Generated Narrative: Questionnaire MBODAQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints 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 #xD; diagnosis-info Diagnosis Information 0..1 group #xD; diagnosis-info|diagnosis-code Diagnosis/ICD-10 code(s) 0..* open-choice #xD; diagnosis-info|diagnosis-description Diagnosis description 0..* string #xD; medication-info Medication Information 0..1 group #xD; medication-info|name Medication name 0..1 string #xD; medication-info|dose Dose 0..1 quantity #xD; medication-info|route Route 0..* open-choice #xD; medication-info|frequency Frequency 0..1 quantity #xD; medication-info|therapy-leng Expected length of therapy 0..1 quantity #xD; medication-info|num-visits Quantity/number of requested visits 0..1 integer #xD; medication-info|service-date Anticipated/actual date of service 0..1 date #xD; medication-info|new-med New Medication or Continued Therapy 0..1 choice Options: 2 options #xD; medication-info|date-initiallized Date therapy initially started 0..1 date Enable When: medication-info|new-med = ContinuedTherapy (MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy) #xD; medication-info|requested-drug-code HCPCS/CPT code/J code/NDC code of requested drug 0..1 string #xD; medication-info|associated-procedure Associated procedure codes requiring prior auth 0..1 string #xD; request-for-expedited-review Request for Expedited Review 0..1 group #xD; 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 #xD; request-for-expedited-review|rationale URGENT - rationale 0..1 string #xD; ordering-provider-signature Ordering Provider Signature 0..1 group #xD; ordering-provider-signature|author-signature Signature: 0..1 attachment #xD; 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") Contained Resources Metadata Type module-definition from http://terminology.hl7.org/CodeSystem/library-type Dependency Description: USCore model information Resource: US Core Model Informationversion: null6.1.0-derived) Canonical URL: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived Dependency Description: FHIR model information Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Parameters Parameter None Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates
The patient that is to be used to pre-populate the form
Example Medical Benefit Outpatient Drug Authorization Questionnaire
HL7 International / Clinical Decision Support
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
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
HCPCS/CPT code/J code/NDC code of requested drug
Associated procedure codes requiring prior auth
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.