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 Medical Necessity For Authorization Of Catheters Questionnaire (Experimental)

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

Copyright/Legal: This content is informed by the following source, used with permission: https://www.hca.wa.gov/assets/billers-and-providers/13-760.pdf

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

Structure
LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. MNACQuestionnaireThis is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.Questionnairehttp://hl7.org/fhir/us/cql/Questionnaire/MNACQuestionnaire#1.0.0
... request-infoRequest Information0..1group
.... request-info|date-of-requestDATE OF REQUEST0..1date
... diagnosis-infoDiagnosis Information0..1group
.... diagnosis-info|diagnosisDiagnosis0..1string
... item-requestedItem Requested0..1group
.... item-requested|itemItem requested0..1string
... uti-historyUTI History0..1group
.... uti-history|uti-last-yearThe patient has|had documented recurrent urinary tract infections while on a program of clean cathing, twice within a 12 month period prior to beginning sterile cathing0..1boolean
.... uti-history|uti-datesDates of UTIs in the last year0..1stringEnable When: uti-history|uti-last-year =
.... uti-history|antibiotics-usedAntibiotics used for UTIs in the last year0..1stringEnable When: uti-history|uti-last-year =
... symptoms-infoSymptoms Information0..1group
.... symptoms-info|symptomsCheck those that apply to your patient0..*choiceOptions: 7 options
.... symptoms-info|fever-temperatureIf fever, state temperature in degrees0..1decimalEnable When: symptoms-info|symptoms =
... catheterization-frequencyCatheterization Frequency0..1group
.... catheterization-frequency|frequencyHow many times per day does the patient catheterize?0..1choiceOptions: 4 options
... additional-commentsAdditional Comments0..1group
.... additional-comments|commentsAdditional Comment0..1string
... physician-infoPhysician Information0..1group
.... physician-info|namePhysician's Name0..1string
.... physician-info|mobileTelephone0..1string
.... physician-info|faxFAX0..1string
.... physician-info|signaturePhysician's Signature0..1attachment
.... physician-info|phone-referringReferring Physician Telephone0..1string
.... physician-info|dateDate0..1string

doco Documentation for this format

Options Sets

Answer options for symptoms-info|symptoms

  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Fever ("Fever; state temperature in degree")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#UrinaryUrgencyFrequency ("Change in urinary urgency, frequency, or incontinence")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#AutonomicDysreflexia ("Appearance of new or increase in autonomic dysreflexia")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#PhysicalSignsProstatitis ("Physical signs of prostatitis, epididymitis, orchitis")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Immunosuppressed ("The patient is immunosuppressed")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#Pyuria ("Pyuria")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-symptoms-info-symptoms#SystemicLeukocytosis ("Systemic leukocytosis")

Answer options for catheterization-frequency|frequency

  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#2-4Times ("2-4 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#4-6Times ("4-6 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#6-8Times ("6-8 times")
  • http://example.org/fhir/CodeSystem/MNACQuestionnaire-catheterization-frequency-frequency#8TimesOrMore ("8 times or more")