Common CQL Artifacts for FHIR (US-Based)
2.0.0-ballot - Informative 2 Ballot

Common CQL Artifacts for FHIR (US-Based) - Downloaded Version null See the Directory of published versions

## Questionnaire: Example Uniform Pharmacy Prior Authorization Request Form (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Informative Active as of 2023-10-19 | Computable Name: UPPARFQuestionnaire
Copyright/Legal: This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509

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

- Tree view
- Sample Rendering
- Form Logic

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
urgency | Urgency | 0..1 | choice | Value Set: Options: 2 options
drug-info | Drug Information | 0..1 | group | Value Set:
drug-info|drug-name | Requested Drug Name | 0..1 | string | Value Set:
drug-info|drug-intention-opioid | Is this drug intended to treat opioid dependence? | 0..1 | boolean | Value Set:
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 Value Set:
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 Value Set:
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 Value Set:
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 Value Set:
completing-form|patient-info | Patient Info | 0..1 | group | Value Set:
completing-form|patient-info|prescription-date | Prescription Date | 0..1 | string | Value Set:
completing-form|prescriber-info | Prescriber Info | 0..1 | group | Value Set:
completing-form|prescriber-info|prescriber-name | Prescriber Name | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-fax | Prescriber Fax | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-phone | Prescriber Phone | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-pager | Prescriber Pager | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-address | Prescriber Address | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-contact | Prescriber Office Contact | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-npi | Prescriber NPI | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-dea | Prescriber DEA | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-tax-id | Prescriber Tax ID | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-specialty | Specialty/Facility Name If applicable | 0..1 | string | Value Set:
completing-form|prescriber-info|prescriber-email | Email Address | 0..1 | string | Value Set:
completing-form|drug-benefit | Prior Authorization Request for Drug Benefit | 0..1 | group | Value Set:
completing-form|drug-benefit|request-type | New Request | 0..1 | choice | Value Set: Options: 2 options
completing-form|drug-benefit|diagnosis-codes | Patient ICD Diagnostic Codes | 0..* | open-choice | Value Set: ICD-10 Codes
completing-form|drug-benefit|diagnosis-descriptions | Patient Diagnosis | 0..* | string | Value Set:
completing-form|drug-benefit|drugs | Drugs Requested with J-Code; if applicable | 0..* | string | Value Set:
completing-form|drug-benefit|strength-route-frequency | Strength/Route/Frequency | 0..1 | string | Value Set:
completing-form|drug-benefit|unit-volume | Unit/Volume of Named Drugs | 0..1 | string | Value Set:
completing-form|drug-benefit|start-length | Start Date and Length of Therapy | 0..1 | string | Value Set:
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 | Value Set:
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 | Value Set:
completing-form|drug-benefit|for-trial | For use in clinical trial? | 0..1 | boolean | Value Set:
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 Value Set:
completing-form|drug-benefit|drug-name | Drug Name Brand Name and Scientific Name/Strength: | 0..1 | string | Value Set:
completing-form|drug-benefit|dose | Dose | 0..1 | string | Value Set:
completing-form|drug-benefit|route | Route | 0..1 | string | Value Set:
completing-form|drug-benefit|frequency | Frequency | 0..1 | string | Value Set:
completing-form|drug-benefit|quantity | Quantity | 0..1 | quantity | Value Set:
completing-form|drug-benefit|refills | Number of Refills | 0..1 | integer | Value Set:
completing-form|drug-benefit|delivery | Product will be delivered to: | 0..1 | choice | Value Set: Options: 3 options
completing-form|drug-benefit|signature | Prescriber or Authorized Signature: | 0..1 | attachment | Value Set:
completing-form|drug-benefit|pharmacy | Dispensing Pharmacy Name and Phone Number: | 0..1 | string | Value Set:
completing-form|drug-benefit|date | Date | 0..1 | date | Value Set:
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

Urgency

- linkId: urgency
- Answers:
- Answers: 2 options

Drug Information

- linkId: drug-info
- Answers:

Requested Drug Name

- linkId: drug-info|drug-name
- Answers:

Is this drug intended to treat opioid dependence?

- linkId: drug-info|drug-intention-opioid
- Answers:

Is this a first request for prior authorization for this drug?

- linkId: drug-info|drug-intention-opioid|first-prior-authentication
- Enable When: todo
- Answers:

What was the date of the first request?

- linkId: drug-info|drug-intention-opioid|date-first-request
- Enable When: todo
- Answers:

Has the date of the first request been greater than twelve months ago?

- linkId: drug-info|drug-intention-opioid|twelve-months-since-request
- Enable When: todo
- Answers:

Prior authentication is required and this form needs to be completed

- linkId: completing-form
- Enable When: todo
- Answers:

Patient Info

- linkId: completing-form|patient-info
- Answers:

Prescription Date

- linkId: completing-form|patient-info|prescription-date
- Answers:

Prescriber Info

- linkId: completing-form|prescriber-info
- Answers:

Prescriber Name

- linkId: completing-form|prescriber-info|prescriber-name
- Answers:

Prescriber Fax

- linkId: completing-form|prescriber-info|prescriber-fax
- Answers:

Prescriber Phone

- linkId: completing-form|prescriber-info|prescriber-phone
- Answers:

Prescriber Pager

- linkId: completing-form|prescriber-info|prescriber-pager
- Answers:

Prescriber Address

- linkId: completing-form|prescriber-info|prescriber-address
- Answers:

Prescriber Office Contact

- linkId: completing-form|prescriber-info|prescriber-contact
- Answers:

Prescriber NPI

- linkId: completing-form|prescriber-info|prescriber-npi
- Answers:

Prescriber DEA

- linkId: completing-form|prescriber-info|prescriber-dea
- Answers:

Prescriber Tax ID

- linkId: completing-form|prescriber-info|prescriber-tax-id
- Answers:

Specialty/Facility Name If applicable

- linkId: completing-form|prescriber-info|prescriber-specialty
- Answers:

Email Address

- linkId: completing-form|prescriber-info|prescriber-email
- Answers:

Prior Authorization Request for Drug Benefit

- linkId: completing-form|drug-benefit
- Answers:

New Request

- linkId: completing-form|drug-benefit|request-type
- Answers:
- Answers: 2 options

Patient ICD Diagnostic Codes

- linkId: completing-form|drug-benefit|diagnosis-codes
- Answers: ICD-10 Codes

Patient Diagnosis

- linkId: completing-form|drug-benefit|diagnosis-descriptions
- Answers:

Drugs Requested with J-Code; if applicable

- linkId: completing-form|drug-benefit|drugs
- Answers:

Strength/Route/Frequency

- linkId: completing-form|drug-benefit|strength-route-frequency
- Answers:

Unit/Volume of Named Drugs

- linkId: completing-form|drug-benefit|unit-volume
- Answers:

Start Date and Length of Therapy

- linkId: completing-form|drug-benefit|start-length
- Answers:

Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:

- linkId: completing-form|drug-benefit|location
- Answers:

Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:

- linkId: completing-form|drug-benefit|criteria
- Answers:

For use in clinical trial?

- linkId: completing-form|drug-benefit|for-trial
- Answers:

Provide trial name and registration number

- linkId: completing-form|drug-benefit|for-trial|registration-number
- Enable When: todo
- Answers:

Drug Name Brand Name and Scientific Name/Strength:

- linkId: completing-form|drug-benefit|drug-name
- Answers:

Dose

- linkId: completing-form|drug-benefit|dose
- Answers:

Route

- linkId: completing-form|drug-benefit|route
- Answers:

Frequency

- linkId: completing-form|drug-benefit|frequency
- Answers:

Quantity

- linkId: completing-form|drug-benefit|quantity
- Answers:

Number of Refills

- linkId: completing-form|drug-benefit|refills
- Answers:

Product will be delivered to:

- linkId: completing-form|drug-benefit|delivery
- Answers:
- Answers: 3 options

Prescriber or Authorized Signature:

- linkId: completing-form|drug-benefit|signature
- Answers:

Dispensing Pharmacy Name and Phone Number:

- linkId: completing-form|drug-benefit|pharmacy
- Answers:

Date

- linkId: completing-form|drug-benefit|date
- Answers:

LinkID | Description & Constraints
--- | ---
urgency | Value Set: Options: 2 options
drug-info | Value Set:
drug-info|drug-name | Value Set:
drug-info|drug-intention-opioid | Value Set:
drug-info|drug-intention-opioid|first-prior-authentication | Enable When: Not done yet Value Set:
drug-info|drug-intention-opioid|date-first-request | Enable When: Not done yet Value Set:
drug-info|drug-intention-opioid|twelve-months-since-request | Enable When: Not done yet Value Set:
completing-form | Enable When: Not done yet Value Set:
completing-form|patient-info | Value Set:
completing-form|patient-info|prescription-date | Value Set:
completing-form|prescriber-info | Value Set:
completing-form|prescriber-info|prescriber-name | Value Set:
completing-form|prescriber-info|prescriber-fax | Value Set:
completing-form|prescriber-info|prescriber-phone | Value Set:
completing-form|prescriber-info|prescriber-pager | Value Set:
completing-form|prescriber-info|prescriber-address | Value Set:
completing-form|prescriber-info|prescriber-contact | Value Set:
completing-form|prescriber-info|prescriber-npi | Value Set:
completing-form|prescriber-info|prescriber-dea | Value Set:
completing-form|prescriber-info|prescriber-tax-id | Value Set:
completing-form|prescriber-info|prescriber-specialty | Value Set:
completing-form|prescriber-info|prescriber-email | Value Set:
completing-form|drug-benefit | Value Set:
completing-form|drug-benefit|request-type | Value Set: Options: 2 options
completing-form|drug-benefit|diagnosis-codes | Value Set: ICD-10 Codes
completing-form|drug-benefit|diagnosis-descriptions | Value Set:
completing-form|drug-benefit|drugs | Value Set:
completing-form|drug-benefit|strength-route-frequency | Value Set:
completing-form|drug-benefit|unit-volume | Value Set:
completing-form|drug-benefit|start-length | Value Set:
completing-form|drug-benefit|location | Value Set:
completing-form|drug-benefit|criteria | Value Set:
completing-form|drug-benefit|for-trial | Value Set:
completing-form|drug-benefit|for-trial|registration-number | Enable When: Not done yet Value Set:
completing-form|drug-benefit|drug-name | Value Set:
completing-form|drug-benefit|dose | Value Set:
completing-form|drug-benefit|route | Value Set:
completing-form|drug-benefit|frequency | Value Set:
completing-form|drug-benefit|quantity | Value Set:
completing-form|drug-benefit|refills | Value Set:
completing-form|drug-benefit|delivery | Value Set: Options: 3 options
completing-form|drug-benefit|signature | Value Set:
completing-form|drug-benefit|pharmacy | Value Set:
completing-form|drug-benefit|date | Value Set:
Documentation for this format

#### Contained resources

- EffectiveDataRequirements

### Test this Questionnaire

Try this questionnaire out:

- NLM Forms Library

### Responses for this Questionnaire

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