Generated Narrative: Questionnaire UPPARFQuestionnaire 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#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 Prescriber Pager 0..1 string #xD; completing-form|prescriber-info|prescriber-address Prescriber Address 0..1 string #xD; completing-form|prescriber-info|prescriber-contact Prescriber Office Contact 0..1 string #xD; completing-form|prescriber-info|prescriber-npi Prescriber NPI 0..1 string #xD; completing-form|prescriber-info|prescriber-dea Prescriber DEA 0..1 string #xD; completing-form|prescriber-info|prescriber-tax-id Prescriber Tax ID 0..1 string #xD; completing-form|prescriber-info|prescriber-specialty Specialty/Facility Name If applicable 0..1 string #xD; completing-form|prescriber-info|prescriber-email Email Address 0..1 string #xD; completing-form|drug-benefit Prior Authorization Request for Drug Benefit 0..1 group #xD; completing-form|drug-benefit|request-type New Request 0..1 choice Options: 2 options #xD; completing-form|drug-benefit|diagnosis-codes Patient ICD Diagnostic Codes 0..* open-choice Value Set: ICD-10 Codes #xD; completing-form|drug-benefit|diagnosis-descriptions Patient Diagnosis 0..* string #xD; completing-form|drug-benefit|drugs Drugs Requested with J-Code; if applicable 0..* string #xD; completing-form|drug-benefit|strength-route-frequency Strength/Route/Frequency 0..1 string #xD; completing-form|drug-benefit|unit-volume Unit/Volume of Named Drugs 0..1 string #xD; completing-form|drug-benefit|start-length Start Date and Length of Therapy 0..1 string #xD; 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 #xD; 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 #xD; completing-form|drug-benefit|for-trial For use in clinical trial? 0..1 boolean #xD; 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 = true #xD; completing-form|drug-benefit|drug-name Drug Name Brand Name and Scientific Name/Strength: 0..1 string #xD; completing-form|drug-benefit|dose Dose 0..1 string #xD; completing-form|drug-benefit|route Route 0..1 string #xD; completing-form|drug-benefit|frequency Frequency 0..1 string #xD; completing-form|drug-benefit|quantity Quantity 0..1 quantity #xD; completing-form|drug-benefit|refills Number of Refills 0..1 integer #xD; completing-form|drug-benefit|delivery Product will be delivered to: 0..1 choice Options: 3 options #xD; completing-form|drug-benefit|signature Prescriber or Authorized Signature: 0..1 attachment #xD; completing-form|drug-benefit|pharmacy Dispensing Pharmacy Name and Phone Number: 0..1 string #xD; completing-form|drug-benefit|date Date 0..1 date #xD; 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 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 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: MedicationRequest Profile(s): US Core MedicationRequest Profile Must Support Elements: id Parameters Name Use Card. Type Documentation MedicationRequest In 0..1 Resource Urgency Out 0..1 string Generated using version 0.5.3-cibuild of the sample-content-ig Liquid templates
Retrieve Medication Request test parameter
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 })
define "Medication Request": Coalesce( MedicationRequest, "Retrieve Medication Request test parameter" )
define "Most Recent Medication Request": "Medication Request"
define "Urgency": "Most Recent Medication Request".priority P return ( if P != 'routine' then 'Urgent' else 'Not Urgent' )
define function ToString(value string): value.value
define function ToString(value MedicationRequestPriority): value.value
The patient that is to be used to pre-populate the form
The MedicationRequest that is to be used to pre-populate the form
Example Uniform Pharmacy Prior Authorization Request Form
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=4136509
Is this drug intended to treat opioid dependence?
Is this a first request for prior authorization for this drug?
Has the date of the first request been greater than twelve months ago?
Prior authentication is required and this form needs to be completed
Prior Authorization Request for Drug Benefit
Drugs Requested with J-Code; if applicable
Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:
Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:
Provide trial name and registration number
Drug Name Brand Name and Scientific Name/Strength:
Dispensing Pharmacy Name and Phone Number: