Common CQL Artifacts for FHIR (US-Based)
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Common CQL Artifacts for FHIR (US-Based), published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-cql-ig/ and changes regularly. See the Directory of published versions

Questionnaire: Example Medical Benefit Outpatient Drug Authorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire Version: 1.0.0-ballot
Standards status: Informative Computable Name: MBODAQuestionnaire

Copyright/Legal: This content is is informed by the following source, used with permission: https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/medical-benefit-outpatient-drug-authorization-form-050819.pdf?sc_lang=en&hash=6EDE27E13FCCB5731E081FC49B85359D

This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. MBODAQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire#1.0.0-ballot
... patient-infoPatient Information0..1group
.... patient-info|drug-allergiesDrug allergies0..*open-choice
.... patient-info|heightHeight0..1decimal
.... patient-info|weightWeight0..1decimal
.... patient-info|bsaBSA0..1decimal
... provider-infoOrdering Provider Information0..1group
.... provider-info|nameOrdering provider name0..1string
.... provider-info|npiOrdering provider NPI #0..1string
.... provider-info|addressOrdering provider address0..1string
.... provider-info|cityCity0..1string
.... provider-info|stateState0..1string
.... provider-info|zip-codeZip0..1string
.... person-submitting-requestPerson submitting request0..1group
..... person-submitting-request|nameName0..1string
..... person-submitting-request|phone-numberPhone0..1string
..... person-submitting-request|faxFax0..1string
.... office-contactOffice contact0..1group
..... office-contact|nameName0..1string
..... office-contact|phone-numberPhone0..1string
..... office-contact|faxFax0..1string
... servicing-provider-facility-infoServicing Provider/Facility Information0..1group
.... servicing-provider-facility-info|drug-adminWho is administering the drug?0..1choiceOptions: 3 options
.... select-onePlease select if the medication will be dispensed or administered0..1choiceOptions: 2 options
..... if-buy-billIf buy & bill, who will be billing for the drug?0..1choiceEnable When: select-one =
Options: 3 options
..... provider-participating-ghpIs the billing provider participating with GHP?0..1choiceEnable When: select-one =
Options: 2 options
...... no-ghpIf No, is this a request for out-of-network services?0..1choiceEnable When: provider-participating-ghp =
Options: 2 options
... servicing-providerServicing provider0..1group
.... servicing-provider|nameProvider name0..1string
.... servicing-provider|npiNPI #0..1string
.... servicing-provider|addressAddress0..1string
.... servicing-provider|phone-numberPhone0..1string
.... servicing-provider|faxFax0..1string
.... servicing-provider|office-contactOffice contact0..1string
... facility-of-serviceFacility/location of service0..1group
.... facility-of-service|nameFacility/location name0..1string
.... facility-of-service|npiNPI #0..1string
.... facility-of-service|addressAddress0..1string
.... facility-of-service|phone-numberPhone0..1string
.... facility-of-service|faxFax0..1string
.... facility-of-service|office-contactFacility contact0..1string
... specialty-vendorSpecialty vendor (if applicable)0..1group
.... specialty-vendor|nameSpecialty pharmacy name0..1string
.... specialty-vendor|npiNPI #0..1string
.... specialty-vendor|addressAddress0..1string
.... specialty-vendor|phone-numberPhone0..1string
.... specialty-vendor|faxFax0..1string
.... specialty-vendor|office-contactPharmacy contact0..1string
... diagnosis-infoDiagnosis Information0..1group
.... diagnosis-info|diagnosis-codeDiagnosis/ICD-10 code(s)0..*open-choice
.... diagnosis-info|diagnosis-descriptionDiagnosis description0..*string
... medication-infoMedication Information0..1group
.... medication-info|nameMedication name0..1string
.... medication-info|doseDose0..1quantity
.... medication-info|routeRoute0..*open-choice
.... medication-info|frequencyFrequency0..1quantity
.... medication-info|therapy-lengExpected length of therapy0..1quantity
.... medication-info|num-visitsQuantity/number of requested visits0..1integer
.... medication-info|service-dateAnticipated/actual date of service0..1date
.... medication-info|new-medNew Medication or Continued Therapy0..1choiceOptions: 2 options
.... medication-info|date-initiallizedDate therapy initially started0..1dateEnable When: medication-info|new-med =
.... medication-info|requested-drug-codeHCPCS/CPT code/J code/NDC code of requested drug0..1string
.... medication-info|associated-procedureAssociated procedure codes requiring prior auth0..1string
... request-for-expedited-reviewRequest for Expedited Review0..1group
.... request-for-expedited-review|paraWhen a request needs to be reviewed in an expedited manner because the standard review time frame may SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION, note this below by checking URGENT in the space provided, along with the reason the request is urgent. Requests will not be processed as urgent unless a rationale for urgency is provided.0..1group
..... request-for-expedited-review|rationaleURGENT - rationale0..1string
... ordering-provider-signatureOrdering Provider Signature0..1group
.... ordering-provider-signature|author-signatureSignature:0..1attachment

doco Documentation for this format

Options Sets

Answer options for servicing-provider-facility-info|drug-admin

  • null#OrderingProvider ("Ordering Provider")
  • null#ServicingProvider ("Servicing Provider")
  • null#HomeHealthAgency ("Home Health Agency - if yes, name of agency")

Answer options for select-one

  • null#AdministeredFromProviderStock ("Medication will be administered from provider stock and billed by provider (buy & bill)")
  • null#DispensedByPharmacy ("Medication will be dispensed by a specialty pharmacy and billed by the pharmacy")

Answer options for if-buy-bill

  • null#OrderingProvider ("Ordering Provider")
  • null#ServicingProvider ("Servicing Provider")
  • null#Facility ("Facility")

Answer options for provider-participating-ghp

  • null#Y ("Yes")
  • null#N ("No")

Answer options for no-ghp

  • null#Y ("Yes")
  • null#N ("No")

Answer options for medication-info|new-med

  • null#NewMedication ("New Medication")
  • null#ContinuedTherapy ("Continuation of therapy")