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: Humana Uniform Pharmacy Prior Authorization Request Form (Experimental)

Official URL: http://fhir.org/guides/cqf/us/common/Questionnaire/UPPARFQuestionnaire Version: 0.1.0
Active as of 2023-10-19 Computable Name: UPPARFQuestionnaire

Humana Uniform Pharmacy Prior Authorization Request Form

Generated Narrative: Questionnaire UPPARFQuestionnaire

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. UPPARFQuestionnaireHumana Uniform Pharmacy Prior Authorization Request FormQuestionnairehttp://fhir.org/guides/cqf/us/common/Questionnaire/UPPARFQuestionnaire#0.1.0
... urgencyUrgency0..1choiceOptions: 2 options
... drug-infoDrug Information0..1group
.... drug-info|drug-nameRequested Drug Name0..1string
.... drug-info|drug-intention-opioidIs this drug intended to treat opioid dependence?0..1boolean
..... drug-info|drug-intention-opioid|first-prior-authenticationIs this a first request for prior authorization for this drug?0..1booleanEnable When: drug-info|drug-intention-opioid =
..... drug-info|drug-intention-opioid|date-first-requestWhat was the date of the first request?0..1dateEnable When: drug-info|drug-intention-opioid|first-prior-authentication =
..... drug-info|drug-intention-opioid|twelve-months-since-requestHas the date of the first request been greater than twelve months ago?0..1booleanEnable When: drug-info|drug-intention-opioid|first-prior-authentication =
... completing-formPrior authentication is required and this form needs to be completed0..1groupEnable When:
.... completing-form|patient-infoPatient Info0..1group
..... completing-form|patient-info|prescription-datePrescription Date0..1string
.... completing-form|prescriber-infoPrescriber Info0..1group
..... completing-form|prescriber-info|prescriber-namePrescriber Name0..1string
..... completing-form|prescriber-info|prescriber-faxPrescriber Fax0..1string
..... completing-form|prescriber-info|prescriber-phonePrescriber Phone0..1string
..... completing-form|prescriber-info|prescriber-pagerPrescriber Pager0..1string
..... completing-form|prescriber-info|prescriber-addressPrescriber Address0..1string
..... completing-form|prescriber-info|prescriber-contactPrescriber Office Contact0..1string
..... completing-form|prescriber-info|prescriber-npiPrescriber NPI0..1string
..... completing-form|prescriber-info|prescriber-deaPrescriber DEA0..1string
..... completing-form|prescriber-info|prescriber-tax-idPrescriber Tax ID0..1string
..... completing-form|prescriber-info|prescriber-specialtySpecialty/Facility Name If applicable0..1string
..... completing-form|prescriber-info|prescriber-emailEmail Address0..1string
.... completing-form|drug-benefitPrior Authorization Request for Drug Benefit0..1group
..... completing-form|drug-benefit|request-typeNew Request0..1choiceOptions: 2 options
..... completing-form|drug-benefit|diagnosis-codesPatient ICD Diagnostic Codes0..*open-choiceValue Set: ICD-10 Codes
..... completing-form|drug-benefit|diagnosis-descriptionsPatient Diagnosis0..*string
..... completing-form|drug-benefit|drugsDrugs Requested with J-Code; if applicable0..*string
..... completing-form|drug-benefit|strength-route-frequencyStrength/Route/Frequency0..1string
..... completing-form|drug-benefit|unit-volumeUnit/Volume of Named Drugs0..1string
..... completing-form|drug-benefit|start-lengthStart Date and Length of Therapy0..1string
..... completing-form|drug-benefit|locationLocation of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:0..1string
..... completing-form|drug-benefit|criteriaClinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:0..1string
..... completing-form|drug-benefit|for-trialFor use in clinical trial?0..1boolean
..... completing-form|drug-benefit|for-trial|registration-numberProvide trial name and registration number0..1stringEnable When: completing-form|drug-benefit|for-trial =
..... completing-form|drug-benefit|drug-nameDrug Name Brand Name and Scientific Name/Strength:0..1string
..... completing-form|drug-benefit|doseDose0..1string
..... completing-form|drug-benefit|routeRoute0..1string
..... completing-form|drug-benefit|frequencyFrequency0..1string
..... completing-form|drug-benefit|quantityQuantity0..1quantity
..... completing-form|drug-benefit|refillsNumber of Refills0..1integer
..... completing-form|drug-benefit|deliveryProduct will be delivered to:0..1choiceOptions: 3 options
..... completing-form|drug-benefit|signaturePrescriber or Authorized Signature:0..1attachment
..... completing-form|drug-benefit|pharmacyDispensing Pharmacy Name and Phone Number:0..1string
..... completing-form|drug-benefit|dateDate0..1date

doco Documentation for this format

Options Sets

Answer options for urgency

  • null#urgent ("Urgent")
  • null#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