MBODAQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: MBODAQuestionnaire
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire MBODAQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> 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#2.0.0-ballot #xD; diagnosis-info Diagnosis Information 0..1 group #xD; diagnosis-info|diagnosis-code Diagnosis/ICD-10 code(s) 0..* open-choice #xD; diagnosis-info|diagnosis-description Diagnosis description 0..* string #xD; medication-info Medication Information 0..1 group #xD; medication-info|name Medication name 0..1 string #xD; medication-info|dose Dose 0..1 quantity #xD; medication-info|route Route 0..* open-choice #xD; medication-info|frequency Frequency 0..1 quantity #xD; medication-info|therapy-leng Expected length of therapy 0..1 quantity #xD; medication-info|num-visits Quantity/number of requested visits 0..1 integer #xD; medication-info|service-date Anticipated/actual date of service 0..1 date #xD; medication-info|new-med New Medication or Continued Therapy 0..1 choice Options: 2 options #xD; medication-info|date-initiallized Date therapy initially started 0..1 date Enable When: medication-info|new-med = ContinuedTherapy (MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy) #xD; medication-info|requested-drug-code HCPCS/CPT code/J code/NDC code of requested drug 0..1 string #xD; medication-info|associated-procedure Associated procedure codes requiring prior auth 0..1 string #xD; request-for-expedited-review Request for Expedited Review 0..1 group #xD; 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 wi…
contained: Library
  id:
    v: effective-data-requirements
  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
    display:
      v: FHIR model information
    resource:
      v: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
      l: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/cqf-library
    l: cqf-library
  value: Canonical
    v: http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions
    l: MBODAInitialExpressions
extension:
  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: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
    l: structuredefinition-wg
  value: Code
    v: cds
extension:
  url:
    v: http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements
    l: crmi-effectiveDataRequirements
  value: Canonical
    v: #effective-data-requirements
    l: effective-data-requirements
extension:
  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
url:
  v: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire
  l: MBODAQuestionnaire
version:
  v: 2.0.0-ballot
name:
  v: MBODAQuestionnaire
title:
  v: Example Medical Benefit Outpatient Drug Authorization Questionnaire
status:
  v: active
experimental:
  v: true
date:
  v: 2023-08-14T00:00:00+00:00
publisher:
  v: HL7 International / Clinical Decision Support
contact:
  telecom:
    system:
      v: url
    value:
      v: http://www.hl7.org/Special/committees/dss
description:
  v: This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.
jurisdiction:
  coding:
    system:
      v: urn:iso:std:iso:3166
      l: 3166
    code:
      v: US
    display:
      v: United States of America
copyright:
  v: 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
item:
  link id:
    v: diagnosis-info
  text:
    v: Diagnosis Information
  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: diagnosis-info|diagnosis-code
    text:
      v: Diagnosis/ICD-10 code(s)
    type:
      v: open-choice
    repeats:
      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: diagnosis-info|diagnosis-description
    text:
      v: Diagnosis description
    type:
      v: string
    repeats:
      v: true
item:
  link id:
    v: medication-info
  text:
    v: Medication Information
  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: medication-info|name
    text:
      v: Medication name
    type:
      v: string
  item:
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
        l: questionnaire-unitOption
      value: Coding
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
        l: questionnaire-unitOption
      value: Coding

v: text/cql-identifier

v: Diagnosis Codes

v: text/cql-identifier

v: Diagnosis Descriptions

v: text/cql-identifier

v: Medication Name

v: ug

v: ug

v: mg

v: mg

url:
  v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
  l: questionnaire-unitOption
value: Coding
  system:
    v: http://unitsofmeasure.org
    l: unitsofmeasure.org
  code:
    v: g
  display:
    v: g

url:
  v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
  l: questionnaire-unitOption
value: Coding
  system:
    v: http://unitsofmeasure.org
    l: unitsofmeasure.org
  code:
    v: ml
  display:
    v: ml

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: Medication Dose

v: medication-info|dose

v: Dose

v: quantity

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: Medication Route
link id:
  v: medication-info|route
text:
  v: Route
type:
  v: open-choice
repeats:
  v: true

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: h
    display:
      v: h
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: d
    display:
      v: d
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: wk
    display:
      v: wk
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mo
    display:
      v: mo
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: Medication Frequency
link id:
  v: medication-info|frequency
text:
  v: Frequency
type:
  v: quantity

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: h
    display:
      v: h
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: d
    display:
      v: d
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: wk
    display:
      v: wk
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: mo
    display:
      v: mo
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption
    l: questionnaire-unitOption
  value: Coding
    system:
      v: http://unitsofmeasure.org
      l: unitsofmeasure.org
    code:
      v: a
    display:
      v: a
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: Expected Therapy Length
link id:
  v: medication-info|therapy-leng
text:
  v: Expected length of therapy
type:
  v: quantity

link id:
  v: medication-info|num-visits
text:
  v: Quantity/number of requested visits
type:
  v: integer

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: Anticipated/actual date of service
link id:
  v: medication-info|service-date
text:
  v: Anticipated/actual date of service
type:
  v: date

link id:
  v: medication-info|new-med
text:
  v: New Medication or Continued Therapy
type:
  v: choice
answer option:
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med
      l: MBODAQuestionnaire-medication-info-new-med
    code:
      v: NewMedication
    display:
      v: New Medication
answer option:
  value: Coding
    system:
      v: http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med
      l: MBODAQuestionnaire-medication-info-new-med
    code:
      v: ContinuedTherapy
    display:
      v: Continuation of therapy

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: Initial date of therapy
link id:
  v: medication-info|date-initiallized
text:
  v: Date therapy initially started
type:
  v: date
enable when:
  question:
    v: medication-info|new-med
  operator:
    v: =
  answer: Coding
    system:
      v: http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med
      l: MBODAQuestionnaire-medication-info-new-med
    code:
      v: ContinuedTherapy

link id:
  v: medication-info|requested-drug-code
text:
  v: HCPCS/CPT code/J code/NDC code of requested drug
type:
  v: string

link id:
  v: medication-info|associated-procedure
text:
  v: Associated procedure codes requiring prior auth
type:
  v: string

link id:
  v: request-for-expedited-review
text:
  v: Request for Expedited Review
type:
  v: group
item:
  link id:
    v: request-for-expedited-review|para
  text:
    v: 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.
  type:
    v: group
  item:
    link id:
      v: request-for-expedited-review|rationale
    text:
      v: URGENT - rationale
    type:
      v: string

link id:
  v: ordering-provider-signature
text:
  v: Ordering Provider Signature
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired
      l: questionnaire-signatureRequired
    value: CodeableConcept
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/questionnaire-usageMode
      l: questionnaire-usageMode
    value: Code
      v: capture
  link id:
    v: ordering-provider-signature|author-signature
  text:
    v: Signature:
  type:
    v: attachment

v: urn:iso-astm:E1762-95:2013
l: 2013

v: 1.2.840.10065.1.12.1.1

v: Author's Signature