Segment
X12 EDI Release 00303
To specify the claim service detail for dental work
Elements
  • SV301235Product/Service ID Qualifier
    ID
    M必须(Mandatory)

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

    Codes (275)
  • SV302234Product/Service ID
    AN
    M必须(Mandatory)
    Min 1 / Max 30

    Identifying number for a product or service.

  • SV303782Monetary Amount
    R
    O可选(Optional)
    Min 1 / Max 15

    Monetary amount.

  • SV3041331Facility Code
    ID
    O可选(Optional)
    Min 1 / Max 2

    Code identifying the type of facility where services were performed; the first 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

  • SV305127Reference 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.

  • SV3061369Tooth Surface Code
    ID
    O可选(Optional)

    Code identifying the area of the tooth that was treated

    Codes (7)
  • SV3071361Dental Quadrant Code
    ID
    O可选(Optional)

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

    Codes (9)
  • SV3081358Prosthesis, Crown or Inlay Code
    ID
    O可选(Optional)

    Code specifying the placement status for the dental work

    Codes (2)
  • SV309380Quantity
    R
    O可选(Optional)
    Min 1 / Max 15

    Numeric value of quantity.

  • SV310352Description
    AN
    O可选(Optional)
    Min 1 / Max 80

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

  • SV3111327Copay 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)
  • SV3121360Provider Agreement Code
    ID
    O可选(Optional)

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

    Codes (7)