GMTPQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: GMTPQuestionnaire
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire GMTPQuestionnaire LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> GMTPQuestionnaire This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. Questionnaire http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire#1.0.0 #xD; billing-provider-question Is the billing provider/referring lab different from servicing provider? 0..1 boolean #xD; billing-provider-info Billing provider/referring lab information 0..1 group Enable When: billing-provider-question = #xD; billing-provider-info|name Requesting provider name 0..1 string #xD; billing-provider-info|phone-number Phone 0..1 string #xD; billing-provider-info|address Ordering provider address 0..1 string #xD; billing-provider-info|npi Ordering provider Tax ID/NPI # 0..1 string #xD; billing-provider-info|fax Fax 0..1 string #xD; test-requested Test requested 0..1 group #xD; test-requested|service-date Date of service 0..1 date #xD; test-requested|test-id Test ID 0..1 string #xD; test-requested|test-name Test name 0..1 string #xD; test-requested|diagnosis-description Diagnosis description 0..1 string #xD; test-requested|diagnosis-icd-code ICD-10 code(s) 0..* open-choice Value Set: ICD-10 Codes #xD; test-requested|diagnosis-cpt-code CPT code(s) 0..* open-choice Value Set: AMA CPT All Codes #xD; clinical-trial Clinical Trial Information 0..1 group #xD; clinical-trial-question Is the requested test part of a clinical trial? 0..1 boolean #xD; clinical-trial|yes-clinial-trial If Yes, provide the registration or ID number for the specific trial in which this test is being studied. 0..1 string Enable When: clinical-trial-question = #xD; history Patient history and related findings 0..1 group #xD; history|patient-history Patient history including age at diagnosis 0..1 group #xD; history|patient-history|diagnosis Diagnosis 0..1 string #xD; history|patient-his…
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/cqf-library
  value: canonical
    v: http://hl7.org/fhir/us/cql/Library/GMTPInitialExpressions
    link: http://hl7.org/fhir/us/cql/Library/GMTPInitialExpressions
extension:
  extension:
    url:
      v: name
    value: Coding
      system:
        v: http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext
      code:
        v: patient
      display:
        v: Patient
  extension:
    url:
      v: type
    value: code
      v: Patient
  extension:
    url:
      v: description
    value: string
      v: The patient that is to be used to pre-populate the form
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
extension:
  extension:
    url:
      v: name
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/additionalLaunchContext
      code:
        v: Coverage
      display:
        v: Coverage
  extension:
    url:
      v: type
    value: code
      v: Coverage
  extension:
    url:
      v: description
    value: string
      v: The Coverage that is to be used to pre-populate the form
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
extension:
  extension:
    url:
      v: name
    value: Coding
      system:
        v: http://example.org/fhir/CodeSystem/additionalLaunchContext
      code:
        v: ServiceRequest
      display:
        v: ServiceRequest
  extension:
    url:
      v: type
    value: code
      v: ServiceRequest
  extension:
    url:
      v: description
    value: string
      v: The ServiceRequest that is to be used to pre-populate the form
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
  value: code
    v: cds
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status
  value: code
    v: informative
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
      value: canonical
        v: http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql
        link: http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql
url:
  v: http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire
version:
  v: 1.0.0
name:
  v: GMTPQuestionnaire
title:
  v: Example Genetic/Molecular Testing Preauthorization Questionnaire
status:
  v: active
experimental:
  v: true
date:
  v: 2023-10-12T00:00:00+00:00
publisher:
  v: HL7 International / Clinical Decision Support
contact:
  telecom:
    system:
      v: url
    value:
      v: http://www.hl7.org/Special/committees/dss
description:
  v: This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
jurisdiction:
  coding:
    system:
      v: urn:iso:std:iso:3166
    code:
      v: US
    display:
      v: United States of America
copyright:
  v: This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1986712
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Billing Provider different from Servicing Provider
  link id:
    v: billing-provider-question
  text:
    v: Is the billing provider/referring lab different from servicing provider?
  type:
    v: boolean
  item:
    link id:
      v: billing-provider-info
    text:
      v: Billing provider/referring lab information
    type:
      v: group
    enable when:
      question:
        v: billing-provider-question
      operator:
        v: =
      answer: boolean
        v: true
    item:
      extension:
        value: Expression
      link id:
        v: billing-provider-info|name
      text:
        v: Requesting provider name
      type:
        v: string
    item:
      extension:
        value: Expression
      link id:
        v: billing-provider-info|phone-number
      text:
        v: Phone
      type:
        v: string
    item:
      extension:
        value: Expression
      link id:
        v: billing-provider-info|address
      text:
        v: Ordering provider address
      type:
        v: string
    item:
      extension:
        value: Expression
      link id:
        v: billing-provider-info|npi
      text:
        v: Ordering provider Tax ID/NPI #
      type:
        v: string
    item:
      extension:
        value: Expression
      link id:
        v: billing-provider-info|fax

Expression
language:
  v: text/cql-identifier
expression:
  v: Billing Provider Name

Expression
language:
  v: text/cql-identifier
expression:
  v: Billing Provider Phone

Expression
language:
  v: text/cql-identifier
expression:
  v: Billing Provider Address

Expression
language:
  v: text/cql-identifier
expression:
  v: Billing Provider NPI

Expression
language:
  v: text/cql-identifier
expression:
  v: Billing Provider Fax

v: Fax

v: string

link id:
  v: test-requested
text:
  v: Test requested
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Date of Service
  link id:
    v: test-requested|service-date
  text:
    v: Date of service
  type:
    v: date
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Test ID
  link id:
    v: test-requested|test-id
  text:
    v: Test ID
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Test name
  link id:
    v: test-requested|test-name
  text:
    v: Test name
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Diagnosis Descriptions
  link id:
    v: test-requested|diagnosis-description
  text:
    v: Diagnosis description
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Test ICD Codes
  link id:
    v: test-requested|diagnosis-icd-code
  text:
    v: ICD-10 code(s)
  type:
    v: open-choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/ValueSet/icd-10
    link: http://hl7.org/fhir/ValueSet/icd-10
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Test CPT Codes
  link id:
    v: test-requested|diagnosis-cpt-code
  text:
    v: CPT code(s)
  type:
    v: open-choice
  repeats:
    v: true
  answer value set:
    v: http://terminology.hl7.org/ValueSet/cpt-all
    link: http://terminology.hl7.org/ValueSet/cpt-all

link id:
  v: clinical-trial
text:
  v: Clinical Trial Information
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Part of clinical trial
  link id:
    v: clinical-trial-question
  text:
    v: Is the requested test part of a clinical trial?
  type:
    v: boolean
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: clinical-trial|yes-clinial-trial
    text:
      v: If Yes, provide the registration or ID number for the specific trial in which this test is being studied.
    type:
      v: string
    enable when:
      question:
        v: clinical-trial-question
      operator:
        v: =
      answer: boolean
        v: true

v: text/cql-identifier

v: Clinical Trial ID

link id:
  v: history
text:
  v: Patient history and related findings
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext
    value: Expression
      name:
        v: PatientHistory
      language:
        v: text/cql-identifier
      expression:
        v: Patient history
  link id:
    v: history|patient-history
  text:
    v: Patient history including age at diagnosis
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: history|patient-history|diagnosis
    text:
      v: Diagnosis
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: history|patient-history|age-at-onset
    text:
      v: Age at onset
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: history|patient-history|abatement
    text:
      v: Abatement
    type:
      v: string
item:
  link id:
    v: history|family-history
  text:
    v: Family history, including age at diagnosis, availability for testing e.g., family member deceased, refused testing or patient not in contact with affected family member and any genetic testing performed on family member - attach pedigree, if available
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Previous genetic testing for condition
  link id:
    v: history|other-findings
  text:
    v: Other findings/testing completed - previous genetic testing for condition
  type:
    v: string
item:
  link id:
    v: history|treatment-relation
  text:
    v: How will testing be used in relation to treatment or management of the patient?
  type:
    v: string

v: text/cql-expression

v: %PatientHistory.diagnosis

v: text/cql-expression

v: %PatientHistory.ageAtOnset

v: text/cql-expression

v: %PatientHistory.abatement

link id:
  v: person-filling-out-form
text:
  v: Person filling out form
type:
  v: group
item:
  link id:
    v: person-filling-out-form|name
  text:
    v: Name
  type:
    v: string
item:
  link id:
    v: person-filling-out-form|phone-number
  text:
    v: Phone number
  type:
    v: string
item:
  link id:
    v: person-filling-out-form|facility
  text:
    v: Phone number
  type:
    v: string