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 Medical Benefit Outpatient Drug Authorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Informative Active as of 2023-08-14 | Computable Name: MBODAQuestionnaire
Copyright/Legal: 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

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
--- | --- | --- | --- | ---
MBODAQuestionnaire | 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/MBODAQuestionnaire#2.0.0-ballot
diagnosis-info | Diagnosis Information | 0..1 | group | Value Set:
diagnosis-info|diagnosis-code | Diagnosis/ICD-10 code(s) | 0..* | open-choice | Value Set:
diagnosis-info|diagnosis-description | Diagnosis description | 0..* | string | Value Set:
medication-info | Medication Information | 0..1 | group | Value Set:
medication-info|name | Medication name | 0..1 | string | Value Set:
medication-info|dose | Dose | 0..1 | quantity | Value Set:
medication-info|route | Route | 0..* | open-choice | Value Set:
medication-info|frequency | Frequency | 0..1 | quantity | Value Set:
medication-info|therapy-leng | Expected length of therapy | 0..1 | quantity | Value Set:
medication-info|num-visits | Quantity/number of requested visits | 0..1 | integer | Value Set:
medication-info|service-date | Anticipated/actual date of service | 0..1 | date | Value Set:
medication-info|new-med | New Medication or Continued Therapy | 0..1 | choice | Value Set: Options: 2 options
medication-info|date-initiallized | Date therapy initially started | 0..1 | date | Enable When: medication-info|new-med = ContinuedTherapy (MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy) Value Set:
medication-info|requested-drug-code | HCPCS/CPT code/J code/NDC code of requested drug | 0..1 | string | Value Set:
medication-info|associated-procedure | Associated procedure codes requiring prior auth | 0..1 | string | Value Set:
request-for-expedited-review | Request for Expedited Review | 0..1 | group | Value Set:
request-for-expedited-review|para | 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. | 0..1 | group | Value Set:
request-for-expedited-review|rationale | URGENT - rationale | 0..1 | string | Value Set:
ordering-provider-signature | Ordering Provider Signature | 0..1 | group | Value Set:
ordering-provider-signature|author-signature | Signature: | 0..1 | attachment | Value Set:
Documentation for this format

Options Sets

Answer options for medication-info|new-med

- http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#NewMedication ("New Medication")
- http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med#ContinuedTherapy ("Continuation of therapy")

Diagnosis Information

- linkId: diagnosis-info
- Answers:

Diagnosis/ICD-10 code(s)

- linkId: diagnosis-info|diagnosis-code
- Answers:

Diagnosis description

- linkId: diagnosis-info|diagnosis-description
- Answers:

Medication Information

- linkId: medication-info
- Answers:

Medication name

- linkId: medication-info|name
- Answers:

Dose

- linkId: medication-info|dose
- Answers:

Route

- linkId: medication-info|route
- Answers:

Frequency

- linkId: medication-info|frequency
- Answers:

Expected length of therapy

- linkId: medication-info|therapy-leng
- Answers:

Quantity/number of requested visits

- linkId: medication-info|num-visits
- Answers:

Anticipated/actual date of service

- linkId: medication-info|service-date
- Answers:

New Medication or Continued Therapy

- linkId: medication-info|new-med
- Answers:
- Answers: 2 options

Date therapy initially started

- linkId: medication-info|date-initiallized
- Enable When: todo
- Answers:

HCPCS/CPT code/J code/NDC code of requested drug

- linkId: medication-info|requested-drug-code
- Answers:

Associated procedure codes requiring prior auth

- linkId: medication-info|associated-procedure
- Answers:

Request for Expedited Review

- linkId: request-for-expedited-review
- Answers:

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.

- linkId: request-for-expedited-review|para
- Answers:

URGENT - rationale

- linkId: request-for-expedited-review|rationale
- Answers:

Ordering Provider Signature

- linkId: ordering-provider-signature
- Answers:

Signature:

- linkId: ordering-provider-signature|author-signature
- Answers:

LinkID | Description & Constraints
--- | ---
diagnosis-info | Value Set:
diagnosis-info|diagnosis-code | Value Set:
diagnosis-info|diagnosis-description | Value Set:
medication-info | Value Set:
medication-info|name | Value Set:
medication-info|dose | Value Set:
medication-info|route | Value Set:
medication-info|frequency | Value Set:
medication-info|therapy-leng | Value Set:
medication-info|num-visits | Value Set:
medication-info|service-date | Value Set:
medication-info|new-med | Value Set: Options: 2 options
medication-info|date-initiallized | Enable When: Not done yet Value Set:
medication-info|requested-drug-code | Value Set:
medication-info|associated-procedure | Value Set:
request-for-expedited-review | Value Set:
request-for-expedited-review|para | Value Set:
request-for-expedited-review|rationale | Value Set:
ordering-provider-signature | Value Set:
ordering-provider-signature|author-signature | 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.