# Example Genetic/Molecular Testing Preauthorization Questionnaire - Common CQL Artifacts for FHIR (US-Based) v2.0.0-ballot

## Questionnaire: Example Genetic/Molecular Testing Preauthorization Questionnaire (Experimental) 

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

*  [Tree view](#tabs-tree) 
*  [Sample Rendering](#tabs-sample) 
*  [Form Logic](#tabs-logic) 

#### Contained resources

### Test this Questionnaire

### Responses for this Questionnaire

There are currently no QuestionnaireResponse instances for this Questionnaire defined in this IG.



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "GMTPQuestionnaire",
  "contained" : [{
    "resourceType" : "Library",
    "id" : "effective-data-requirements",
    "extension" : [{
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Retrieve Member Coverage test parameter"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Retrieve Member Coverage test parameter\":\n  // When executing CQL with the VSCode extension retrieve the resource specific for the test case\n  //   the list of resource ids match the resources from the test case folders\n  singleton from ([FHIR.Coverage] CV where CV.id in {\n    'Coverage-example-GMTP', // testcase: GMTP-example-patient-2\n    'coverage-GMTP-1'        // testcase: USCorePatient-GMTP-1\n  })"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 0
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Member Coverage"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Member Coverage\":\n  Coalesce(\n    Coverage,\n    \"Retrieve Member Coverage test parameter\"\n  )"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 1
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Billing Provider"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Billing Provider\":\n  UCE.BillingProvider(\"Member Coverage\")"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 2
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Retrieve Service Request test parameter"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Retrieve Service Request test parameter\":\n  // When executing CQL with the VSCode extension retrieve the resource specific for the test case\n  //   the list of resource ids match the resources from the test case folders\n  singleton from ([FHIR.ServiceRequest] SR where SR.id in {\n    'ServiceRequest-example-1-GMTP',       // testcase: GMTP-example-patient-2\n    'service-request-USCorePatient-GMTP-1' // testcase: USCorePatient-GMTP-1\n  })"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 3
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Most Recent ServiceRequest"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Most Recent ServiceRequest\":\n  Coalesce(\n    ServiceRequest,\n    \"Retrieve Service Request test parameter\"\n  )"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 4
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "GMTPInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Billing Provider different from Servicing Provider"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Billing Provider different from Servicing Provider\":\n  if \"Billing Provider\".id != First(UCE.ServicingProvider(\"Most Recent ServiceRequest\").id) then\n  'Yes'\n  else \n  'No'"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 5
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "USCoreElements"
      },
      {
        "url" : "name",
        "valueString" : "BillingProvider"
      },
      {
        "url" : "statement",
        "valueString" : "define function BillingProvider(coverage FHIR.Coverage):\n  singleton from([OrganizationProfile] O\n    where EndsWith(First(coverage.payor.reference.value), O.id))"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 6
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToString"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToString(value string): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 7
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "USCoreElements"
      },
      {
        "url" : "name",
        "valueString" : "ServicingProvider"
      },
      {
        "url" : "statement",
        "valueString" : "define function ServicingProvider(serviceRequest FHIR.ServiceRequest):\n  [PractitionerProfile] P\n    where EndsWith(First(serviceRequest.performer.reference.value), P.id)"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 8
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    }],
    "name" : "EffectiveDataRequirements",
    "status" : "active",
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/library-type",
        "code" : "module-definition"
      }]
    },
    "relatedArtifact" : [{
      "type" : "depends-on",
      "display" : "USCore model information",
      "resource" : "http://hl7.org/fhir/us/cql/Library/USCore-ModelInfo|6.1.0-derived"
    },
    {
      "type" : "depends-on",
      "display" : "FHIR model information",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1"
    },
    {
      "type" : "depends-on",
      "display" : "Library UCE",
      "resource" : "http://hl7.org/fhir/us/cql/Library/USCoreElements|2.0.0-ballot"
    },
    {
      "type" : "depends-on",
      "display" : "Library FHIRHelpers",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1"
    },
    {
      "type" : "depends-on",
      "display" : "Library FHIRHelpers",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1"
    }],
    "parameter" : [{
      "name" : "Coverage",
      "use" : "in",
      "min" : 0,
      "max" : "1",
      "type" : "Coverage"
    },
    {
      "name" : "ServiceRequest",
      "use" : "in",
      "min" : 0,
      "max" : "1",
      "type" : "ServiceRequest"
    },
    {
      "name" : "Billing Provider different from Servicing Provider",
      "use" : "out",
      "min" : 0,
      "max" : "1",
      "type" : "string"
    }],
    "dataRequirement" : [{
      "type" : "Organization",
      "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"],
      "mustSupport" : ["id"]
    },
    {
      "type" : "Coverage",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Coverage"],
      "mustSupport" : ["id"]
    },
    {
      "type" : "Practitioner",
      "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"],
      "mustSupport" : ["id"]
    },
    {
      "type" : "ServiceRequest",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/ServiceRequest"],
      "mustSupport" : ["id"]
    },
    {
      "type" : "ServiceRequest",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/ServiceRequest"],
      "mustSupport" : ["id"]
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/GMTPInitialExpressions"
  },
  {
    "extension" : [{
      "url" : "name",
      "valueCoding" : {
        "system" : "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "code" : "patient",
        "display" : "Patient"
      }
    },
    {
      "url" : "type",
      "valueCode" : "Patient"
    },
    {
      "url" : "description",
      "valueString" : "The patient that is to be used to pre-populate the form"
    }],
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
  },
  {
    "extension" : [{
      "url" : "name",
      "valueCoding" : {
        "system" : "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "code" : "Coverage",
        "display" : "Coverage"
      }
    },
    {
      "url" : "type",
      "valueCode" : "Coverage"
    },
    {
      "url" : "description",
      "valueString" : "The Coverage that is to be used to pre-populate the form"
    }],
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
  },
  {
    "extension" : [{
      "url" : "name",
      "valueCoding" : {
        "system" : "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "code" : "ServiceRequest",
        "display" : "ServiceRequest"
      }
    },
    {
      "url" : "type",
      "valueCode" : "ServiceRequest"
    },
    {
      "url" : "description",
      "valueString" : "The ServiceRequest that is to be used to pre-populate the form"
    }],
    "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "cds"
  },
  {
    "url" : "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements",
    "valueCanonical" : "#effective-data-requirements"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "informative",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/cql/ImplementationGuide/hl7.fhir.us.cql"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire",
  "version" : "2.0.0-ballot",
  "name" : "GMTPQuestionnaire",
  "title" : "Example Genetic/Molecular Testing Preauthorization Questionnaire",
  "status" : "active",
  "experimental" : true,
  "date" : "2023-10-12T00:00:00+00:00",
  "publisher" : "HL7 International / Clinical Decision Support",
  "contact" : [{
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/dss"
    }]
  }],
  "description" : "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US",
      "display" : "United States of America"
    }]
  }],
  "copyright" : "This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1986712",
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
      "valueExpression" : {
        "language" : "text/cql-identifier",
        "expression" : "Billing Provider different from Servicing Provider"
      }
    }],
    "linkId" : "billing-provider-question",
    "text" : "Is the billing provider/referring lab different from servicing provider?",
    "type" : "boolean",
    "item" : [{
      "linkId" : "billing-provider-info",
      "text" : "Billing provider/referring lab information",
      "type" : "group",
      "enableWhen" : [{
        "question" : "billing-provider-question",
        "operator" : "=",
        "answerBoolean" : true
      }],
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Billing Provider Name"
          }
        }],
        "linkId" : "billing-provider-info|name",
        "text" : "Requesting provider name",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Billing Provider Phone"
          }
        }],
        "linkId" : "billing-provider-info|phone-number",
        "text" : "Phone",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Billing Provider Address"
          }
        }],
        "linkId" : "billing-provider-info|address",
        "text" : "Ordering provider address",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Billing Provider NPI"
          }
        }],
        "linkId" : "billing-provider-info|npi",
        "text" : "Ordering provider Tax ID/NPI #",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Billing Provider Fax"
          }
        }],
        "linkId" : "billing-provider-info|fax",
        "text" : "Fax",
        "type" : "string"
      }]
    }]
  },
  {
    "linkId" : "test-requested",
    "text" : "Test requested",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Date of Service"
        }
      }],
      "linkId" : "test-requested|service-date",
      "text" : "Date of service",
      "type" : "date"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Test ID"
        }
      }],
      "linkId" : "test-requested|test-id",
      "text" : "Test ID",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Test name"
        }
      }],
      "linkId" : "test-requested|test-name",
      "text" : "Test name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Diagnosis Descriptions"
        }
      }],
      "linkId" : "test-requested|diagnosis-description",
      "text" : "Diagnosis description",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Test ICD Codes"
        }
      }],
      "linkId" : "test-requested|diagnosis-icd-code",
      "text" : "ICD-10 code(s)",
      "type" : "open-choice",
      "repeats" : true,
      "answerValueSet" : "http://hl7.org/fhir/ValueSet/icd-10"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Test CPT Codes"
        }
      }],
      "linkId" : "test-requested|diagnosis-cpt-code",
      "text" : "CPT code(s)",
      "type" : "open-choice",
      "repeats" : true,
      "answerValueSet" : "http://terminology.hl7.org/ValueSet/cpt-all"
    }]
  },
  {
    "linkId" : "clinical-trial",
    "text" : "Clinical Trial Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Part of clinical trial"
        }
      }],
      "linkId" : "clinical-trial-question",
      "text" : "Is the requested test part of a clinical trial?",
      "type" : "boolean",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Clinical Trial ID"
          }
        }],
        "linkId" : "clinical-trial|yes-clinial-trial",
        "text" : "If Yes, provide the registration or ID number for the specific trial in which this test is being studied.",
        "type" : "string",
        "enableWhen" : [{
          "question" : "clinical-trial-question",
          "operator" : "=",
          "answerBoolean" : true
        }]
      }]
    }]
  },
  {
    "linkId" : "history",
    "text" : "Patient history and related findings",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext",
        "valueExpression" : {
          "name" : "PatientHistory",
          "language" : "text/cql-identifier",
          "expression" : "Patient history"
        }
      }],
      "linkId" : "history|patient-history",
      "text" : "Patient history including age at diagnosis",
      "type" : "group",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-expression",
            "expression" : "%PatientHistory.diagnosis"
          }
        }],
        "linkId" : "history|patient-history|diagnosis",
        "text" : "Diagnosis",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-expression",
            "expression" : "%PatientHistory.ageAtOnset"
          }
        }],
        "linkId" : "history|patient-history|age-at-onset",
        "text" : "Age at onset",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-expression",
            "expression" : "%PatientHistory.abatement"
          }
        }],
        "linkId" : "history|patient-history|abatement",
        "text" : "Abatement",
        "type" : "string"
      }]
    },
    {
      "linkId" : "history|family-history",
      "text" : "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",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Previous genetic testing for condition"
        }
      }],
      "linkId" : "history|other-findings",
      "text" : "Other findings/testing completed - previous genetic testing for condition",
      "type" : "string"
    },
    {
      "linkId" : "history|treatment-relation",
      "text" : "How will testing be used in relation to treatment or management of the patient?",
      "type" : "string"
    }]
  },
  {
    "linkId" : "person-filling-out-form",
    "text" : "Person filling out form",
    "type" : "group",
    "item" : [{
      "linkId" : "person-filling-out-form|name",
      "text" : "Name",
      "type" : "string"
    },
    {
      "linkId" : "person-filling-out-form|phone-number",
      "text" : "Phone number",
      "type" : "string"
    },
    {
      "linkId" : "person-filling-out-form|facility",
      "text" : "Phone number",
      "type" : "string"
    }]
  }]
}

```
