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Segment
in
X12 Release 003030

SV4 Drug Service

To specify the claim service detail for prescription drugs
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
127
Reference Number
String (AN)
Mandatory
1
30
-
Reference number or identification number as defined for a particular Transaction Set, or as specified by the Reference Number Qualifier.
SV401 is prescription number.
02
Product/Service ID Qualifier
Identifier (ID)
Conditional
2
2
-
Code identifying the type/source of the descriptive number used in Product/Service ID (234).
P0203
Codes (275)
03
Product/Service ID
String (AN)
Conditional
1
30
-
Identifying number for a product or service.
SV403 is national drug code (NDC).
04
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.
SV404 is new or refill number. A value of zero indicates a new prescription. Any other value is the refill number of an existing prescription.
05
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
SV405 is generic indicator. A ``Y'' value indicates a generic drug. An ``N'' value indicates a branded drug.
Codes (3)
06
Dispense as Written Code
Identifier (ID)
Optional
1
1
-
Code indicating whether or not the prescriber's instructions regarding generic substitution were followed
Codes (8)
07
Level of Service Code
Identifier (ID)
Optional
1
3
-
Code specifying the level of service rendered
Codes (10)
08
Prescription Origin Code
Identifier (ID)
Optional
1
1
-
Code indicating the origin of a prescription
Codes (4)
09
Description
String (AN)
Optional
1
80
-
A free-form description to clarify the related data elements and their content.
SV409 is drug name.
10
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
SV410 is multi-source indicator. A ``Y'' value indicates drug is available from more than one manufacturer. A ``N'' value indicates drug is available from one manufacturer.
Codes (3)
11
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
SV411 is compound indicator. A ``Y'' value indicates a compound drug. An ``N'' value indicates a non-compound drug. A ``U'' value indicates a non-specified drug compound.
Codes (3)
12
Unit Dose Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of unit dose dispensing done
Codes (4)
13
Basis of Cost Determination Code
Identifier (ID)
Optional
1
2
-
Code indicating the method by which the ingredient cost was calculated
Codes (10)
14
Basis of Days Supply Determination Code
Identifier (ID)
Optional
1
1
-
Code indicating the method by which the days supply was determined
Codes (4)
15
Dosage Form Code
Identifier (ID)
Optional
2
2
-
Code indicating the form in which the drug is dispensed
Codes (60)
16
Copay Status Code
Identifier (ID)
Optional
1
1
-
Code indicating whether or not co-payment requirements were met on a line by line basis
Codes (4)
17
Patient Location Code
Identifier (ID)
Optional
1
1
-
Code identifying the location where patient is receiving medical treatment
Codes (5)
18
Level of Care Code
Identifier (ID)
Optional
1
1
-
Code specifying the level of care provided by a nursing home facility
Codes (7)
19
Prior Authorization Type Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of prior authorization or medical certification that has occurred
Codes (8)
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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.