To specify the service line item detail for a health care professional
TRANSACTION SETS USED IN:
| 278 | 837 |
| REF | ELE ID | NAME | RPT | ATTRIBUTES | ||
|---|---|---|---|---|---|---|
| 01 | C003 | Composite Medical Procedure Identifier | M | |||
| 02 | 782 | Monetary Amount | O/Z | R | 1/18 | |
| 03 | 355 | Unit or Basis for Measurement Code | X | ID | 2/2 | |
| 04 | 380 | Quantity | X | R | 1/15 | |
| 05 | 1331 | Facility Code Value | O/Z | AN | 1/2 | |
| 06 | 1365 | Service Type Code | O | ID | 1/2 | |
| 07 | C004 | Composite Diagnosis Code Pointer | O | |||
| 08 | 782 | Monetary Amount | O/Z | R | 1/18 | |
| 09 | 1073 | Yes/No Condition or Response Code | O/Z | ID | 1/1 | |
| 10 | 1340 | Multiple Procedure Code | O | ID | 1/2 | |
| 11 | 1073 | Yes/No Condition or Response Code | O/Z | ID | 1/1 | |
| 12 | 1073 | Yes/No Condition or Response Code | O/Z | ID | 1/1 | |
| 13 | 1364 | Review Code | O | ID | 1/2 | |
| 14 | 1341 | National or Local Assigned Review Value | O | AN | 1/2 | |
| 15 | 1327 | Copay Status Code | O | ID | 1/1 | |
| 16 | 1334 | Health Care Professional Shortage Area Code | O | ID | 1/1 | |
| 17 | 127 | Reference Identification | O/Z | AN | 1/50 | |
| 18 | 116 | Postal Code | O/Z | ID | 3/15 | |
| 19 | 782 | Monetary Amount | O/Z | R | 1/18 | |
| 20 | 1337 | Level of Care Code | O | ID | 1/1 | |
| 21 | 1360 | Provider Agreement Code | O | ID | 1/1 | |
| Syntax Notes | |
| 03 | P0304 - If either SV103 or SV104 is present, then the other is required. |
| Semantic Notes | |
| 02 | SV102 is the submitted service line item amount. |
| 05 | SV105 is the place of service. |
| 08 | SV108 is the independent lab charges. |
| 09 | SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. |
| 11 | SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. |
| 12 | SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. |
| 17 | SV117 is the health care manpower shortage area (HMSA) facility identification. |
| 18 | SV118 is the health care manpower shortage area (HMSA) zip code. |
| 19 | SV119 is a non-covered service amount. |
| Comments | |
| 13 | If SV113 is equal to "L" or "N", then SV114 is required. |