Segment
X12 EDI Release 00504
To specify the service line item detail for dental work
Elements
  • SV301C003Composite Medical Procedure IdentifierM必须(Mandatory)
    23523413391339133913393522341339133913391339
    • 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 (511)
    • SV30102234Product/Service ID
      AN
      M必须(Mandatory)
      Min 0 / Max 48

      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

    • SV30108234Product/Service ID
      AN
      O可选(Optional)
      Min 1 / Max 48

      Identifying number for a product or service

    • SV301091339Procedure 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

    • SV301101339Procedure 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

    • SV301111339Procedure 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

    • SV301121339Procedure 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

  • SV302782Monetary Amount
    R
    O可选(Optional)
    Min 1 / Max 18

    Monetary amount

  • SV3031331Facility Code Value
    AN
    O可选(Optional)
    Min 1 / Max 3

    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.

  • SV304C006Oral Cavity DesignationO可选(Optional)
    13611361136113611361
    • SV304011361Oral Cavity Designation Code
      ID
      M必须(Mandatory)
      Min 0 / Max 3

      Code Identifying the area of the oral cavity in which service is rendered

    • SV304021361Oral Cavity Designation Code
      ID
      O可选(Optional)
      Min 1 / Max 3

      Code Identifying the area of the oral cavity in which service is rendered

    • SV304031361Oral Cavity Designation Code
      ID
      O可选(Optional)
      Min 1 / Max 3

      Code Identifying the area of the oral cavity in which service is rendered

    • SV304041361Oral Cavity Designation Code
      ID
      O可选(Optional)
      Min 1 / Max 3

      Code Identifying the area of the oral cavity in which service is rendered

    • SV304051361Oral Cavity Designation Code
      ID
      O可选(Optional)
      Min 1 / Max 3

      Code Identifying the area of the oral cavity in which service is rendered

  • SV3051358Prosthesis, Crown or Inlay Code
    ID
    O可选(Optional)

    Code specifying the placement status for the dental work

    Codes (2)
  • SV306380Quantity
    R
    O可选(Optional)
    Min 1 / Max 15

    Numeric value of quantity

  • SV307352Description
    AN
    O可选(Optional)
    Min 1 / Max 80

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

  • SV3081327Copay 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)
  • SV3091360Provider Agreement Code
    ID
    O可选(Optional)

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

    Codes (7)
  • SV3101073Yes/No Condition or Response Code
    ID
    O可选(Optional)

    Code indicating a Yes or No condition or response

    Codes (4)
  • SV311C004Composite Diagnosis Code PointerO可选(Optional)
    1328132813281328
    • SV311011328Diagnosis Code Pointer
      N
      M必须(Mandatory)
      Min 0 / Max 2

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

    • SV311021328Diagnosis Code Pointer
      N
      O可选(Optional)
      Min 1 / Max 2

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

    • SV311031328Diagnosis Code Pointer
      N
      O可选(Optional)
      Min 1 / Max 2

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

    • SV311041328Diagnosis Code Pointer
      N
      O可选(Optional)
      Min 1 / Max 2

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