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 Uniform Pharmacy Prior Authorization Request Form (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire | Version: 1.0.0
Standards status: Informative | Computable Name: UPPARFQuestionnaire
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=4136509

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
--- | --- | --- | --- | ---
UPPARFQuestionnaire | 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/UPPARFQuestionnaire#1.0.0
urgency | Urgency | 0..1 | choice | Options: 2 options
drug-info | Drug Information | 0..1 | group |
drug-info|drug-name | Requested Drug Name | 0..1 | string |
drug-info|drug-intention-opioid | Is this drug intended to treat opioid dependence? | 0..1 | boolean |
drug-info|drug-intention-opioid|first-prior-authentication | Is this a first request for prior authorization for this drug? | 0..1 | boolean | Enable When: drug-info|drug-intention-opioid =
drug-info|drug-intention-opioid|date-first-request | What was the date of the first request? | 0..1 | date | Enable When: drug-info|drug-intention-opioid|first-prior-authentication =
drug-info|drug-intention-opioid|twelve-months-since-request | Has the date of the first request been greater than twelve months ago? | 0..1 | boolean | Enable When: drug-info|drug-intention-opioid|first-prior-authentication =
completing-form | Prior authentication is required and this form needs to be completed | 0..1 | group | Enable When: drug-info|drug-intention-opioid = drug-info|drug-intention-opioid|twelve-months-since-request =
completing-form|patient-info | Patient Info | 0..1 | group |
completing-form|patient-info|prescription-date | Prescription Date | 0..1 | string |
completing-form|prescriber-info | Prescriber Info | 0..1 | group |
completing-form|prescriber-info|prescriber-name | Prescriber Name | 0..1 | string |
completing-form|prescriber-info|prescriber-fax | Prescriber Fax | 0..1 | string |
completing-form|prescriber-info|prescriber-phone | Prescriber Phone | 0..1 | string |
completing-form|prescriber-info|prescriber-pager | Prescriber Pager | 0..1 | string |
completing-form|prescriber-info|prescriber-address | Prescriber Address | 0..1 | string |
completing-form|prescriber-info|prescriber-contact | Prescriber Office Contact | 0..1 | string |
completing-form|prescriber-info|prescriber-npi | Prescriber NPI | 0..1 | string |
completing-form|prescriber-info|prescriber-dea | Prescriber DEA | 0..1 | string |
completing-form|prescriber-info|prescriber-tax-id | Prescriber Tax ID | 0..1 | string |
completing-form|prescriber-info|prescriber-specialty | Specialty/Facility Name If applicable | 0..1 | string |
completing-form|prescriber-info|prescriber-email | Email Address | 0..1 | string |
completing-form|drug-benefit | Prior Authorization Request for Drug Benefit | 0..1 | group |
completing-form|drug-benefit|request-type | New Request | 0..1 | choice | Options: 2 options
completing-form|drug-benefit|diagnosis-codes | Patient ICD Diagnostic Codes | 0..* | open-choice | Value Set: ICD-10 Codes
completing-form|drug-benefit|diagnosis-descriptions | Patient Diagnosis | 0..* | string |
completing-form|drug-benefit|drugs | Drugs Requested with J-Code; if applicable | 0..* | string |
completing-form|drug-benefit|strength-route-frequency | Strength/Route/Frequency | 0..1 | string |
completing-form|drug-benefit|unit-volume | Unit/Volume of Named Drugs | 0..1 | string |
completing-form|drug-benefit|start-length | Start Date and Length of Therapy | 0..1 | string |
completing-form|drug-benefit|location | Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID: | 0..1 | string |
completing-form|drug-benefit|criteria | Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response: | 0..1 | string |
completing-form|drug-benefit|for-trial | For use in clinical trial? | 0..1 | boolean |
completing-form|drug-benefit|for-trial|registration-number | Provide trial name and registration number | 0..1 | string | Enable When: completing-form|drug-benefit|for-trial =
completing-form|drug-benefit|drug-name | Drug Name Brand Name and Scientific Name/Strength: | 0..1 | string |
completing-form|drug-benefit|dose | Dose | 0..1 | string |
completing-form|drug-benefit|route | Route | 0..1 | string |
completing-form|drug-benefit|frequency | Frequency | 0..1 | string |
completing-form|drug-benefit|quantity | Quantity | 0..1 | quantity |
completing-form|drug-benefit|refills | Number of Refills | 0..1 | integer |
completing-form|drug-benefit|delivery | Product will be delivered to: | 0..1 | choice | Options: 3 options
completing-form|drug-benefit|signature | Prescriber or Authorized Signature: | 0..1 | attachment |
completing-form|drug-benefit|pharmacy | Dispensing Pharmacy Name and Phone Number: | 0..1 | string |
completing-form|drug-benefit|date | Date | 0..1 | date |
Documentation for this format

Options Sets

Answer options for urgency

- http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#urgent ("Urgent")
- http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency#routine ("Non-Urgent")

Answer options for completing-form|drug-benefit|request-type

- New Request
- Reauthorization

Answer options for completing-form|drug-benefit|delivery

- Patient's Home
- Physician Office
- Other