UPPARFQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: UPPARFQuestionnaire
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire UPPARFQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> 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#2.0.0-ballot #xD; urgency Urgency 0..1 choice Options: 2 options #xD; drug-info Drug Information 0..1 group #xD; drug-info|drug-name Requested Drug Name 0..1 string #xD; drug-info|drug-intention-opioid Is this drug intended to treat opioid dependence? 0..1 boolean #xD; 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 = true #xD; 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 = false #xD; 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 = false #xD; completing-form Prior authentication is required and this form needs to be completed 0..1 group Enable When: drug-info|drug-intention-opioid = false drug-info|drug-intention-opioid|twelve-months-since-request = false #xD; completing-form|patient-info Patient Info 0..1 group #xD; completing-form|patient-info|prescription-date Prescription Date 0..1 string #xD; completing-form|prescriber-info Prescriber Info 0..1 group #xD; completing-form|prescriber-info|prescriber-name Prescriber Name 0..1 string #xD; completing-form|prescriber-info|prescriber-fax Prescriber Fax 0..1 string #xD; completing-form|prescriber-info|prescriber-phone Prescriber Phone 0..1 string #xD; completing-form|prescriber-info|prescriber-pager …
contained: Library
  id:
    v: effective-data-requirements
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: UPPARFInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Retrieve Medication Request test parameter
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Retrieve Medication Request test parameter": // The VSCode extension doesn't support parameters // 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 ([USCore.MedicationRequestProfile] MR where MR.id in { 'reference-nizatidine', // from tests/library/UPPARFInitialExpressions/example/MedicationRequest-new-reference-nizatidine.json 'MedicationRequest-1-nizatidine', // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-1/MedicationRequest-1-nizatidine.json 'MedicationRequest-lisinopril-example' // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-2/MedicationRequest-lisinopril-example.json })
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 0
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: UPPARFInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Medication Request
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Medication Request": Coalesce( MedicationRequest, "Retrieve Medication Request test parameter" )
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 1
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: UPPARFInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Most Recent Medication Request
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Most Recent Medication Request": "Medication Request"
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 2
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: UPPARFInitialExpressions
    extension:
      url:
        v: name
        l: name
      value: String
        v: Urgency
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Urgency": "Most Recent Medication Request".priority P return ( if P != 'routine' then 'Urgent' else 'Not Urgent' )
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 3
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: FHIRHelpers
    extension:
      url:
        v: name
        l: name
      value: String
        v: ToString
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define function ToString(value string): value.value
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 4
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: FHIRHelpers
    extension:
      url:
        v: name
        l: name
      value: String
        v: ToString
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define function ToString(value MedicationRequestPriority): value.value
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 5
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  name:
    v: EffectiveDataRequirements
  status:
    v: active
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/library-type
        l: library-type
      code:
        v: module-definition
  related artifact:
    type:
      v: depends-on
    display:
      v: USCore model information
    resource:
      v: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived
      l: http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo
  related artifact:
    type:
      v: depends-on

v: FHIR model information

type:
  v: depends-on
display:
  v: Library FHIRHelpers
resource:
  v: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
  l: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers

name:
  v: MedicationRequest
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: Resource

name:
  v: Urgency
use:
  v: out
min:
  v: 0
max:
  v: 1
type:
  v: string

type:
  v: MedicationRequest
profile:
  v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest
  l: us-core-medicationrequest
must support:
  v: id

type:
  v: MedicationRequest
profile:
  v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest
  l: us-core-medicationrequest
must support:
  v: id

extension:
  url:
    v: name
    l: name
  value: Coding
    system:
      v: http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext
      l: launchContext
    code:
      v: patient
    display:
      v: Patient
extension:
  url:
    v: type
    l: type
  value: Code
    v: Patient
extension:
  url:
    v: description
    l: description
  value: String
    v: The patient that is to be used to pre-populate the form
url:
  v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
  l: sdc-questionnaire-launchContext

extension:
  url:
    v: name
    l: name
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/additionalLaunchContext
      l: additionalLaunchContext
    code:
      v: MedicationRequest
    display:
      v: MedicationRequest
extension:
  url:
    v: type
    l: type
  value: Code
    v: MedicationRequest
extension:
  url:
    v: description
    l: description
  value: String
    v: The MedicationRequest that is to be used to pre-populate the form
url:
  v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext
  l: sdc-questionnaire-launchContext

url:
  v: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
  l: structuredefinition-wg
value: Code
  v: cds

url:
  v: http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements
  l: crmi-effectiveDataRequirements
value: Canonical
  v: #effective-data-requirements
  l: effective-data-requirements

url:
  v: http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status
  l: structuredefinition-standards-status
value: Code
  v: informative
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
      l: structuredefinition-conformance-derivedFrom
    value: Canonical
      v: http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql
      l: hl7.fhir.us.cql

v: 2.0.0-ballot

v: UPPARFQuestionnaire

v: Example Uniform Pharmacy Prior Authorization Request Form

v: active

v: true

v: 2023-10-19T00:00:00+00:00

v: HL7 International / Clinical Decision Support

telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/dss

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

coding:
  system:
    v: urn:iso:std:iso:3166
    l: 3166
  code:
    v: US
  display:
    v: United States of America

v: This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509

extension:
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    l: sdc-questionnaire-initialExpression
  value: Expression
    language:
      v: text/cql-identifier
    expression:
      v: Urgency
link id:
  v: urgency
text:
  v: Urgency
type:
  v: choice
answer option:
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency
      l: UPPARFQuestionnaire-urgency
    code:
      v: urgent
    display:
      v: Urgent
answer option:
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency
      l: UPPARFQuestionnaire-urgency
    code:
      v: routine
    display:
      v: Non-Urgent

link id:
  v: drug-info
text:
  v: Drug Information
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Most Recent Medication Name
  link id:
    v: drug-info|drug-name
  text:
    v: Requested Drug Name
  type:
    v: string
item:
  extension:
    url:
      v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
      l: sdc-questionnaire-initialExpression
    value: Expression
      language:
        v: text/cql-identifier
      expression:
        v: Is Opioid Treatment
  link id:
    v: drug-info|drug-intention-opioid
  text:
    v: Is this drug intended to treat opioid dependence?
  type:
    v: boolean
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: drug-info|drug-intention-opioid|first-prior-authentication
    text:
      v: Is this a first request for prior authorization for this drug?
    type:
      v: boolean
    enable when:
      question:
        v: drug-info|drug-intention-opioid
      operator:
        v: =
      answer: Boolean
        v: true
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: drug-info|drug-intention-opioid|date-first-request
    text:
      v: What was the date of the first request?
    type:
      v: date
    enable when:
      question:
        v: drug-info|drug-intention-opioid|first-prior-authentication
      operator:
        v: =
      answer: Boolean
        v: false
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: drug-info|drug-intention-opioid|twelve-months-since-request
    text:
      v: Has the date of the first request been greater than twelve months ago?
    type:
      v: boolean
    enable when:
      question:
        v: drug-info|drug-intention-opioid|first-prior-authentication
      operator:
        v: =
      answer: Boolean
        v: false

v: text/cql-identifier

v: Is First Prior Authentication

v: text/cql-identifier

v: Initial Request Date

v: text/cql-identifier

v: Is First Request > 12 Months

link id:
  v: completing-form
text:
  v: Prior authentication is required and this form needs to be completed
type:
  v: group
enable when:
  question:
    v: drug-info|drug-intention-opioid
  operator:
    v: =
  answer: Boolean
    v: false
enable when:
  question:
    v: drug-info|drug-intention-opioid|twelve-months-since-request
  operator:
    v: =
  answer: Boolean
    v: false
enable behavior:
  v: any
item:
  link id:
    v: completing-form|patient-info
  text:
    v: Patient Info
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|patient-info|prescription-date
    text:
      v: Prescription Date
    type:
      v: string
item:
  link id:
    v: completing-form|prescriber-info
  text:
    v: Prescriber Info
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-name
    text:
      v: Prescriber Name
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-fax
    text:
      v: Prescriber Fax
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-phone
    text:
      v: Prescriber Phone
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-pager
    text:
      v: Prescriber Pager
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-address
    text:
      v: Prescriber Address
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-contact
    text:
      v: Prescriber Office Contact
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-npi
    text:
      v: Prescriber NPI
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-dea
    text:
      v: Prescriber DEA
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-tax-id
    text:
      v: Prescriber Tax ID
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-specialty
    text:
      v: Specialty/Facility Name If applicable
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|prescriber-info|prescriber-email
    text:
      v: Email Address
    type:
      v: string
item:
  link id:
    v: completing-form|drug-benefit
  text:
    v: Prior Authorization Request for Drug Benefit
  type:
    v: group
  item:
    extension:
      url:
        v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
        l: sdc-questionnaire-initialExpression
      value: Expression
    link id:
      v: completing-form|drug-benefit|request-type
    text:
      v: New Request
    type:
      v: choice
    answer option:
      value: String
        v: New Request

v: text/cql-identifier

v: Prescription Date

v: text/cql-identifier

v: Prescriber Name

v: text/cql-identifier

v: Prescriber Fax

v: text/cql-identifier

v: Prescriber Phone

v: text/cql-identifier

v: Prescriber Pager

v: text/cql-identifier

v: Prescriber Address

v: text/cql-identifier

v: Prescriber Contact

v: text/cql-identifier

v: Prescriber NPI

v: text/cql-identifier

v: Prescriber DEA

v: text/cql-identifier

v: Prescriber Tax ID

v: text/cql-identifier

v: Prescriber Specialty

v: text/cql-identifier

v: Prescriber Email Address

v: text/cql-identifier

v: Request Type

value: String
  v: Reauthorization

extension:
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    l: sdc-questionnaire-initialExpression
  value: Expression
    language:
      v: text/cql-identifier
    expression:
      v: ICD 10 Codes
link id:
  v: completing-form|drug-benefit|diagnosis-codes
text:
  v: Patient ICD Diagnostic Codes
type:
  v: open-choice
repeats:
  v: true
answer value set:
  v: http://hl7.org/fhir/ValueSet/icd-10
  l: icd-10

extension:
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    l: sdc-questionnaire-initialExpression
  value: Expression
    language:
      v: text/cql-identifier
    expression:
      v: Diagnosis Descriptions
link id:
  v: completing-form|drug-benefit|diagnosis-descriptions
text:
  v: Patient Diagnosis
type:
  v: string
repeats:
  v: true

link id:
  v: completing-form|drug-benefit|drugs
text:
  v: Drugs Requested with J-Code; if applicable
type:
  v: string
repeats:
  v: true

link id:
  v: completing-form|drug-benefit|strength-route-frequency
text:
  v: Strength/Route/Frequency
type:
  v: string

link id:
  v: completing-form|drug-benefit|unit-volume
text:
  v: Unit/Volume of Named Drugs
type:
  v: string

extension:
  url:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression
    l: sdc-questionnaire-initialExpression
  value: Expression
    language:
      v: text/cql-identifier
    expression:
      v: Start Date and Length
link id:
  v: completing-form|drug-benefit|start-length
text:
  v: Start Date and Length of Therapy
type:
  v: string

link id:
  v: completing-form|drug-benefit|location
text:
  v: Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:
type:
  v: string

link id:
  v: completing-form|drug-benefit|criteria
text:
  v: Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:
type:
  v: string

link id:
  v: completing-form|drug-benefit|for-trial
text:
  v: For use in clinical trial?
type:
  v: boolean

link id:
  v: completing-form|drug-benefit|for-trial|registration-number
text:
  v: Provide trial name and registration number
type:
  v: string
enable when:
  question:
    v: completing-form|drug-benefit|for-trial
  operator:
    v: =
  answer: Boolean
    v: true

link id:
  v: completing-form|drug-benefit|drug-name
text:
  v: Drug Name Brand Name and Scientific Name/Strength:
type:
  v: string

link id:
  v: completing-form|drug-benefit|dose
text:
  v: Dose
type:
  v: string

link id:
  v: completing-form|drug-benefit|route
text:
  v: Route
type:
  v: string

link id:
  v: completing-form|drug-benefit|frequency
text:
  v: Frequency
type:
  v: string

link id:
  v: completing-form|drug-benefit|quantity
text:
  v: Quantity
type:
  v: quantity

link id:
  v: completing-form|drug-benefit|refills
text:
  v: Number of Refills
type:
  v: integer

link id:
  v: completing-form|drug-benefit|delivery
text:
  v: Product will be delivered to:
type:
  v: choice
answer option:
  value: String
    v: Patient's Home
answer option:
  value: String
    v: Physician Office
answer option:
  value: String
    v: Other

link id:
  v: completing-form|drug-benefit|signature
text:
  v: Prescriber or Authorized Signature:
type:
  v: attachment

link id:
  v: completing-form|drug-benefit|pharmacy
text:
  v: Dispensing Pharmacy Name and Phone Number:
type:
  v: string

link id:
  v: completing-form|drug-benefit|date
text:
  v: Date
type:
  v: date