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 Medical Benefit Outpatient Drug Authorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire | Version: 1.0.0
Standards status: Informative | Computable Name: MBODAQuestionnaire
Copyright/Legal: 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

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

Structure

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
MBODAQuestionnaire | 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/MBODAQuestionnaire#1.0.0
diagnosis-info | Diagnosis Information | 0..1 | group |
diagnosis-info|diagnosis-code | Diagnosis/ICD-10 code(s) | 0..* | open-choice |
diagnosis-info|diagnosis-description | Diagnosis description | 0..* | string |
medication-info | Medication Information | 0..1 | group |
medication-info|name | Medication name | 0..1 | string |
medication-info|dose | Dose | 0..1 | quantity |
medication-info|route | Route | 0..* | open-choice |
medication-info|frequency | Frequency | 0..1 | quantity |
medication-info|therapy-leng | Expected length of therapy | 0..1 | quantity |
medication-info|num-visits | Quantity/number of requested visits | 0..1 | integer |
medication-info|service-date | Anticipated/actual date of service | 0..1 | date |
medication-info|new-med | New Medication or Continued Therapy | 0..1 | choice | Options: 2 options
medication-info|date-initiallized | Date therapy initially started | 0..1 | date | Enable When: medication-info|new-med =
medication-info|requested-drug-code | HCPCS/CPT code/J code/NDC code of requested drug | 0..1 | string |
medication-info|associated-procedure | Associated procedure codes requiring prior auth | 0..1 | string |
request-for-expedited-review | Request for Expedited Review | 0..1 | group |
request-for-expedited-review|para | 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. | 0..1 | group |
request-for-expedited-review|rationale | URGENT - rationale | 0..1 | string |
ordering-provider-signature | Ordering Provider Signature | 0..1 | group |
ordering-provider-signature|author-signature | Signature: | 0..1 | attachment |
Documentation for this format

Options Sets

Answer options for medication-info|new-med

- http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#NewMedication ("New Medication")
- http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy ("Continuation of therapy")