GMTPQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: GMTPQuestionnaire
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: 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#2.0.0-cibuild #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 = true #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 = true #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; h…
contained: Library
  id:
    v: effective-data-requirements
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Retrieve Member Coverage test parameter
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Retrieve Member Coverage test parameter": // When executing CQL with the VSCode extension retrieve the resource specific for the test case // the list of resource ids match the resources from the test case folders singleton from ([FHIR.Coverage] CV where CV.id in { 'Coverage-example-GMTP', // testcase: GMTP-example-patient-2 'coverage-GMTP-1' // testcase: USCorePatient-GMTP-1 })
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 0
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Member Coverage
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Member Coverage": Coalesce( Coverage, "Retrieve Member Coverage test parameter" )
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 1
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Billing Provider
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Billing Provider": UCE.BillingProvider("Member Coverage")
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 2
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Retrieve Service Request test parameter
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Retrieve Service Request test parameter": // When executing CQL with the VSCode extension retrieve the resource specific for the test case // the list of resource ids match the resources from the test case folders singleton from ([FHIR.ServiceRequest] SR where SR.id in { 'ServiceRequest-example-1-GMTP', // testcase: GMTP-example-patient-2 'service-request-USCorePatient-GMTP-1' // testcase: USCorePatient-GMTP-1 })
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 3
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Most Recent ServiceRequest
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Most Recent ServiceRequest": Coalesce( ServiceRequest, "Retrieve Service Request test parameter" )
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 4
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GMTPInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Billing Provider different from Servicing Provider
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Billing Provider different from Servicing Provider": if "Billing Provider".id != First(UCE.ServicingProvider("Most Recent ServiceRequest").id) then 'Yes' else 'No'
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 5
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: USCoreElements
    extension:
      url:
        v: name
        l: name
      value: String
        v: BillingProvider
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define function BillingProvider(coverage FHIR.Coverage): singleton from([OrganizationProfile] O where EndsWith(First(coverage.payor.reference.value), O.id))
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer

Integer
v: 6

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: FHIRHelpers
extension:
  url:
    v: name
    l: name
  value: String
    v: ToString
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define function ToString(value string): value.value
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 7
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: USCoreElements
extension:
  url:
    v: name
    l: name
  value: String
    v: ServicingProvider
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define function ServicingProvider(serviceRequest FHIR.ServiceRequest): [PractitionerProfile] P where EndsWith(First(serviceRequest.performer.reference.value), P.id)
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 8
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

v: EffectiveDataRequirements

v: active

coding:
  system:
    v: http://terminology.hl7.org/CodeSystem/library-type
    l: library-type
  code:
    v: module-definition

type:
  v: depends-on
display:
  v: USCore model information
resource:
  v: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived
  l: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo

type:
  v: depends-on
display:
  v: FHIR model information
resource:
  v: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
  l: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo

type:
  v: depends-on
display:
  v: Library UCE
resource:
  v: http://hl7.org/fhir/us/cql/Library/USCoreElements|2.0.0-cibuild
  l: http://hl7.org/fhir/us/cql/Library/USCoreElements

type:
  v: depends-on
display:
  v: Library FHIRHelpers
resource:
  v: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
  l: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers

type:
  v: depends-on
display:
  v: Library FHIRHelpers
resource:
  v: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
  l: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers

name:
  v: Coverage
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: Coverage

name:
  v: ServiceRequest
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: ServiceRequest

name:
  v: Billing Provider different from Servicing Provider
use:
  v: out
min:
  v: 0
max:
  v: 1
type:
  v: string

type:
  v: Organization
profile:
  v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization
  l: us-core-organization
must support:
  v: id

type:
  v: Coverage
profile:
  v: http://hl7.org/fhir/StructureDefinition/Coverage
  l: Coverage
must support:
  v: id

type:
  v: Practitioner
profile:
  v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner
  l: us-core-practitioner
must support:
  v: id

type:
  v: ServiceRequest
profile:
  v: http://hl7.org/fhir/StructureDefinition/ServiceRequest
  l: ServiceRequest
must support:
  v: id

type:
  v: ServiceRequest
profile:
  v: http://hl7.org/fhir/StructureDefinition/ServiceRequest
  l: ServiceRequest
must support:
  v: id

extension:
  url:
    v: name
    l: name
  value: Coding
    system:
      v: http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext
      l: launchContext
    code:
      v: patient
    display:
      v: Patient
extension:
  url:
    v: type
    l: type
  value: Code
    v: Patient
extension:
  url:
    v: description
    l: 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
  l: sdc-questionnaire-launchContext

extension:
  url:
    v: name
    l: name
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/additionalLaunchContext
      l: additionalLaunchContext
    code:
      v: Coverage
    display:
      v: Coverage
extension:
  url:
    v: type
    l: type
  value: Code
    v: Coverage
extension:
  url:
    v: description
    l: 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
  l: sdc-questionnaire-launchContext

extension:
  url:
    v: name
    l: name
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/additionalLaunchContext
      l: additionalLaunchContext
    code:
      v: ServiceRequest
    display:
      v: ServiceRequest
extension:
  url:
    v: type
    l: type
  value: Code
    v: ServiceRequest
extension:
  url:
    v: description
    l: 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
  l: sdc-questionnaire-launchContext

url:
  v: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
  l: structuredefinition-wg
value: Code
  v: cds

url:
  v: http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements
  l: crmi-effectiveDataRequirements
value: Canonical
  v: #effective-data-requirements
  l: effective-data-requirements

url:
  v: http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status
  l: structuredefinition-standards-status
value: Code
  v: informative
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
      l: structuredefinition-conformance-derivedFrom
    value: Canonical
      v: http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql
      l: hl7.fhir.us.cql

v: 2.0.0-cibuild

v: GMTPQuestionnaire

v: Example Genetic/Molecular Testing Preauthorization Questionnaire

v: active

v: true

v: 2023-10-12T00:00:00+00:00

v: HL7 International / Clinical Decision Support

telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/dss

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

coding:
  system:
    v: urn:iso:std:iso:3166
    l: 3166
  code:
    v: US
  display:
    v: United States of America

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

extension:
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    l: 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:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: billing-provider-info|name
    text:
      v: Requesting provider name
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: billing-provider-info|phone-number
    text:
      v: Phone
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: billing-provider-info|address
    text:
      v: Ordering provider address
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: billing-provider-info|npi
    text:
      v: Ordering provider Tax ID/NPI #
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: billing-provider-info|fax
    text:
      v: Fax
    type:
      v: string

v: text/cql-identifier

v: Billing Provider Name

v: text/cql-identifier

v: Billing Provider Phone

v: text/cql-identifier

v: Billing Provider Address

v: text/cql-identifier

v: Billing Provider NPI

v: text/cql-identifier

v: Billing Provider Fax

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
      l: 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
      l: 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
      l: 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
      l: 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
      l: 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
    l: icd-10
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: 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
    l: 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
      l: 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
        l: 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
      l: 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
        l: 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
        l: 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
        l: 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
      l: 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