Common CQL Artifacts for FHIR (US-Based)
1.0.0 - Informative 1

Common CQL Artifacts for FHIR (US-Based) - Downloaded Version null See the Directory of published versions

## : Example Medical Benefit Outpatient Drug Authorization Questionnaire - TTL Representation

Page standards status: Informative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:Questionnaire ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "MBODAQuestionnaire"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire MBODAQuestionnaire</b></p><a name=\"MBODAQuestionnaire\"> </a><a name=\"hcMBODAQuestionnaire\"> </a><b>Structure</b><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description &amp; Constraints</a><span style=\"float: right\"><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64, \" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> MBODAQuestionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire#1.0.0</td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.diagnosis-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> diagnosis-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Diagnosis Information</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.diagnosis-info|diagnosis-code\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> diagnosis-info|diagnosis-code</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Diagnosis/ICD-10 code(s)</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-open-choice\">open-choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck100.png)\" id=\"item.diagnosis-info|diagnosis-description\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> diagnosis-info|diagnosis-description</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Diagnosis description</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.medication-info\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> medication-info</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Medication Information</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|name\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> medication-info|name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Medication name</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|dose\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-quantity.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"quantity\" class=\"hierarchy\"/> medication-info|dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Dose</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity\">quantity</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|route\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> medication-info|route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Route</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-open-choice\">open-choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|frequency\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-quantity.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"quantity\" class=\"hierarchy\"/> medication-info|frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Frequency</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity\">quantity</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|therapy-leng\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-quantity.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"quantity\" class=\"hierarchy\"/> medication-info|therapy-leng</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Expected length of therapy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-quantity\">quantity</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|num-visits\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-integer.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"integer\" class=\"hierarchy\"/> medication-info|num-visits</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Quantity/number of requested visits</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer\">integer</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|service-date\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> medication-info|service-date</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Anticipated/actual date of service</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|new-med\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> medication-info|new-med</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">New Medication or Continued Therapy</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.medication-info|new-med\">2 options</a></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|date-initiallized\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-date.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"date\" class=\"hierarchy\"/> medication-info|date-initiallized</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Date therapy initially started</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date\">date</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.medication-info|new-med\">medication-info|new-med</a> = </span></td></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.medication-info|requested-drug-code\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> medication-info|requested-drug-code</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">HCPCS/CPT code/J code/NDC code of requested drug</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck100.png)\" id=\"item.medication-info|associated-procedure\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> medication-info|associated-procedure</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Associated procedure codes requiring prior auth</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.request-for-expedited-review\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> request-for-expedited-review</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Request for Expedited Review</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck101.png)\" id=\"item.request-for-expedited-review|para\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> request-for-expedited-review|para</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">When 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.</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1000.png)\" id=\"item.request-for-expedited-review|rationale\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-string.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"string\" class=\"hierarchy\"/> request-for-expedited-review|rationale</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">URGENT - rationale</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string\">string</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck01.png)\" id=\"item.ordering-provider-signature\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> ordering-provider-signature</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Ordering Provider Signature</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck000.png)\" id=\"item.ordering-provider-signature|author-signature\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_blank.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-attachment.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"attachment\" class=\"hierarchy\"/> ordering-provider-signature|author-signature</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Signature:</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-attachment\">attachment</a></td><td style=\"vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>#xD;\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"https://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64, \" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table><hr/><p><b>Options Sets</b></p><a name=\"opt-item.medication-info|new-med\"> </a><p><b>Answer options for medication-info|new-med </b></p><ul><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#NewMedication (\"New Medication\")</li><li style=\"font-size: 11px\">http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy (\"Continuation of therapy\")</li></ul></div>"^^rdf:XMLLiteral
      ] ; #
      fhir:extension ( [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/cqf-library"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:canonical ;
    fhir:v "http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions"^^xsd:anyURI ;
    fhir:link <http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions>     ]
      ] [
        ( fhir:extension [
    fhir:url [ fhir:v "name"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "patient" ] ;
    fhir:display [ fhir:v "Patient" ]       ]     ] [
    fhir:url [ fhir:v "type"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:code ;
    fhir:v "Patient"       ]     ] [
    fhir:url [ fhir:v "description"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:string ;
    fhir:v "The patient that is to be used to pre-populate the form"       ]     ] ) ;
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"^^xsd:anyURI ]
      ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:code ;
    fhir:v "cds"     ]
      ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:code ;
    fhir:v "informative" ;
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:canonical ;
    fhir:v "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"^^xsd:anyURI ;
    fhir:link <http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql>         ]       ] )     ]
      ] ) ; #
      fhir:url [ fhir:v "http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire"^^xsd:anyURI] ; #
      fhir:version [ fhir:v "1.0.0"] ; #
      fhir:name [ fhir:v "MBODAQuestionnaire"] ; #
      fhir:title [ fhir:v "Example Medical Benefit Outpatient Drug Authorization Questionnaire"] ; #
      fhir:status [ fhir:v "active"] ; #
      fhir:experimental [ fhir:v true] ; #
      fhir:date [ fhir:v "2023-08-14T00:00:00+00:00"^^xsd:dateTime] ; #
      fhir:publisher [ fhir:v "HL7 International / Clinical Decision Support"] ; #
      fhir:contact ( [
        ( fhir:telecom [
    fhir:system [ fhir:v "url" ] ;
    fhir:value [ fhir:v "http://www.hl7.org/Special/committees/dss" ]     ] )
      ] ) ; #
      fhir:description [ fhir:v "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form."] ; #
      fhir:jurisdiction ( [
        ( fhir:coding [
    fhir:system [ fhir:v "urn:iso:std:iso:3166"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "US" ] ;
    fhir:display [ fhir:v "United States of America" ]     ] )
      ] ) ; #
      fhir:copyright [ fhir:v "This content is is informed by the following source, used with permission: https://www.geisinger.org/-/media/OneGeisinger/Files/PDFs/Provider/NaviNet/Forms/medical-benefit-outpatient-drug-authorization-form-050819.pdf?sc_lang=en&hash=6EDE27E13FCCB5731E081FC49B85359D"] ; #
      fhir:item ( [
    fhir:linkId [ fhir:v "diagnosis-info" ] ;
    fhir:text [ fhir:v "Diagnosis Information" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:item [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Diagnosis Codes" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "diagnosis-info|diagnosis-code" ] ;
    fhir:text [ fhir:v "Diagnosis/ICD-10 code(s)" ] ;
    fhir:type [ fhir:v "open-choice" ] ;
    fhir:repeats [ fhir:v true ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Diagnosis Descriptions" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "diagnosis-info|diagnosis-description" ] ;
    fhir:text [ fhir:v "Diagnosis description" ] ;
    fhir:type [ fhir:v "string" ] ;
    fhir:repeats [ fhir:v true ]     ] )
      ] [
    fhir:linkId [ fhir:v "medication-info" ] ;
    fhir:text [ fhir:v "Medication Information" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:item [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Medication Name" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|name" ] ;
    fhir:text [ fhir:v "Medication name" ] ;
    fhir:type [ fhir:v "string" ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "ug" ] ;
    fhir:display [ fhir:v "ug" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "mg" ] ;
    fhir:display [ fhir:v "mg" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "g" ] ;
    fhir:display [ fhir:v "g" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "ml" ] ;
    fhir:display [ fhir:v "ml" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Medication Dose" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|dose" ] ;
    fhir:text [ fhir:v "Dose" ] ;
    fhir:type [ fhir:v "quantity" ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Medication Route" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|route" ] ;
    fhir:text [ fhir:v "Route" ] ;
    fhir:type [ fhir:v "open-choice" ] ;
    fhir:repeats [ fhir:v true ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "h" ] ;
    fhir:display [ fhir:v "h" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "d" ] ;
    fhir:display [ fhir:v "d" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "wk" ] ;
    fhir:display [ fhir:v "wk" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "mo" ] ;
    fhir:display [ fhir:v "mo" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Medication Frequency" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|frequency" ] ;
    fhir:text [ fhir:v "Frequency" ] ;
    fhir:type [ fhir:v "quantity" ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "h" ] ;
    fhir:display [ fhir:v "h" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "d" ] ;
    fhir:display [ fhir:v "d" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "wk" ] ;
    fhir:display [ fhir:v "wk" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "mo" ] ;
    fhir:display [ fhir:v "mo" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "a" ] ;
    fhir:display [ fhir:v "a" ]         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Expected Therapy Length" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|therapy-leng" ] ;
    fhir:text [ fhir:v "Expected length of therapy" ] ;
    fhir:type [ fhir:v "quantity" ]     ] [
    fhir:linkId [ fhir:v "medication-info|num-visits" ] ;
    fhir:text [ fhir:v "Quantity/number of requested visits" ] ;
    fhir:type [ fhir:v "integer" ]     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Anticipated/actual date of service" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|service-date" ] ;
    fhir:text [ fhir:v "Anticipated/actual date of service" ] ;
    fhir:type [ fhir:v "date" ]     ] [
    fhir:linkId [ fhir:v "medication-info|new-med" ] ;
    fhir:text [ fhir:v "New Medication or Continued Therapy" ] ;
    fhir:type [ fhir:v "choice" ] ;
          ( fhir:answerOption [
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "NewMedication" ] ;
    fhir:display [ fhir:v "New Medication" ]         ]       ] [
    fhir:value [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "ContinuedTherapy" ] ;
    fhir:display [ fhir:v "Continuation of therapy" ]         ]       ] )     ] [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:Expression ;
    fhir:language [ fhir:v "text/cql-identifier" ] ;
    fhir:expression [ fhir:v "Initial date of therapy" ]         ]       ] ) ;
    fhir:linkId [ fhir:v "medication-info|date-initiallized" ] ;
    fhir:text [ fhir:v "Date therapy initially started" ] ;
    fhir:type [ fhir:v "date" ] ;
          ( fhir:enableWhen [
    fhir:question [ fhir:v "medication-info|new-med" ] ;
    fhir:operator [ fhir:v "=" ] ;
    fhir:answer [
    a fhir:Coding ;
    fhir:system [ fhir:v "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "ContinuedTherapy" ]         ]       ] )     ] [
    fhir:linkId [ fhir:v "medication-info|requested-drug-code" ] ;
    fhir:text [ fhir:v "HCPCS/CPT code/J code/NDC code of requested drug" ] ;
    fhir:type [ fhir:v "string" ]     ] [
    fhir:linkId [ fhir:v "medication-info|associated-procedure" ] ;
    fhir:text [ fhir:v "Associated procedure codes requiring prior auth" ] ;
    fhir:type [ fhir:v "string" ]     ] )
      ] [
    fhir:linkId [ fhir:v "request-for-expedited-review" ] ;
    fhir:text [ fhir:v "Request for Expedited Review" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:item [
    fhir:linkId [ fhir:v "request-for-expedited-review|para" ] ;
    fhir:text [ fhir:v "When 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." ] ;
    fhir:type [ fhir:v "group" ] ;
          ( fhir:item [
    fhir:linkId [ fhir:v "request-for-expedited-review|rationale" ] ;
    fhir:text [ fhir:v "URGENT - rationale" ] ;
    fhir:type [ fhir:v "string" ]       ] )     ] )
      ] [
    fhir:linkId [ fhir:v "ordering-provider-signature" ] ;
    fhir:text [ fhir:v "Ordering Provider Signature" ] ;
    fhir:type [ fhir:v "group" ] ;
        ( fhir:item [
          ( fhir:extension [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:CodeableConcept ;
              ( fhir:coding [
    fhir:system [ fhir:v "urn:iso-astm:E1762-95:2013"^^xsd:anyURI ] ;
    fhir:code [ fhir:v "1.2.840.10065.1.12.1.1" ] ;
    fhir:display [ fhir:v "Author's Signature" ]           ] )         ]       ] [
    fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/questionnaire-usageMode"^^xsd:anyURI ] ;
    fhir:value [
    a fhir:code ;
    fhir:v "capture"         ]       ] ) ;
    fhir:linkId [ fhir:v "ordering-provider-signature|author-signature" ] ;
    fhir:text [ fhir:v "Signature:" ] ;
    fhir:type [ fhir:v "attachment" ]     ] )
      ] ) . #