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: Medical Benefit Outpatient Drug Authorization Form (Experimental)

Official URL: http://fhir.org/guides/cqf/us/common/Questionnaire/MBODAQuestionnaire Version: 0.1.0
Active as of 2023-08-14 Computable Name: MBODAQuestionnaire

Drugs administered by healthcare professionals in an outpatient setting are covered under the Medical Benefit. Information on drugs requiring prior authorization can be found on NaviNet.net or the For Providers section of the Geisinger Health Plan website.

Generated Narrative: Questionnaire MBODAQuestionnaire

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. MBODAQuestionnaireDrugs administered by healthcare professionals in an outpatient setting are covered under the Medical Benefit. Information on drugs requiring prior authorization can be found on NaviNet.net or the For Providers section of the Geisinger Health Plan website.Questionnairehttp://fhir.org/guides/cqf/us/common/Questionnaire/MBODAQuestionnaire#0.1.0
... patient-infoPatient Information0..1group
.... patient-info|drug-allergiesDrug allergies0..*open-choice
.... patient-info|heightHeight0..1decimal
.... patient-info|weightWeight0..1decimal
.... patient-info|bsaBSA0..1decimal
... provider-infoOrdering Provider Information0..1group
.... provider-info|nameOrdering provider name0..1string
.... provider-info|npiOrdering provider NPI #0..1string
.... provider-info|addressOrdering provider address0..1string
.... provider-info|cityCity0..1string
.... provider-info|stateState0..1string
.... provider-info|zip-codeZip0..1string
.... person-submitting-requestPerson submitting request0..1group
..... person-submitting-request|nameName0..1string
..... person-submitting-request|phone-numberPhone0..1string
..... person-submitting-request|faxFax0..1string
.... office-contactOffice contact0..1group
..... office-contact|nameName0..1string
..... office-contact|phone-numberPhone0..1string
..... office-contact|faxFax0..1string
... servicing-provider-facility-infoServicing Provider/Facility Information0..1group
.... servicing-provider-facility-info|drug-adminWho is administering the drug?0..1choiceOptions: 3 options
.... select-onePlease select if the medication will be dispensed or administered0..1choiceOptions: 2 options
..... if-buy-billIf buy & bill, who will be billing for the drug?0..1choiceEnable When: select-one =
Options: 3 options
..... provider-participating-ghpIs the billing provider participating with GHP?0..1choiceEnable When: select-one =
Options: 2 options
...... no-ghpIf No, is this a request for out-of-network services?0..1choiceEnable When: provider-participating-ghp =
Options: 2 options
... servicing-providerServicing provider0..1group
.... servicing-provider|nameProvider name0..1string
.... servicing-provider|npiNPI #0..1string
.... servicing-provider|addressAddress0..1string
.... servicing-provider|phone-numberPhone0..1string
.... servicing-provider|faxFax0..1string
.... servicing-provider|office-contactOffice contact0..1string
... facility-of-serviceFacility/location of service0..1group
.... facility-of-service|nameFacility/location name0..1string
.... facility-of-service|npiNPI #0..1string
.... facility-of-service|addressAddress0..1string
.... facility-of-service|phone-numberPhone0..1string
.... facility-of-service|faxFax0..1string
.... facility-of-service|office-contactFacility contact0..1string
... specialty-vendorSpecialty vendor (if applicable)0..1group
.... specialty-vendor|nameSpecialty pharmacy name0..1string
.... specialty-vendor|npiNPI #0..1string
.... specialty-vendor|addressAddress0..1string
.... specialty-vendor|phone-numberPhone0..1string
.... specialty-vendor|faxFax0..1string
.... specialty-vendor|office-contactPharmacy contact0..1string
... diagnosis-infoDiagnosis Information0..1group
.... diagnosis-info|diagnosis-codeDiagnosis/ICD-10 code(s)0..*open-choice
.... diagnosis-info|diagnosis-descriptionDiagnosis description0..*string
... medication-infoMedication Information0..1group
.... medication-info|nameMedication name0..1string
.... medication-info|doseDose0..1quantity
.... medication-info|routeRoute0..*open-choice
.... medication-info|frequencyFrequency0..1quantity
.... medication-info|therapy-lengExpected length of therapy0..1quantity
.... medication-info|num-visitsQuantity/number of requested visits0..1integer
.... medication-info|service-dateAnticipated/actual date of service0..1date
.... medication-info|new-medNew Medication or Continued Therapy0..1choiceOptions: 2 options
.... medication-info|date-initiallizedDate therapy initially started0..1dateEnable When: medication-info|new-med =
.... medication-info|requested-drug-codeHCPCS/CPT code/J code/NDC code of requested drug0..1string
.... medication-info|associated-procedureAssociated procedure codes requiring prior auth0..1string
... request-for-expedited-reviewRequest for Expedited Review0..1group
.... request-for-expedited-review|paraWhen 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..1group
..... request-for-expedited-review|rationaleURGENT - rationale0..1string
... ordering-provider-signatureOrdering Provider Signature0..1group
.... ordering-provider-signature|author-signatureSignature:0..1attachment

doco Documentation for this format

Options Sets

Answer options for servicing-provider-facility-info|drug-admin

  • null#OrderingProvider ("Ordering Provider")
  • null#ServicingProvider ("Servicing Provider")
  • null#HomeHealthAgency ("Home Health Agency - if yes, name of agency")

Answer options for select-one

  • null#AdministeredFromProviderStock ("Medication will be administered from provider stock and billed by provider (buy & bill)")
  • null#DispensedByPharmacy ("Medication will be dispensed by a specialty pharmacy and billed by the pharmacy")

Answer options for if-buy-bill

  • null#OrderingProvider ("Ordering Provider")
  • null#ServicingProvider ("Servicing Provider")
  • null#Facility ("Facility")

Answer options for provider-participating-ghp

  • null#Y ("Yes")
  • null#N ("No")

Answer options for no-ghp

  • null#Y ("Yes")
  • null#N ("No")

Answer options for medication-info|new-med

  • null#NewMedication ("New Medication")
  • null#ContinuedTherapy ("Continuation of therapy")