · Element: 1384 · Name: Patient Location Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code identifying the location where patient is receiving medical treatment

Position: SV4-17 · Element: 1337 · Name: Level of Care Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code specifying the level of care provided by a nursing home facility

Position: SV4-18 · Element: 1357 · Name: Prior Authorization Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating the type of prior authorization or medical certification that has occurred

Position: SV4-19 · Element: 1734 · Name: Submission Clarification Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating that the pharmacist is clarifying the submission

Position: SV4-20 · Element: 1735 · Name: Additional Drug Coverage Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating whether or not the patient has other insurance coverage

Position: SV4-21 · Element: 1736 · Name: Compound Route of Administration Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating the route of administration of the complete compound mixture

Position: SV4-22 · Element: 1737 · Name: Submitted Drug Sales Tax Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: 1

Code indicating the basis for percentage sales tax

Position: SV4-23 · Element: 954 · Name: Percentage as Decimal · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 10 · Repeat: 1

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SV423 is the submitted drug sales tax rate used to calculate the submitted drug sales tax amount.

Position: SV4-24 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 18 · Repeat: 1

Monetary amount

SV424 is the submitted drug sales tax amount.