Common CQL Artifacts for FHIR (US-Based)
1.0.0 - Informative 1 United States of America flag

This page is part of the Common CQL Assets for FHIR (US-Based) (v1.0.0: Informative 1 - Informative) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Questionnaire: Example Genetic/Molecular Testing Preauthorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire Version: 1.0.0
Standards status: Informative Computable Name: GMTPQuestionnaire

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=1986712

This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. GMTPQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire#1.0.0
... billing-provider-questionIs the billing provider/referring lab different from servicing provider?0..1boolean
.... 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..1boolean
..... 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..1group
..... history|patient-history|diagnosisDiagnosis0..1string
..... history|patient-history|age-at-onsetAge at onset0..1string
..... history|patient-history|abatementAbatement0..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