Please explain the SV306 situational rule and its relationship to rejecting a 837D. The situational rule explains that the quantity is required when the procedure in the SV301-2 was performed more than once, and is not required to identify areas of the oral cavity or individual teeth.
We have noticed some confusion within the industry in regards to how a trading partner is to handle validation of the SV306. Some dental trading partners send a value in the SV306 and in many cases this value is 1. Other dental trading partners only send a value in the SV306 if the value is greater than 1. The confusion on the SV306 originates from the following three areas: the situational rule that explains quantity is required when the procedure reported in the SV301-2 was performed more than once; multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID 2400 SV306 is equal to one; and finally the information on Rejecting Claims Based on the Inclusion of Situational Data.
Reference: 005010X224
The situational rule for SV306 reads "Required when the procedure reported in SV301-2 was performed more than once and it is not required to identify areas of the oral cavity or individual teeth. If not required, do not send." The operative phrase is "performed more than once". As a result, the default value when SV306 is not present is "1". Reporting of SV306 with a value of "1" is prohibited by the guide.
The TR3 Note on the TOO segment reads "Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one."
When multiple teeth are involved in mutiple units of a service and the teeth/oral cavity must be identified, then each service line must be reported with one unit of service (SV306 not present). If identification of the teeth/oral cavities is not required, then multiple units may be reported in SV306 for a single 2400 loop.
Guidance for rejecting of transactions is provided in RFI # 1512.
Section 1.12.2 (Rejecting Claims Based on the Inclusion of Situational Data) starts "This implementation guide contains a number of Situational Rules which state the element or segment is required when a payer's adjudication is known to be impacted by the information." These segments/elements don't include such a situational rule and the section is not applicable.
Prior Related RFI: 1304