| Lvl | Code | Display | Definition | Not Selectable | Not Selectable |
| 1 | _limitation | Limitation details | Identifies detail codes that define limitations of coverage. (Category should be 'cat-limitation') | true, true | true, true |
| 2 | allowed-quantity | Maximum quantity | Indicates limitations on the number of services/products allowed (possibly per time period). Value should be a Quantity | | |
| 2 | allowed-period | Maximum allowed period | Indicates the maximum period of time that can be covered in a single order. Value should be a Period | | |
| 2 | allowed-quantity | Maximum quantity | Indicates limitations on the number of services/products allowed (possibly per time period). Value should be a Quantity | | |
| 2 | allowed-period | Maximum allowed period | Indicates the maximum period of time that can be covered in a single order. Value should be a Period | | |
| 1 | _decisional | Decisional details | Identifies detail codes that may impact patient and clinician decision making (Category should be 'cat-decisional') | true, true | true, true |
| 2 | in-network-copay | Copay for in-network | Indicates a percentage co-pay to expect if delivered in-network. Value should be a Quantity. | | |
| 2 | out-network-copay | Copay for out-of-network | Indicates a percentage co-pay to expect if delivered out-of-network. Value should be a Quantity. | | |
| 2 | concurrent-review | Concurrent review | Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean. | | |
| 2 | appropriate-use-needed | Appropriate use | Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean. | | |
| 2 | in-network-copay | Copay for in-network | Indicates a percentage co-pay to expect if delivered in-network. Value should be a Quantity. | | |
| 2 | out-network-copay | Copay for out-of-network | Indicates a percentage co-pay to expect if delivered out-of-network. Value should be a Quantity. | | |
| 2 | concurrent-review | Concurrent review | Additional payer-defined documentation will be required prior to claim payment. Value should be a boolean. | | |
| 2 | appropriate-use-needed | Appropriate use | Payer-defined appropriate use process must be invoked to determine coverage. Value should be a boolean. | | |
| 1 | _other | Other details | Identifies detail codes that are generally not relevant to clinicians/patients (Category should be 'cat-other') | true, true | true, true |
| 2 | policy-link | Policy Link | A URL pointing to the specific portion of a payer policy, coverage agreement or similar authoritative document that provides a portion of the basis for the decision documented in the coverage-information. Value should be a url. | | |
| 2 | policy-link | Policy Link | A URL pointing to the specific portion of a payer policy, coverage agreement or similar authoritative document that provides a portion of the basis for the decision documented in the coverage-information. Value should be a url. | | |
| 1 | instructions | Instructions | Information to display to the user that gives guidance about what steps to take in achieving the recommended actions identified by this coverage-information (e.g. special instructions about requesting authorization, details about information needed, details about data retention, etc.). Value should be a string. (Category may vary.) | | |