Segment
X12 EDI Release 00304
To specify the claim service detail for dental work
Elements
  • SV301C003Composite Medical Procedure IdentifierM必须(Mandatory)
    2352341339133913391339352
    • SV30101235Product/Service ID Qualifier
      ID
      M必须(Mandatory)

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

      Codes (307)
    • SV30102234Product/Service ID
      AN
      M必须(Mandatory)
      Min 0 / Max 30

      Identifying number for a product or service.

    • SV301031339Procedure Modifier
      AN
      O可选(Optional)
      Min 2 / Max 2

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

    • SV301041339Procedure Modifier
      AN
      O可选(Optional)
      Min 2 / Max 2

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

    • SV301051339Procedure Modifier
      AN
      O可选(Optional)
      Min 2 / Max 2

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

    • SV301061339Procedure Modifier
      AN
      O可选(Optional)
      Min 2 / Max 2

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

    • SV30107352Description
      AN
      O可选(Optional)
      Min 1 / Max 80

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

  • SV302782Monetary Amount
    R
    M必须(Mandatory)
    Min 1 / Max 15

    Monetary amount.

  • SV3031331Facility Code Value
    AN
    O可选(Optional)
    Min 1 / Max 2

    Code identifying the type of facility where services were performed; the first and second position of the uniform bill type or place of service from health care financing administration claim form, or place of treatment from the dental claim form

  • SV304127Reference Number
    AN
    O可选(Optional)
    Min 1 / Max 30

    Reference number or identification number as defined for a particular Transaction Set, or as specified by the Reference Number Qualifier.

  • SV3051369Tooth Surface Code
    ID
    O可选(Optional)

    Code identifying the area of the tooth that was treated

    Codes (7)
  • SV3061361Dental Quadrant Code
    ID
    O可选(Optional)

    Code identifying the dental quadrant of the mouth in which service is rendered

    Codes (9)
  • SV3071358Prosthesis, Crown or Inlay Code
    ID
    O可选(Optional)

    Code specifying the placement status for the dental work

    Codes (2)
  • SV308380Quantity
    R
    O可选(Optional)
    Min 1 / Max 15

    Numeric value of quantity.

  • SV309352Description
    AN
    O可选(Optional)
    Min 1 / Max 80

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

  • SV3101327Copay Status Code
    ID
    O可选(Optional)

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

    Codes (4)
  • SV3111360Provider Agreement Code
    ID
    O可选(Optional)

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

    Codes (7)