| # | 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 | CareTeamClaimScope | hl7.fhir.us.davinci-pas#current | R4 | A flag that indicates whether the care team applies to the entire claim or a single item. | |
| 4 | CertificationEffectiveDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization became effective. | |
| 5 | CertificationEffectiveDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization became effective. | |
| 6 | CertificationExpirationDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization expires. | |
| 7 | CertificationExpirationDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization expires. | |
| 8 | CertificationIssueDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization was issued. | |
| 9 | CertificationIssueDate | hl7.fhir.us.davinci-pas#current | R4 | The specific date or period within which this item's preauthorization was issued. | |
| 10 | CertificationType | hl7.fhir.us.davinci-pas#current | R4 | A code representing the type of certification being requested (UM02) | |
| 11 | CertificationType | hl7.fhir.us.davinci-pas#current | R4 | A code representing the type of certification being requested (UM02) | |
| 12 | ConditionCode | hl7.fhir.us.davinci-pas#current | R4 | Information to supply various patient conditions. | |
| 13 | DiagnosisRecordedDate | hl7.fhir.us.davinci-pas#current | R4 | The date that a diagnosis was recorded. (HIxx-4) | |
| 14 | EPSDTIndicator | hl7.fhir.us.davinci-pas#current | R4 | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. | |
| 15 | HomeHealthCareInformation | hl7.fhir.us.davinci-pas#current | R4 | Information needed for home health care requests. | |
| 16 | InfoCancelledFlag | hl7.fhir.us.davinci-pas#current | R4 | A flag indicating whether the piece of information was cancelled. | |
| 17 | InfoChanged | hl7.fhir.us.davinci-pas#current | R4 | A code indicating how the piece of information has changed. | |
| 18 | ItemTraceNumber | hl7.fhir.us.davinci-pas#current | R4 | Uniquely identifies this claim item. (2000F-TRN) | |
| 19 | LevelOfServiceCode | hl7.fhir.us.davinci-pas#current | R4 | A code specifying the level of service being requested (UM06) | |
| 20 | NursingHomeLevelOfCare | hl7.fhir.us.davinci-pas#current | R4 | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) | |
| 21 | NursingHomeResidentialStatus | hl7.fhir.us.davinci-pas#current | R4 | A code specifying the status of a nursing home resident at the time of service. (SV209) | |
| 22 | ProductOrServiceCodeEnd | hl7.fhir.us.davinci-pas#current | R4 | Used to provide the last code in a series of codes for the service being requested. | |
| 23 | RequestedService | hl7.fhir.us.davinci-pas#current | R4 | The details of the service being requested. | |
| 24 | RevenueUnitRateLimit | hl7.fhir.us.davinci-pas#current | R4 | The limit on the rate per unit of revenue for hospital accomodation. (SV206) | |
| 25 | ReviewAction | hl7.fhir.us.davinci-pas#current | R4 | The details of the review action that is necessary for the authorization. | |
| 26 | ReviewActionCode | hl7.fhir.us.davinci-pas#current | R4 | The code describing the result of the review. | |
| 27 | ServiceItemRequestType | hl7.fhir.us.davinci-pas#current | R4 | A code that identifies the type of service being requested. |
| 1 | 2 | 3 | 5 | 5 | 7 | 7 | 9 | 9 | 11 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | |
| Extension | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D | D |
| Extension.extension | C | C | C | C | C | C | C | C | C | C | C | S C (4) | C | C | S C (3) | C | C | C | C | C | C | C | C | C | S C (4) | C | C |
| Extension.extension.value[x] | B M (3) | I B M (2) | B M (3) | ||||||||||||||||||||||||
| Extension.extension.url | F (3) | F (2) | F (3) | ||||||||||||||||||||||||
| Extension.extension.extension | C (3) | 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] | S C I (3) | S C I (3) | S C I (3) | S C I (3) | S C I (3) | S C I (3) | B M | B M | C | I | C | B M | B M | B M | B M | C | B M | B M | |||||||||
| Extension.value[x].end | I | I | I | I | I | I | |||||||||||||||||||||
| Extension.value[x].start | I | I | I | I | I | I |
Produced 08 Sep 2023