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 2.0.0-cibuild 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 Genetic/Molecular Testing Preauthorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire Version: 2.0.0-cibuild
Standards status: Informative Active as of 2023-10-12 Computable Name: GMTPQuestionnaire

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=1986712

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

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. 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#2.0.0-cibuild
... billing-provider-question Is the billing provider/referring lab different from servicing provider? 0..1 boolean Value Set:
.... billing-provider-info Billing provider/referring lab information 0..1 group Enable When: billing-provider-question = true
Value Set:
..... billing-provider-info|name Requesting provider name 0..1 string Value Set:
..... billing-provider-info|phone-number Phone 0..1 string Value Set:
..... billing-provider-info|address Ordering provider address 0..1 string Value Set:
..... billing-provider-info|npi Ordering provider Tax ID/NPI # 0..1 string Value Set:
..... billing-provider-info|fax Fax 0..1 string Value Set:
... test-requested Test requested 0..1 group Value Set:
.... test-requested|service-date Date of service 0..1 date Value Set:
.... test-requested|test-id Test ID 0..1 string Value Set:
.... test-requested|test-name Test name 0..1 string Value Set:
.... test-requested|diagnosis-description Diagnosis description 0..1 string Value Set:
.... test-requested|diagnosis-icd-code ICD-10 code(s) 0..* open-choice Value Set: ICD-10 Codes
.... test-requested|diagnosis-cpt-code CPT code(s) 0..* open-choice Value Set: AMA CPT All Codes
... clinical-trial Clinical Trial Information 0..1 group Value Set:
.... clinical-trial-question Is the requested test part of a clinical trial? 0..1 boolean Value Set:
..... 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 = true
Value Set:
.... history|patient-history Patient history including age at diagnosis 0..1 group Value Set:
..... history|patient-history|diagnosis Diagnosis 0..1 string Value Set:
..... history|patient-history|age-at-onset Age at onset 0..1 string Value Set:
..... history|patient-history|abatement Abatement 0..1 string Value Set:
.... history|family-history 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 0..1 string Value Set:
.... history|other-findings Other findings/testing completed - previous genetic testing for condition 0..1 string Value Set:
.... history|treatment-relation How will testing be used in relation to treatment or management of the patient? 0..1 string Value Set:
... person-filling-out-form Person filling out form 0..1 group Value Set:
.... person-filling-out-form|name Name 0..1 string Value Set:
.... person-filling-out-form|phone-number Phone number 0..1 string Value Set:
.... person-filling-out-form|facility Phone number 0..1 string Value Set:

doco Documentation for this format

Is the billing provider/referring lab different from servicing provider?

  • linkId: billing-provider-question
  • Answers:

Billing provider/referring lab information

  • linkId: billing-provider-info
  • Enable When: todo
  • Answers:

Requesting provider name

  • linkId: billing-provider-info|name
  • Answers:

Phone

  • linkId: billing-provider-info|phone-number
  • Answers:

Ordering provider address

  • linkId: billing-provider-info|address
  • Answers:

Ordering provider Tax ID/NPI #

  • linkId: billing-provider-info|npi
  • Answers:

Fax

  • linkId: billing-provider-info|fax
  • Answers:

Test requested

  • linkId: test-requested
  • Answers:

Date of service

  • linkId: test-requested|service-date
  • Answers:

Test ID

  • linkId: test-requested|test-id
  • Answers:

Test name

  • linkId: test-requested|test-name
  • Answers:

Diagnosis description

  • linkId: test-requested|diagnosis-description
  • Answers:

ICD-10 code(s)

  • linkId: test-requested|diagnosis-icd-code
  • Answers: ICD-10 Codes

CPT code(s)

Clinical Trial Information

  • linkId: clinical-trial
  • Answers:

Is the requested test part of a clinical trial?

  • linkId: clinical-trial-question
  • Answers:

If Yes, provide the registration or ID number for the specific trial in which this test is being studied.

  • linkId: clinical-trial|yes-clinial-trial
  • Enable When: todo
  • Answers:

Patient history and related findings

  • linkId: history
  • Answers:

Patient history including age at diagnosis

  • linkId: history|patient-history
  • Answers:

Diagnosis

  • linkId: history|patient-history|diagnosis
  • Answers:

Age at onset

  • linkId: history|patient-history|age-at-onset
  • Answers:

Abatement

  • linkId: history|patient-history|abatement
  • Answers:

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

  • linkId: history|family-history
  • Answers:

Other findings/testing completed - previous genetic testing for condition

  • linkId: history|other-findings
  • Answers:

How will testing be used in relation to treatment or management of the patient?

  • linkId: history|treatment-relation
  • Answers:

Person filling out form

  • linkId: person-filling-out-form
  • Answers:

Name

  • linkId: person-filling-out-form|name
  • Answers:

Phone number

  • linkId: person-filling-out-form|phone-number
  • Answers:

Phone number

  • linkId: person-filling-out-form|facility
  • Answers:

LinkIDDescription & Constraintsdoco
.. billing-provider-question Value Set:
... billing-provider-info Enable When: Not done yet
Value Set:
.... billing-provider-info|name Value Set:
.... billing-provider-info|phone-number Value Set:
.... billing-provider-info|address Value Set:
.... billing-provider-info|npi Value Set:
.... billing-provider-info|fax Value Set:
.. test-requested Value Set:
... test-requested|service-date Value Set:
... test-requested|test-id Value Set:
... test-requested|test-name Value Set:
... test-requested|diagnosis-description Value Set:
... test-requested|diagnosis-icd-code Value Set: ICD-10 Codes
... test-requested|diagnosis-cpt-code Value Set: AMA CPT All Codes
.. clinical-trial Value Set:
... clinical-trial-question Value Set:
.... clinical-trial|yes-clinial-trial Enable When: Not done yet
Value Set:
.. history Value Set:
... history|patient-history Value Set:
.... history|patient-history|diagnosis Value Set:
.... history|patient-history|age-at-onset Value Set:
.... history|patient-history|abatement Value Set:
... history|family-history Value Set:
... history|other-findings Value Set:
... history|treatment-relation Value Set:
.. person-filling-out-form Value Set:
... person-filling-out-form|name Value Set:
... person-filling-out-form|phone-number Value Set:
... person-filling-out-form|facility Value Set:

doco Documentation for this format

Contained resources

Test this Questionnaire

Try this questionnaire out:

Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.