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Segment
in
X12 Release 008010

SV3 Dental Service

To specify the service line item detail for dental work
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
C003
Composite Medical Procedure Identifier
Composite (composite)
Mandatory
1
01
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.
Codes (544)
02
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
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
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
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
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
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
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
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
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
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
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.
02
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
SV302 is the submitted service line item amount.
03
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.
04
Oral Cavity Designation
Composite (composite)
Optional
1
01
Oral Cavity Designation Code
Identifier (ID)
Mandatory
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
02
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
03
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
04
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
05
Oral Cavity Designation Code
Identifier (ID)
Optional
1
3
-
Code Identifying the area of the oral cavity in which service is rendered
05
Prosthesis, Crown or Inlay Code
Identifier (ID)
Optional
1
1
1
Code specifying the placement status for the dental work
Codes (2)
06
Quantity
Decimal number (R)
Optional
1
15
1
Numeric value of quantity
SV306 is the number of procedures.
07
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.
08
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
Codes (4)
09
Provider Agreement Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)
10
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.
Codes (9)
11
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.
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.
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.