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 Uniform Pharmacy Prior Authorization Request Form (Experimental)

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

Copyright/Legal: This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509

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

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. UPPARFQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire#1.0.0-ballot
... urgencyUrgency0..1choiceOptions: 2 options
... drug-infoDrug Information0..1group
.... drug-info|drug-nameRequested Drug Name0..1string
.... drug-info|drug-intention-opioidIs this drug intended to treat opioid dependence?0..1boolean
..... drug-info|drug-intention-opioid|first-prior-authenticationIs this a first request for prior authorization for this drug?0..1booleanEnable When: drug-info|drug-intention-opioid =
..... drug-info|drug-intention-opioid|date-first-requestWhat was the date of the first request?0..1dateEnable When: drug-info|drug-intention-opioid|first-prior-authentication =
..... drug-info|drug-intention-opioid|twelve-months-since-requestHas the date of the first request been greater than twelve months ago?0..1booleanEnable When: drug-info|drug-intention-opioid|first-prior-authentication =
... completing-formPrior authentication is required and this form needs to be completed0..1groupEnable When:
.... completing-form|patient-infoPatient Info0..1group
..... completing-form|patient-info|prescription-datePrescription Date0..1string
.... completing-form|prescriber-infoPrescriber Info0..1group
..... completing-form|prescriber-info|prescriber-namePrescriber Name0..1string
..... completing-form|prescriber-info|prescriber-faxPrescriber Fax0..1string
..... completing-form|prescriber-info|prescriber-phonePrescriber Phone0..1string
..... completing-form|prescriber-info|prescriber-pagerPrescriber Pager0..1string
..... completing-form|prescriber-info|prescriber-addressPrescriber Address0..1string
..... completing-form|prescriber-info|prescriber-contactPrescriber Office Contact0..1string
..... completing-form|prescriber-info|prescriber-npiPrescriber NPI0..1string
..... completing-form|prescriber-info|prescriber-deaPrescriber DEA0..1string
..... completing-form|prescriber-info|prescriber-tax-idPrescriber Tax ID0..1string
..... completing-form|prescriber-info|prescriber-specialtySpecialty/Facility Name If applicable0..1string
..... completing-form|prescriber-info|prescriber-emailEmail Address0..1string
.... completing-form|drug-benefitPrior Authorization Request for Drug Benefit0..1group
..... completing-form|drug-benefit|request-typeNew Request0..1choiceOptions: 2 options
..... completing-form|drug-benefit|diagnosis-codesPatient ICD Diagnostic Codes0..*open-choiceValue Set: ICD-10 Codes
..... completing-form|drug-benefit|diagnosis-descriptionsPatient Diagnosis0..*string
..... completing-form|drug-benefit|drugsDrugs Requested with J-Code; if applicable0..*string
..... completing-form|drug-benefit|strength-route-frequencyStrength/Route/Frequency0..1string
..... completing-form|drug-benefit|unit-volumeUnit/Volume of Named Drugs0..1string
..... completing-form|drug-benefit|start-lengthStart Date and Length of Therapy0..1string
..... completing-form|drug-benefit|locationLocation of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:0..1string
..... completing-form|drug-benefit|criteriaClinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:0..1string
..... completing-form|drug-benefit|for-trialFor use in clinical trial?0..1boolean
..... completing-form|drug-benefit|for-trial|registration-numberProvide trial name and registration number0..1stringEnable When: completing-form|drug-benefit|for-trial =
..... completing-form|drug-benefit|drug-nameDrug Name Brand Name and Scientific Name/Strength:0..1string
..... completing-form|drug-benefit|doseDose0..1string
..... completing-form|drug-benefit|routeRoute0..1string
..... completing-form|drug-benefit|frequencyFrequency0..1string
..... completing-form|drug-benefit|quantityQuantity0..1quantity
..... completing-form|drug-benefit|refillsNumber of Refills0..1integer
..... completing-form|drug-benefit|deliveryProduct will be delivered to:0..1choiceOptions: 3 options
..... completing-form|drug-benefit|signaturePrescriber or Authorized Signature:0..1attachment
..... completing-form|drug-benefit|pharmacyDispensing Pharmacy Name and Phone Number:0..1string
..... completing-form|drug-benefit|dateDate0..1date

doco Documentation for this format

Options Sets

Answer options for urgency

  • null#urgent ("Urgent")
  • null#routine ("Non-Urgent")

Answer options for completing-form|drug-benefit|request-type

  • New Request
  • Reauthorization

Answer options for completing-form|drug-benefit|delivery

  • Patient's Home
  • Physician Office
  • Other