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 Medical Benefit Outpatient Drug Authorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire Version: 2.0.0-cibuild
Standards status: Informative Active as of 2023-08-14 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
.. MBODAQuestionnaire 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/MBODAQuestionnaire#2.0.0-cibuild
... diagnosis-info Diagnosis Information 0..1 group Value Set:
.... diagnosis-info|diagnosis-code Diagnosis/ICD-10 code(s) 0..* open-choice Value Set:
.... diagnosis-info|diagnosis-description Diagnosis description 0..* string Value Set:
... medication-info Medication Information 0..1 group Value Set:
.... medication-info|name Medication name 0..1 string Value Set:
.... medication-info|dose Dose 0..1 quantity Value Set:
.... medication-info|route Route 0..* open-choice Value Set:
.... medication-info|frequency Frequency 0..1 quantity Value Set:
.... medication-info|therapy-leng Expected length of therapy 0..1 quantity Value Set:
.... medication-info|num-visits Quantity/number of requested visits 0..1 integer Value Set:
.... medication-info|service-date Anticipated/actual date of service 0..1 date Value Set:
.... medication-info|new-med New Medication or Continued Therapy 0..1 choice Value Set:
Options: 2 options
.... medication-info|date-initiallized Date therapy initially started 0..1 date Enable When: medication-info|new-med = ContinuedTherapy (MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy)
Value Set:
.... medication-info|requested-drug-code HCPCS/CPT code/J code/NDC code of requested drug 0..1 string Value Set:
.... medication-info|associated-procedure Associated procedure codes requiring prior auth 0..1 string Value Set:
... request-for-expedited-review Request for Expedited Review 0..1 group Value Set:
.... request-for-expedited-review|para When 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..1 group Value Set:
..... request-for-expedited-review|rationale URGENT - rationale 0..1 string Value Set:
.... ordering-provider-signature|author-signature Signature: 0..1 attachment Value Set:

doco Documentation for this format

Options Sets

Answer options for medication-info|new-med

  • http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#NewMedication ("New Medication")
  • http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy ("Continuation of therapy")

Diagnosis Information

  • linkId: diagnosis-info
  • Answers:

Diagnosis/ICD-10 code(s)

  • linkId: diagnosis-info|diagnosis-code
  • Answers:

Diagnosis description

  • linkId: diagnosis-info|diagnosis-description
  • Answers:

Medication Information

  • linkId: medication-info
  • Answers:

Medication name

  • linkId: medication-info|name
  • Answers:

Dose

  • linkId: medication-info|dose
  • Answers:

Route

  • linkId: medication-info|route
  • Answers:

Frequency

  • linkId: medication-info|frequency
  • Answers:

Expected length of therapy

  • linkId: medication-info|therapy-leng
  • Answers:

Quantity/number of requested visits

  • linkId: medication-info|num-visits
  • Answers:

Anticipated/actual date of service

  • linkId: medication-info|service-date
  • Answers:

New Medication or Continued Therapy

Date therapy initially started

  • linkId: medication-info|date-initiallized
  • Enable When: todo
  • Answers:

HCPCS/CPT code/J code/NDC code of requested drug

  • linkId: medication-info|requested-drug-code
  • Answers:

Associated procedure codes requiring prior auth

  • linkId: medication-info|associated-procedure
  • Answers:

Request for Expedited Review

  • linkId: request-for-expedited-review
  • Answers:

When 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.

  • linkId: request-for-expedited-review|para
  • Answers:

URGENT - rationale

  • linkId: request-for-expedited-review|rationale
  • Answers:

Ordering Provider Signature

  • linkId: ordering-provider-signature
  • Answers:

Signature:

  • linkId: ordering-provider-signature|author-signature
  • Answers:

LinkIDDescription & Constraintsdoco
.. diagnosis-info Value Set:
... diagnosis-info|diagnosis-code Value Set:
... diagnosis-info|diagnosis-description Value Set:
.. medication-info Value Set:
... medication-info|name Value Set:
... medication-info|dose Value Set:
... medication-info|route Value Set:
... medication-info|frequency Value Set:
... medication-info|therapy-leng Value Set:
... medication-info|num-visits Value Set:
... medication-info|service-date Value Set:
... medication-info|new-med Value Set:
Options: 2 options
... medication-info|date-initiallized Enable When: Not done yet
Value Set:
... medication-info|requested-drug-code Value Set:
... medication-info|associated-procedure Value Set:
.. request-for-expedited-review Value Set:
... request-for-expedited-review|para Value Set:
.... request-for-expedited-review|rationale Value Set:
.. ordering-provider-signature Value Set:
... ordering-provider-signature|author-signature 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.