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Examples

Page standards status: Informative

This implementation guide includes several worked examples of prior authorization questionnaires:

Example Patient and Coverage Questionnaire

For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.

The examples above are informed by the prior-authorization use case. Additional examples not included in this implementation guide are available in the github source repository.

Other Potential Examples

The following links provide other potential examples to be worked include:

• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=2787759
• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1830868
• https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/maryland/providers/pdfs/abhmd_maryland_prenatal_risk_assesment_mdh.pdf
• https://www.uhcprovider.com/en/resource-library/maternity-support.html
• https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/medical-policies/Knee-Arthroplasty-Adults.pdf

Complex questionnaires:

• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4728932
• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=5106036

State questionnaires:

• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=5029375
• https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4197323

Cohere Humana: - select Humana dropdown and type to find a list of several questionnaires

• https://payerinfo.zendesk.com/hc/en-us/categories/10629830321047-Fax-Forms

Geisinger:

• https://www.geisinger.org/health-plan/providers/forms-and-resources-for-providers

Potential Nut Allergy:

• https://fm.formularynavigator.com/FormularyNavigator/DocumentManager/Download?clientDocumentId=nU_SBgZRGEKjIxwVIRtrEQ