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

## 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.

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
GMTPQuestionnaire | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. |  | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire#1.0.0
billing-provider-question | Is the billing provider/referring lab different from servicing provider? | 0..1 | boolean |
billing-provider-info | Billing provider/referring lab information | 0..1 | group | Enable When: billing-provider-question =
billing-provider-info|name | Requesting provider name | 0..1 | string |
billing-provider-info|phone-number | Phone | 0..1 | string |
billing-provider-info|address | Ordering provider address | 0..1 | string |
billing-provider-info|npi | Ordering provider Tax ID/NPI # | 0..1 | string |
billing-provider-info|fax | Fax | 0..1 | string |
test-requested | Test requested | 0..1 | group |
test-requested|service-date | Date of service | 0..1 | date |
test-requested|test-id | Test ID | 0..1 | string |
test-requested|test-name | Test name | 0..1 | string |
test-requested|diagnosis-description | Diagnosis description | 0..1 | string |
test-requested|diagnosis-icd-code | ICD-10 code(s) | 0..* | open-choice | Value Set: ICD-10 Codes
test-requested|diagnosis-cpt-code | CPT code(s) | 0..* | open-choice | Value Set: AMA CPT All Codes
clinical-trial | Clinical Trial Information | 0..1 | group |
clinical-trial-question | Is the requested test part of a clinical trial? | 0..1 | boolean |
clinical-trial|yes-clinial-trial | If Yes, provide the registration or ID number for the specific trial in which this test is being studied. | 0..1 | string | Enable When: clinical-trial-question =
history | Patient history and related findings | 0..1 | group |
history|patient-history | Patient history including age at diagnosis | 0..1 | group |
history|patient-history|diagnosis | Diagnosis | 0..1 | string |
history|patient-history|age-at-onset | Age at onset | 0..1 | string |
history|patient-history|abatement | Abatement | 0..1 | string |
history|family-history | Family 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 available | 0..1 | string |
history|other-findings | Other findings/testing completed - previous genetic testing for condition | 0..1 | string |
history|treatment-relation | How will testing be used in relation to treatment or management of the patient? | 0..1 | string |
person-filling-out-form | Person filling out form | 0..1 | group |
person-filling-out-form|name | Name | 0..1 | string |
person-filling-out-form|phone-number | Phone number | 0..1 | string |
person-filling-out-form|facility | Phone number | 0..1 | string |
Documentation for this format