# Example Medical Benefit Outpatient Drug Authorization Questionnaire - Common CQL Artifacts for FHIR (US-Based) v2.0.0-ballot

## Questionnaire: Example Medical Benefit Outpatient Drug Authorization 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" : "MBODAQuestionnaire",
  "contained" : [{
    "resourceType" : "Library",
    "id" : "effective-data-requirements",
    "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"
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical" : "http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions"
  },
  {
    "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"
  },
  {
    "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/MBODAQuestionnaire",
  "version" : "2.0.0-ballot",
  "name" : "MBODAQuestionnaire",
  "title" : "Example Medical Benefit Outpatient Drug Authorization Questionnaire",
  "status" : "active",
  "experimental" : true,
  "date" : "2023-08-14T00:00:00+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 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" : [{
    "linkId" : "diagnosis-info",
    "text" : "Diagnosis Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Diagnosis Codes"
        }
      }],
      "linkId" : "diagnosis-info|diagnosis-code",
      "text" : "Diagnosis/ICD-10 code(s)",
      "type" : "open-choice",
      "repeats" : true
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Diagnosis Descriptions"
        }
      }],
      "linkId" : "diagnosis-info|diagnosis-description",
      "text" : "Diagnosis description",
      "type" : "string",
      "repeats" : true
    }]
  },
  {
    "linkId" : "medication-info",
    "text" : "Medication Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Medication Name"
        }
      }],
      "linkId" : "medication-info|name",
      "text" : "Medication name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "ug",
          "display" : "ug"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "mg",
          "display" : "mg"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "g",
          "display" : "g"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "ml",
          "display" : "ml"
        }
      },
      {
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Medication Dose"
        }
      }],
      "linkId" : "medication-info|dose",
      "text" : "Dose",
      "type" : "quantity"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Medication Route"
        }
      }],
      "linkId" : "medication-info|route",
      "text" : "Route",
      "type" : "open-choice",
      "repeats" : true
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "h",
          "display" : "h"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "d",
          "display" : "d"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "wk",
          "display" : "wk"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "mo",
          "display" : "mo"
        }
      },
      {
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Medication Frequency"
        }
      }],
      "linkId" : "medication-info|frequency",
      "text" : "Frequency",
      "type" : "quantity"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "h",
          "display" : "h"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "d",
          "display" : "d"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "wk",
          "display" : "wk"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "mo",
          "display" : "mo"
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding" : {
          "system" : "http://unitsofmeasure.org",
          "code" : "a",
          "display" : "a"
        }
      },
      {
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Expected Therapy Length"
        }
      }],
      "linkId" : "medication-info|therapy-leng",
      "text" : "Expected length of therapy",
      "type" : "quantity"
    },
    {
      "linkId" : "medication-info|num-visits",
      "text" : "Quantity/number of requested visits",
      "type" : "integer"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Anticipated/actual date of service"
        }
      }],
      "linkId" : "medication-info|service-date",
      "text" : "Anticipated/actual date of service",
      "type" : "date"
    },
    {
      "linkId" : "medication-info|new-med",
      "text" : "New Medication or Continued Therapy",
      "type" : "choice",
      "answerOption" : [{
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med",
          "code" : "NewMedication",
          "display" : "New Medication"
        }
      },
      {
        "valueCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med",
          "code" : "ContinuedTherapy",
          "display" : "Continuation of therapy"
        }
      }]
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Initial date of therapy"
        }
      }],
      "linkId" : "medication-info|date-initiallized",
      "text" : "Date therapy initially started",
      "type" : "date",
      "enableWhen" : [{
        "question" : "medication-info|new-med",
        "operator" : "=",
        "answerCoding" : {
          "system" : "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med",
          "code" : "ContinuedTherapy"
        }
      }]
    },
    {
      "linkId" : "medication-info|requested-drug-code",
      "text" : "HCPCS/CPT code/J code/NDC code of requested drug",
      "type" : "string"
    },
    {
      "linkId" : "medication-info|associated-procedure",
      "text" : "Associated procedure codes requiring prior auth",
      "type" : "string"
    }]
  },
  {
    "linkId" : "request-for-expedited-review",
    "text" : "Request for Expedited Review",
    "type" : "group",
    "item" : [{
      "linkId" : "request-for-expedited-review|para",
      "text" : "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" : "group",
      "item" : [{
        "linkId" : "request-for-expedited-review|rationale",
        "text" : "URGENT - rationale",
        "type" : "string"
      }]
    }]
  },
  {
    "linkId" : "ordering-provider-signature",
    "text" : "Ordering Provider Signature",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired",
        "valueCodeableConcept" : {
          "coding" : [{
            "system" : "urn:iso-astm:E1762-95:2013",
            "code" : "1.2.840.10065.1.12.1.1",
            "display" : "Author's Signature"
          }]
        }
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-usageMode",
        "valueCode" : "capture"
      }],
      "linkId" : "ordering-provider-signature|author-signature",
      "text" : "Signature:",
      "type" : "attachment"
    }]
  }]
}

```
