SV3 Dental Service

To specify the service line item detail for dental work

Position

Element

Name

Type

Requirement

Min

Max

Repeat

SV3-01 C003 Composite Medical Procedure Identifier Composite (composite) Mandatory 1

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)

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

02 · 234 · Product/Service ID · String (AN) · Mandatory · 1 · 80 · -

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.

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 and C003-08.

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 and C003-08.

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 and C003-08.

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 and C003-08.

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.

08 · 234 · Product/Service ID · String (AN) · Optional · 1 · 80 · -

Identifying number for a product or service

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

09 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

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

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

10 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

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

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

11 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

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

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

12 · 1339 · Procedure Modifier · String (AN) · Optional · 2 · 2 · -

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

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

SV3-02 · 782 · Monetary Amount · Decimal number (R) · Optional · 1 · 18 · 1

Monetary amount

SV302 is the submitted service line item amount.

SV3-03 · 1331 · Facility Code Value · String (AN) · Optional · 1 · 3 · 1

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

SV303 is the place of service code representing the location where the dental treatment was rendered.

SV3-04 C006 Oral Cavity Designation Composite (composite) Optional 1

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 · 1

Code specifying the placement status for the dental work

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

Numeric value of quantity

SV306 is the number of procedures.

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

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

SV307 is the reason for replacement.

SV3-08 · 1327 · Copay Status Code · Identifier (ID) · Optional · 1 · 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 · 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 · 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 · 1328 · Diagnosis Code Pointer · Numeric (N0) · Optional · 1 · 2 · 12

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

The first pointer designates the primary diagnosis and remaining diagnosis pointers indicate declining level of importance.