Clinical Quality Framework Common FHIR Assets (US-Based)
0.1.0 - CI Build United States of America (USA)

Clinical Quality Framework Common FHIR Assets (US-Based), published by Clinical Quality Framework. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/cqf-us/ and changes regularly. See the Directory of published versions

Questionnaire: Genetic/Molecular testing preauthorization request (Experimental)

Official URL: http://fhir.org/guides/cqf/us/common/Questionnaire/GMTPQuestionnaire Version: 0.1.0
Active as of 2023-10-12 Computable Name: GMTPQuestionnaire

Automated online preauthorization is available for some tests. Please log into the Availity Portal at Availity.com for a list of available questionnaires. If the appropriate questionnaire is not available, please complete this form.

Generated Narrative: Questionnaire GMTPQuestionnaire

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. GMTPQuestionnaireAutomated online preauthorization is available for some tests. Please log into the Availity Portal at Availity.com for a list of available questionnaires. If the appropriate questionnaire is not available, please complete this form.Questionnairehttp://fhir.org/guides/cqf/us/common/Questionnaire/GMTPQuestionnaire#0.1.0
... provider-infoRequesting Provider Information0..1group
.... provider-info|nameRequesting provider name0..1string
.... provider-info|phone-numberPhone0..1string
.... provider-info|addressOrdering provider address0..1string
.... provider-info|npiOrdering provider Tax ID/NPI #0..1string
.... provider-info|faxFax0..1string
... servicing-providerLaboratory performing testing/Servicing Provider0..1group
.... servicing-provider|nameRequesting provider name0..1string
.... servicing-provider|phone-numberPhone0..1string
.... servicing-provider|addressOrdering provider address0..1string
.... servicing-provider|npiOrdering provider Tax ID/NPI #0..1string
.... servicing-provider|faxFax0..1string
... billing-provider-questionIs the billing provider/referring lab different from servicing provider?0..1choiceOptions: 2 options
.... billing-provider-infoBilling provider/referring lab information0..1groupEnable When: billing-provider-question =
..... billing-provider-info|nameRequesting provider name0..1string
..... billing-provider-info|phone-numberPhone0..1string
..... billing-provider-info|addressOrdering provider address0..1string
..... billing-provider-info|npiOrdering provider Tax ID/NPI #0..1string
..... billing-provider-info|faxFax0..1string
... test-requestedTest requested0..1group
.... test-requested|service-dateDate of service0..1date
.... test-requested|test-idTest ID0..1string
.... test-requested|test-nameTest name0..1string
.... test-requested|diagnosis-descriptionDiagnosis description0..1string
.... test-requested|diagnosis-icd-codeICD-10 code(s)0..*open-choiceValue Set: ICD-10 Codes
.... test-requested|diagnosis-cpt-codeCPT code(s)0..*open-choiceValue Set: AMA CPT All Codes
... clinical-trialClinical Trial Information0..1group
.... clinical-trial-questionIs the requested test part of a clinical trial?0..1choiceOptions: 2 options
..... clinical-trial|yes-clinial-trialIf Yes, provide the registration or ID number for the specific trial in which this test is being studied.0..1stringEnable When: clinical-trial-question =
... historyPatient history and related findings0..1group
.... history|patient-historyPatient history including age at diagnosis0..1string
.... history|family-historyFamily 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 available0..1string
.... history|other-findingsOther findings/testing completed - previous genetic testing for condition0..1string
.... history|treatment-relationHow will testing be used in relation to treatment or management of the patient?0..1string
... person-filling-out-formPerson filling out form0..1group
.... person-filling-out-form|nameName0..1string
.... person-filling-out-form|phone-numberPhone number0..1string
.... person-filling-out-form|facilityPhone number0..1string

doco Documentation for this format

Options Sets

Answer options for billing-provider-question

  • null#Y ("Yes")
  • null#N ("No")

Answer options for clinical-trial-question

  • null#Y ("Yes")
  • null#N ("No")