| # | Name | Source | Ver | Description | |
| 1 | AdministrationReferenceNumber | hl7.fhir.us.davinci-pas#current | R4 | A string assigned by the UMO to the original disallowed review outcome associated with this service item. | |
| 2 | AuthorizationNumber | hl7.fhir.us.davinci-pas#current | R4 | A string assigned by the UMO to an authorized review outcome associated with this service item. | |
| 3 | BeExtEtariffAdjudicationRefusalservicedate | hl7.fhir.be.etariff#current | R4 | Date of the refusal service | |
| 4 | BeExtEtariffAdjudicationRefusalserviceidentifier | hl7.fhir.be.etariff#current | R4 | Id of the preauthorization of the item | |
| 5 | BeExtEtariffItemCommitment | hl7.fhir.be.etariff#current | R4 | tariff commitment number | |
| 6 | BeExtItemPatientFee | hl7.fhir.be.mycarenet#current | R4 | Sum to be paid by the patient per item | |
| 7 | BeExtItemReimbursement | hl7.fhir.be.mycarenet#current | R4 | Reimbursement for the patient per item | |
| 8 | EPSDTIndicator | hl7.fhir.us.davinci-pas#current | R4 | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. | |
| 9 | ErrorElement | hl7.fhir.us.davinci-pas#current | R4 | The specific loop, segment, or element that this error information is about. | |
| 10 | ErrorFollowupAction | hl7.fhir.us.davinci-pas#current | R4 | A code representing what action must occur to resolve this error. | |
| 11 | ErrorPath | hl7.fhir.us.davinci-pas#current | R4 | The FHIRPath expression that indicates which FHIR element that this error information is about. | |
| 12 | ItemAuthorizedDetail | hl7.fhir.us.davinci-pas#current | R4 | The details of what has been authorized for this item if different from what was requested. | |
| 13 | ItemAuthorizedProvider | hl7.fhir.us.davinci-pas#current | R4 | The specific provider who has been authorized to provide this item. | |
| 14 | ItemPreAuthIssueDate | hl7.fhir.us.davinci-pas#current | R4 | The date when this item's preauthorization was issued. | |
| 15 | ItemPreAuthPeriod | hl7.fhir.us.davinci-pas#current | R4 | The date/period when this item's preauthorization is valid. | |
| 16 | ItemRequestedServiceDate | hl7.fhir.us.davinci-pas#current | R4 | The original date/period that was requested by the submitter for this item. | |
| 17 | ItemTraceNumber | hl7.fhir.us.davinci-pas#current | R4 | Uniquely identifies this claim item. (2000F-TRN) | |
| 18 | NursingHomeLevelOfCare | hl7.fhir.us.davinci-pas#current | R4 | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) | |
| 19 | ProductOrServiceCodeEnd | hl7.fhir.us.davinci-pas#current | R4 | Used to provide the last code in a series of codes for the service being requested. | |
| 20 | RequestedService | hl7.fhir.us.davinci-pas#current | R4 | The details of the service being requested. | |
| 21 | RevenueUnitRateLimit | hl7.fhir.us.davinci-pas#current | R4 | The limit on the rate per unit of revenue for hospital accomodation. (SV206) | |
| 22 | ReviewAction | hl7.fhir.us.davinci-pas#current | R4 | The details of the review action that is necessary for the authorization. | |
| 23 | ReviewActionCode | hl7.fhir.us.davinci-pas#current | R4 | The code describing the result of the review. | |
| 24 | ReviewActionCode | hl7.fhir.us.davinci-pas#current | R4 | The code describing the result of the review. | |
| 25 | RTPBC benefitRestriction Extension | hl7.fhir.us.carin-rtpbc#1.0.0 | R4 | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination. | |
| 26 | RTPBC benefitRestriction Extension | hl7.fhir.us.carin-rtpbc#1.0.0 | R4 | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination. | |
| 27 | RTPBC isAlternative Extension | hl7.fhir.us.carin-rtpbc#1.0.0 | R4 | This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service. |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 24 | 24 | 26 | 26 | 27 | |
| Extension | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | C D | C D | C D | |||||
| Extension.extension | C | C | C | C | C | C | C | C | C | C | C | S C (10) | S C (2) | C | C | C | C | C | C | C | C | S C (4) | C | C | C | C | C |
| Extension.extension.value[x] | B M (5) | B M (2) | B M (3) | ||||||||||||||||||||||||
| Extension.extension.url | F (5) | F (2) | F (3) | ||||||||||||||||||||||||
| Extension.extension.extension | C (5) | C (2) | C (3) | ||||||||||||||||||||||||
| Extension.url | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F | F |
| Extension.value[x] | C | S C (2) | C | C | C | B M | C | C | B M | B M | C | B M | B M | C B M | C B M | C | |||||||||||
| Extension.value[x].coding | |||||||||||||||||||||||||||
| Extension.value[x].coding.system | F |
Produced 08 Sep 2023