SV4 Drug Service
Opt
AtMax 1
To specify the claim service detail for prescription drugs
Elements
| Position | Element | Name | Type | Min/Max | Repeat | ||
|---|---|---|---|---|---|---|---|
| 1 | 127 | Reference Identification | Mandatory | Alphanumeric | 1/80 | AtMax 1 | |
AtMax 1 | |||||||
| 3 | 127 | Reference Identification | Opt | Alphanumeric | 1/80 | AtMax 1 | |
| 4 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 5 | 1329 | Dispense as Written Code | Opt | ID | 1/1 | AtMax 1 | |
| 6 | 1338 | Level of Service Code | Opt | ID | 1/3 | AtMax 1 | |
| 7 | 1356 | Prescription Origin Code | Opt | ID | 1/1 | AtMax 1 | |
| 8 | 352 | Description | Opt | Alphanumeric | 1/80 | AtMax 1 | |
| 9 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 10 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | AtMax 1 | |
| 11 | 1370 | Unit Dose Code | Opt | ID | 1/1 | AtMax 1 | |
| 12 | 1319 | Basis of Cost Determination Code | Opt | ID | 1/2 | AtMax 1 | |
| 13 | 1320 | Basis of Days Supply Determination Code | Opt | ID | 1/1 | AtMax 1 | |
| 14 | 1330 | Dosage Form Code | Opt | ID | 2/2 | AtMax 1 | |
| 15 | 1327 | Copay Status Code | Opt | ID | 1/1 | AtMax 1 | |
| 16 | 1384 | Patient Location Code | Opt | ID | 1/1 | AtMax 1 | |
| 17 | 1337 | Level of Care Code | Opt | ID | 1/1 | AtMax 1 | |
| 18 | 1357 | Prior Authorization Type Code | Opt | ID | 1/1 | AtMax 1 | |
| 19 | 1734 | Submission Clarification Code | Opt | ID | 1/2 | AtMax 1 | |
| 20 | 1735 | Additional Drug Coverage Code | Opt | ID | 1/2 | AtMax 1 | |
| 21 | 1736 | Compound Route of Administration Code | Opt | ID | 1/2 | AtMax 1 | |
| 22 | 1737 | Submitted Drug Sales Tax Code | Opt | ID | 2/2 | AtMax 1 | |
| 23 | 954 | Percentage as Decimal | Opt | Decimal | 1/10 | AtMax 1 | |
| 24 | 782 | Monetary Amount | Opt | Decimal | 1/18 | AtMax 1 | |
Element Details
ID127
NameReference Identification
LengthMin 1 / Max 80
Position1
RequirementMandatory