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 Uniform Pharmacy Prior Authorization Request Form (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire Version: 2.0.0-cibuild
Standards status: Informative Active as of 2023-10-19 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
.. UPPARFQuestionnaire 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/UPPARFQuestionnaire#2.0.0-cibuild
... urgency Urgency 0..1 choice Value Set:
Options: 2 options
... drug-info Drug Information 0..1 group Value Set:
.... drug-info|drug-name Requested Drug Name 0..1 string Value Set:
.... drug-info|drug-intention-opioid Is this drug intended to treat opioid dependence? 0..1 boolean Value Set:
..... drug-info|drug-intention-opioid|first-prior-authentication Is this a first request for prior authorization for this drug? 0..1 boolean Enable When: drug-info|drug-intention-opioid = true
Value Set:
..... drug-info|drug-intention-opioid|date-first-request What was the date of the first request? 0..1 date Enable When: drug-info|drug-intention-opioid|first-prior-authentication = false
Value Set:
..... drug-info|drug-intention-opioid|twelve-months-since-request Has the date of the first request been greater than twelve months ago? 0..1 boolean Enable When: drug-info|drug-intention-opioid|first-prior-authentication = false
Value Set:
... completing-form Prior authentication is required and this form needs to be completed 0..1 group Enable When:
Value Set:
.... completing-form|patient-info Patient Info 0..1 group Value Set:
..... completing-form|patient-info|prescription-date Prescription Date 0..1 string Value Set:
.... completing-form|prescriber-info Prescriber Info 0..1 group Value Set:
..... completing-form|prescriber-info|prescriber-name Prescriber Name 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-fax Prescriber Fax 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-phone Prescriber Phone 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-pager Prescriber Pager 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-address Prescriber Address 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-contact Prescriber Office Contact 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-npi Prescriber NPI 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-dea Prescriber DEA 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-tax-id Prescriber Tax ID 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-specialty Specialty/Facility Name If applicable 0..1 string Value Set:
..... completing-form|prescriber-info|prescriber-email Email Address 0..1 string Value Set:
.... completing-form|drug-benefit Prior Authorization Request for Drug Benefit 0..1 group Value Set:
..... completing-form|drug-benefit|request-type New Request 0..1 choice Value Set:
Options: 2 options
..... completing-form|drug-benefit|diagnosis-codes Patient ICD Diagnostic Codes 0..* open-choice Value Set: ICD-10 Codes
..... completing-form|drug-benefit|diagnosis-descriptions Patient Diagnosis 0..* string Value Set:
..... completing-form|drug-benefit|drugs Drugs Requested with J-Code; if applicable 0..* string Value Set:
..... completing-form|drug-benefit|strength-route-frequency Strength/Route/Frequency 0..1 string Value Set:
..... completing-form|drug-benefit|unit-volume Unit/Volume of Named Drugs 0..1 string Value Set:
..... completing-form|drug-benefit|start-length Start Date and Length of Therapy 0..1 string Value Set:
..... completing-form|drug-benefit|location Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID: 0..1 string Value Set:
..... completing-form|drug-benefit|criteria Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response: 0..1 string Value Set:
..... completing-form|drug-benefit|for-trial For use in clinical trial? 0..1 boolean Value Set:
..... completing-form|drug-benefit|for-trial|registration-number Provide trial name and registration number 0..1 string Enable When: completing-form|drug-benefit|for-trial = true
Value Set:
..... completing-form|drug-benefit|drug-name Drug Name Brand Name and Scientific Name/Strength: 0..1 string Value Set:
..... completing-form|drug-benefit|dose Dose 0..1 string Value Set:
..... completing-form|drug-benefit|route Route 0..1 string Value Set:
..... completing-form|drug-benefit|frequency Frequency 0..1 string Value Set:
..... completing-form|drug-benefit|quantity Quantity 0..1 quantity Value Set:
..... completing-form|drug-benefit|refills Number of Refills 0..1 integer Value Set:
..... completing-form|drug-benefit|delivery Product will be delivered to: 0..1 choice Value Set:
Options: 3 options
..... completing-form|drug-benefit|signature Prescriber or Authorized Signature: 0..1 attachment Value Set:
..... completing-form|drug-benefit|pharmacy Dispensing Pharmacy Name and Phone Number: 0..1 string Value Set:
..... completing-form|drug-benefit|date Date 0..1 date Value Set:

doco Documentation for this format

Options Sets

Answer options for urgency

  • http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#urgent ("Urgent")
  • http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#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

Urgency

Drug Information

  • linkId: drug-info
  • Answers:

Requested Drug Name

  • linkId: drug-info|drug-name
  • Answers:

Is this drug intended to treat opioid dependence?

  • linkId: drug-info|drug-intention-opioid
  • Answers:

Is this a first request for prior authorization for this drug?

  • linkId: drug-info|drug-intention-opioid|first-prior-authentication
  • Enable When: todo
  • Answers:

What was the date of the first request?

  • linkId: drug-info|drug-intention-opioid|date-first-request
  • Enable When: todo
  • Answers:

Has the date of the first request been greater than twelve months ago?

  • linkId: drug-info|drug-intention-opioid|twelve-months-since-request
  • Enable When: todo
  • Answers:

Prior authentication is required and this form needs to be completed

  • linkId: completing-form
  • Enable When: todo
  • Answers:

Patient Info

  • linkId: completing-form|patient-info
  • Answers:

Prescription Date

  • linkId: completing-form|patient-info|prescription-date
  • Answers:

Prescriber Info

  • linkId: completing-form|prescriber-info
  • Answers:

Prescriber Name

  • linkId: completing-form|prescriber-info|prescriber-name
  • Answers:

Prescriber Fax

  • linkId: completing-form|prescriber-info|prescriber-fax
  • Answers:

Prescriber Phone

  • linkId: completing-form|prescriber-info|prescriber-phone
  • Answers:

Prescriber Pager

  • linkId: completing-form|prescriber-info|prescriber-pager
  • Answers:

Prescriber Address

  • linkId: completing-form|prescriber-info|prescriber-address
  • Answers:

Prescriber Office Contact

  • linkId: completing-form|prescriber-info|prescriber-contact
  • Answers:

Prescriber NPI

  • linkId: completing-form|prescriber-info|prescriber-npi
  • Answers:

Prescriber DEA

  • linkId: completing-form|prescriber-info|prescriber-dea
  • Answers:

Prescriber Tax ID

  • linkId: completing-form|prescriber-info|prescriber-tax-id
  • Answers:

Specialty/Facility Name If applicable

  • linkId: completing-form|prescriber-info|prescriber-specialty
  • Answers:

Email Address

  • linkId: completing-form|prescriber-info|prescriber-email
  • Answers:

Prior Authorization Request for Drug Benefit

  • linkId: completing-form|drug-benefit
  • Answers:

New Request

Patient ICD Diagnostic Codes

  • linkId: completing-form|drug-benefit|diagnosis-codes
  • Answers: ICD-10 Codes

Patient Diagnosis

  • linkId: completing-form|drug-benefit|diagnosis-descriptions
  • Answers:

Drugs Requested with J-Code; if applicable

  • linkId: completing-form|drug-benefit|drugs
  • Answers:

Strength/Route/Frequency

  • linkId: completing-form|drug-benefit|strength-route-frequency
  • Answers:

Unit/Volume of Named Drugs

  • linkId: completing-form|drug-benefit|unit-volume
  • Answers:

Start Date and Length of Therapy

  • linkId: completing-form|drug-benefit|start-length
  • Answers:

Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:

  • linkId: completing-form|drug-benefit|location
  • Answers:

Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:

  • linkId: completing-form|drug-benefit|criteria
  • Answers:

For use in clinical trial?

  • linkId: completing-form|drug-benefit|for-trial
  • Answers:

Provide trial name and registration number

  • linkId: completing-form|drug-benefit|for-trial|registration-number
  • Enable When: todo
  • Answers:

Drug Name Brand Name and Scientific Name/Strength:

  • linkId: completing-form|drug-benefit|drug-name
  • Answers:

Dose

  • linkId: completing-form|drug-benefit|dose
  • Answers:

Route

  • linkId: completing-form|drug-benefit|route
  • Answers:

Frequency

  • linkId: completing-form|drug-benefit|frequency
  • Answers:

Quantity

  • linkId: completing-form|drug-benefit|quantity
  • Answers:

Number of Refills

  • linkId: completing-form|drug-benefit|refills
  • Answers:

Product will be delivered to:

Prescriber or Authorized Signature:

  • linkId: completing-form|drug-benefit|signature
  • Answers:

Dispensing Pharmacy Name and Phone Number:

  • linkId: completing-form|drug-benefit|pharmacy
  • Answers:

Date

  • linkId: completing-form|drug-benefit|date
  • Answers:

LinkIDDescription & Constraintsdoco
.. urgency Value Set:
Options: 2 options
.. drug-info Value Set:
... drug-info|drug-name Value Set:
... drug-info|drug-intention-opioid Value Set:
.... drug-info|drug-intention-opioid|first-prior-authentication Enable When: Not done yet
Value Set:
.... drug-info|drug-intention-opioid|date-first-request Enable When: Not done yet
Value Set:
.... drug-info|drug-intention-opioid|twelve-months-since-request Enable When: Not done yet
Value Set:
.. completing-form Enable When: Not done yet
Value Set:
... completing-form|patient-info Value Set:
.... completing-form|patient-info|prescription-date Value Set:
... completing-form|prescriber-info Value Set:
.... completing-form|prescriber-info|prescriber-name Value Set:
.... completing-form|prescriber-info|prescriber-fax Value Set:
.... completing-form|prescriber-info|prescriber-phone Value Set:
.... completing-form|prescriber-info|prescriber-pager Value Set:
.... completing-form|prescriber-info|prescriber-address Value Set:
.... completing-form|prescriber-info|prescriber-contact Value Set:
.... completing-form|prescriber-info|prescriber-npi Value Set:
.... completing-form|prescriber-info|prescriber-dea Value Set:
.... completing-form|prescriber-info|prescriber-tax-id Value Set:
.... completing-form|prescriber-info|prescriber-specialty Value Set:
.... completing-form|prescriber-info|prescriber-email Value Set:
... completing-form|drug-benefit Value Set:
.... completing-form|drug-benefit|request-type Value Set:
Options: 2 options
.... completing-form|drug-benefit|diagnosis-codes Value Set: ICD-10 Codes
.... completing-form|drug-benefit|diagnosis-descriptions Value Set:
.... completing-form|drug-benefit|drugs Value Set:
.... completing-form|drug-benefit|strength-route-frequency Value Set:
.... completing-form|drug-benefit|unit-volume Value Set:
.... completing-form|drug-benefit|start-length Value Set:
.... completing-form|drug-benefit|location Value Set:
.... completing-form|drug-benefit|criteria Value Set:
.... completing-form|drug-benefit|for-trial Value Set:
.... completing-form|drug-benefit|for-trial|registration-number Enable When: Not done yet
Value Set:
.... completing-form|drug-benefit|drug-name Value Set:
.... completing-form|drug-benefit|dose Value Set:
.... completing-form|drug-benefit|route Value Set:
.... completing-form|drug-benefit|frequency Value Set:
.... completing-form|drug-benefit|quantity Value Set:
.... completing-form|drug-benefit|refills Value Set:
.... completing-form|drug-benefit|delivery Value Set:
Options: 3 options
.... completing-form|drug-benefit|signature Value Set:
.... completing-form|drug-benefit|pharmacy Value Set:
.... completing-form|drug-benefit|date 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.