Generated Narrative: Questionnaire GMTPQuestionnaire 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#2.0.0-ballot #xD; billing-provider-question Is the billing provider/referring lab different from servicing provider? 0..1 boolean #xD; billing-provider-info Billing provider/referring lab information 0..1 group Enable When: billing-provider-question = true #xD; billing-provider-info|name Requesting provider name 0..1 string #xD; billing-provider-info|phone-number Phone 0..1 string #xD; billing-provider-info|address Ordering provider address 0..1 string #xD; billing-provider-info|npi Ordering provider Tax ID/NPI # 0..1 string #xD; billing-provider-info|fax Fax 0..1 string #xD; test-requested Test requested 0..1 group #xD; test-requested|service-date Date of service 0..1 date #xD; test-requested|test-id Test ID 0..1 string #xD; test-requested|test-name Test name 0..1 string #xD; test-requested|diagnosis-description Diagnosis description 0..1 string #xD; test-requested|diagnosis-icd-code ICD-10 code(s) 0..* open-choice Value Set: ICD-10 Codes #xD; test-requested|diagnosis-cpt-code CPT code(s) 0..* open-choice Value Set: AMA CPT All Codes #xD; clinical-trial Clinical Trial Information 0..1 group #xD; clinical-trial-question Is the requested test part of a clinical trial? 0..1 boolean #xD; 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 = true #xD; history Patient history and related findings 0..1 group #xD; history|patient-history Patient history including age at diagnosis 0..1 group #xD; history|patient-history|diagnosis Diagnosis 0..1 string #xD; history|patient-history|age-at-onset Age at onset 0..1 string #xD; history|patient-history|abatement Abatement 0..1 string #xD; 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 #xD; history|other-findings Other findings/testing completed - previous genetic testing for condition 0..1 string #xD; history|treatment-relation How will testing be used in relation to treatment or management of the patient? 0..1 string #xD; person-filling-out-form Person filling out form 0..1 group #xD; person-filling-out-form|name Name 0..1 string #xD; person-filling-out-form|phone-number Phone number 0..1 string #xD; person-filling-out-form|facility Phone number 0..1 string #xD; Documentation for this format Contained Resources Metadata Type module-definition from http://terminology.hl7.org/CodeSystem/library-type Dependency Description: USCore model information Resource: US Core Model Informationversion: null6.1.0-derived) Canonical URL: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived Dependency Description: FHIR model information Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Dependency Description: Library UCE Resource: US Core Elementsversion: null2.0.0-ballot) Canonical URL: http://hl7.org/fhir/us/cql/Library/USCoreElements|2.0.0-ballot Dependency Description: Library FHIRHelpers Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Dependency Description: Library FHIRHelpers Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Data Requirement Type: Organization Profile(s): US Core Organization Profile Must Support Elements: id Data Requirement Type: Coverage Profile(s): Coverage Must Support Elements: id Data Requirement Type: Practitioner Profile(s): US Core Practitioner Profile Must Support Elements: id Data Requirement Type: ServiceRequest Profile(s): ServiceRequest Must Support Elements: id Parameters Name Use Card. Type Documentation Coverage In 0..1 Coverage ServiceRequest In 0..1 ServiceRequest Billing Provider different from Servicing Provider Out 0..1 string Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates
define "Retrieve Member Coverage test parameter": // When executing CQL with the VSCode extension retrieve the resource specific for the test case // the list of resource ids match the resources from the test case folders singleton from ([FHIR.Coverage] CV where CV.id in { 'Coverage-example-GMTP', // testcase: GMTP-example-patient-2 'coverage-GMTP-1' // testcase: USCorePatient-GMTP-1 })
define "Member Coverage": Coalesce( Coverage, "Retrieve Member Coverage test parameter" )
define "Billing Provider": UCE.BillingProvider("Member Coverage")
define "Retrieve Service Request test parameter": // When executing CQL with the VSCode extension retrieve the resource specific for the test case // the list of resource ids match the resources from the test case folders singleton from ([FHIR.ServiceRequest] SR where SR.id in { 'ServiceRequest-example-1-GMTP', // testcase: GMTP-example-patient-2 'service-request-USCorePatient-GMTP-1' // testcase: USCorePatient-GMTP-1 })
define "Most Recent ServiceRequest": Coalesce( ServiceRequest, "Retrieve Service Request test parameter" )
Billing Provider different from Servicing Provider
define "Billing Provider different from Servicing Provider": if "Billing Provider".id != First(UCE.ServicingProvider("Most Recent ServiceRequest").id) then 'Yes' else 'No'
define function BillingProvider(coverage FHIR.Coverage): singleton from([OrganizationProfile] O where EndsWith(First(coverage.payor.reference.value), O.id))
define function ToString(value string): value.value
define function ServicingProvider(serviceRequest FHIR.ServiceRequest): [PractitionerProfile] P where EndsWith(First(serviceRequest.performer.reference.value), P.id)
The patient that is to be used to pre-populate the form
The Coverage that is to be used to pre-populate the form
The ServiceRequest that is to be used to pre-populate the form
Example Genetic/Molecular Testing Preauthorization Questionnaire
HL7 International / Clinical Decision Support
This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1986712
Is the billing provider/referring lab different from servicing provider?
Billing provider/referring lab information
Is the requested test part of a clinical trial?
If Yes, provide the registration or ID number for the specific trial in which this test is being studied.
Patient history including age at diagnosis
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
Other findings/testing completed - previous genetic testing for condition
How will testing be used in relation to treatment or management of the patient?