# Example Uniform Pharmacy Prior Authorization Request Form - Common CQL Artifacts for FHIR (US-Based) v2.0.0-ballot

## Questionnaire: Example Uniform Pharmacy Prior Authorization Request Form (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" : "UPPARFQuestionnaire",
  "contained" : [{
    "resourceType" : "Library",
    "id" : "effective-data-requirements",
    "extension" : [{
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "UPPARFInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Retrieve Medication Request test parameter"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Retrieve Medication Request test parameter\":\n  // The VSCode extension doesn't support parameters\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 ([USCore.MedicationRequestProfile] MR where MR.id in { \n    'reference-nizatidine',                 // from tests/library/UPPARFInitialExpressions/example/MedicationRequest-new-reference-nizatidine.json\n    'MedicationRequest-1-nizatidine',       // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-1/MedicationRequest-1-nizatidine.json\n    'MedicationRequest-lisinopril-example'  // from tests/library/UPPARFInitialExpressions/Patient-example-UPPARF-2/MedicationRequest-lisinopril-example.json\n  })"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 0
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "UPPARFInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Medication Request"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Medication Request\":\n  Coalesce(\n    MedicationRequest,\n    \"Retrieve Medication Request test parameter\"\n  )"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 1
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "UPPARFInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Most Recent Medication Request"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Most Recent Medication Request\":\n  \"Medication Request\""
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 2
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "UPPARFInitialExpressions"
      },
      {
        "url" : "name",
        "valueString" : "Urgency"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Urgency\":\n\"Most Recent Medication Request\".priority P\n  return (\n    if P != 'routine' then 'Urgent'\n    else  'Not Urgent'\n  )"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 3
      }],
      "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" : 4
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToString"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToString(value MedicationRequestPriority): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 5
      }],
      "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 FHIRHelpers",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1"
    }],
    "parameter" : [{
      "name" : "MedicationRequest",
      "use" : "in",
      "min" : 0,
      "max" : "1",
      "type" : "Resource"
    },
    {
      "name" : "Urgency",
      "use" : "out",
      "min" : 0,
      "max" : "1",
      "type" : "string"
    }],
    "dataRequirement" : [{
      "type" : "MedicationRequest",
      "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"],
      "mustSupport" : ["id"]
    },
    {
      "type" : "MedicationRequest",
      "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"],
      "mustSupport" : ["id"]
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions"
  },
  {
    "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" : "MedicationRequest",
        "display" : "MedicationRequest"
      }
    },
    {
      "url" : "type",
      "valueCode" : "MedicationRequest"
    },
    {
      "url" : "description",
      "valueString" : "The MedicationRequest 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/UPPARFQuestionnaire",
  "version" : "2.0.0-ballot",
  "name" : "UPPARFQuestionnaire",
  "title" : "Example Uniform Pharmacy Prior Authorization Request Form",
  "status" : "active",
  "experimental" : true,
  "date" : "2023-10-19T00:00:00+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=4136509",
  "item" : [{
    "extension" : [{
      "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
      "valueExpression" : {
        "language" : "text/cql-identifier",
        "expression" : "Urgency"
      }
    }],
    "linkId" : "urgency",
    "text" : "Urgency",
    "type" : "choice",
    "answerOption" : [{
      "valueCoding" : {
        "system" : "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
        "code" : "urgent",
        "display" : "Urgent"
      }
    },
    {
      "valueCoding" : {
        "system" : "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
        "code" : "routine",
        "display" : "Non-Urgent"
      }
    }]
  },
  {
    "linkId" : "drug-info",
    "text" : "Drug Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Most Recent Medication Name"
        }
      }],
      "linkId" : "drug-info|drug-name",
      "text" : "Requested Drug Name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Is Opioid Treatment"
        }
      }],
      "linkId" : "drug-info|drug-intention-opioid",
      "text" : "Is this drug intended to treat opioid dependence?",
      "type" : "boolean",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Is First Prior Authentication"
          }
        }],
        "linkId" : "drug-info|drug-intention-opioid|first-prior-authentication",
        "text" : "Is this a first request for prior authorization for this drug?",
        "type" : "boolean",
        "enableWhen" : [{
          "question" : "drug-info|drug-intention-opioid",
          "operator" : "=",
          "answerBoolean" : true
        }]
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Initial Request Date"
          }
        }],
        "linkId" : "drug-info|drug-intention-opioid|date-first-request",
        "text" : "What was the date of the first request?",
        "type" : "date",
        "enableWhen" : [{
          "question" : "drug-info|drug-intention-opioid|first-prior-authentication",
          "operator" : "=",
          "answerBoolean" : false
        }]
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Is First Request > 12 Months"
          }
        }],
        "linkId" : "drug-info|drug-intention-opioid|twelve-months-since-request",
        "text" : "Has the date of the first request been greater than twelve months ago?",
        "type" : "boolean",
        "enableWhen" : [{
          "question" : "drug-info|drug-intention-opioid|first-prior-authentication",
          "operator" : "=",
          "answerBoolean" : false
        }]
      }]
    }]
  },
  {
    "linkId" : "completing-form",
    "text" : "Prior authentication is required and this form needs to be completed",
    "type" : "group",
    "enableWhen" : [{
      "question" : "drug-info|drug-intention-opioid",
      "operator" : "=",
      "answerBoolean" : false
    },
    {
      "question" : "drug-info|drug-intention-opioid|twelve-months-since-request",
      "operator" : "=",
      "answerBoolean" : false
    }],
    "enableBehavior" : "any",
    "item" : [{
      "linkId" : "completing-form|patient-info",
      "text" : "Patient Info",
      "type" : "group",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescription Date"
          }
        }],
        "linkId" : "completing-form|patient-info|prescription-date",
        "text" : "Prescription Date",
        "type" : "string"
      }]
    },
    {
      "linkId" : "completing-form|prescriber-info",
      "text" : "Prescriber Info",
      "type" : "group",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Name"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-name",
        "text" : "Prescriber Name",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Fax"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-fax",
        "text" : "Prescriber Fax",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Phone"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-phone",
        "text" : "Prescriber Phone",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Pager"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-pager",
        "text" : "Prescriber Pager",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Address"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-address",
        "text" : "Prescriber Address",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Contact"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-contact",
        "text" : "Prescriber Office Contact",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber NPI"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-npi",
        "text" : "Prescriber NPI",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber DEA"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-dea",
        "text" : "Prescriber DEA",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Tax ID"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-tax-id",
        "text" : "Prescriber Tax ID",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Specialty"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-specialty",
        "text" : "Specialty/Facility Name If applicable",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Prescriber Email Address"
          }
        }],
        "linkId" : "completing-form|prescriber-info|prescriber-email",
        "text" : "Email Address",
        "type" : "string"
      }]
    },
    {
      "linkId" : "completing-form|drug-benefit",
      "text" : "Prior Authorization Request for Drug Benefit",
      "type" : "group",
      "item" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Request Type"
          }
        }],
        "linkId" : "completing-form|drug-benefit|request-type",
        "text" : "New Request",
        "type" : "choice",
        "answerOption" : [{
          "valueString" : "New Request"
        },
        {
          "valueString" : "Reauthorization"
        }]
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "ICD 10 Codes"
          }
        }],
        "linkId" : "completing-form|drug-benefit|diagnosis-codes",
        "text" : "Patient ICD Diagnostic Codes",
        "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" : "Diagnosis Descriptions"
          }
        }],
        "linkId" : "completing-form|drug-benefit|diagnosis-descriptions",
        "text" : "Patient Diagnosis",
        "type" : "string",
        "repeats" : true
      },
      {
        "linkId" : "completing-form|drug-benefit|drugs",
        "text" : "Drugs Requested with J-Code; if applicable",
        "type" : "string",
        "repeats" : true
      },
      {
        "linkId" : "completing-form|drug-benefit|strength-route-frequency",
        "text" : "Strength/Route/Frequency",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|unit-volume",
        "text" : "Unit/Volume of Named Drugs",
        "type" : "string"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression" : {
            "language" : "text/cql-identifier",
            "expression" : "Start Date and Length"
          }
        }],
        "linkId" : "completing-form|drug-benefit|start-length",
        "text" : "Start Date and Length of Therapy",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|location",
        "text" : "Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|criteria",
        "text" : "Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|for-trial",
        "text" : "For use in clinical trial?",
        "type" : "boolean"
      },
      {
        "linkId" : "completing-form|drug-benefit|for-trial|registration-number",
        "text" : "Provide trial name and registration number",
        "type" : "string",
        "enableWhen" : [{
          "question" : "completing-form|drug-benefit|for-trial",
          "operator" : "=",
          "answerBoolean" : true
        }]
      },
      {
        "linkId" : "completing-form|drug-benefit|drug-name",
        "text" : "Drug Name Brand Name and Scientific Name/Strength:",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|dose",
        "text" : "Dose",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|route",
        "text" : "Route",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|frequency",
        "text" : "Frequency",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|quantity",
        "text" : "Quantity",
        "type" : "quantity"
      },
      {
        "linkId" : "completing-form|drug-benefit|refills",
        "text" : "Number of Refills",
        "type" : "integer"
      },
      {
        "linkId" : "completing-form|drug-benefit|delivery",
        "text" : "Product will be delivered to:",
        "type" : "choice",
        "answerOption" : [{
          "valueString" : "Patient's Home"
        },
        {
          "valueString" : "Physician Office"
        },
        {
          "valueString" : "Other"
        }]
      },
      {
        "linkId" : "completing-form|drug-benefit|signature",
        "text" : "Prescriber or Authorized Signature:",
        "type" : "attachment"
      },
      {
        "linkId" : "completing-form|drug-benefit|pharmacy",
        "text" : "Dispensing Pharmacy Name and Phone Number:",
        "type" : "string"
      },
      {
        "linkId" : "completing-form|drug-benefit|date",
        "text" : "Date",
        "type" : "date"
      }]
    }]
  }]
}

```
