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 Genetic/Molecular Testing Preauthorization Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Informative Active as of 2023-10-12 | Computable Name: GMTPQuestionnaire
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=1986712

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

- Tree view
- Sample Rendering
- Form Logic

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
GMTPQuestionnaire | 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/GMTPQuestionnaire#2.0.0-ballot
billing-provider-question | Is the billing provider/referring lab different from servicing provider? | 0..1 | boolean | Value Set:
billing-provider-info | Billing provider/referring lab information | 0..1 | group | Enable When: billing-provider-question = true Value Set:
billing-provider-info|name | Requesting provider name | 0..1 | string | Value Set:
billing-provider-info|phone-number | Phone | 0..1 | string | Value Set:
billing-provider-info|address | Ordering provider address | 0..1 | string | Value Set:
billing-provider-info|npi | Ordering provider Tax ID/NPI # | 0..1 | string | Value Set:
billing-provider-info|fax | Fax | 0..1 | string | Value Set:
test-requested | Test requested | 0..1 | group | Value Set:
test-requested|service-date | Date of service | 0..1 | date | Value Set:
test-requested|test-id | Test ID | 0..1 | string | Value Set:
test-requested|test-name | Test name | 0..1 | string | Value Set:
test-requested|diagnosis-description | Diagnosis description | 0..1 | string | Value Set:
test-requested|diagnosis-icd-code | ICD-10 code(s) | 0..* | open-choice | Value Set: ICD-10 Codes
test-requested|diagnosis-cpt-code | CPT code(s) | 0..* | open-choice | Value Set: AMA CPT All Codes
clinical-trial | Clinical Trial Information | 0..1 | group | Value Set:
clinical-trial-question | Is the requested test part of a clinical trial? | 0..1 | boolean | Value Set:
clinical-trial|yes-clinial-trial | If Yes, provide the registration or ID number for the specific trial in which this test is being studied. | 0..1 | string | Enable When: clinical-trial-question = true Value Set:
history | Patient history and related findings | 0..1 | group | Value Set:
history|patient-history | Patient history including age at diagnosis | 0..1 | group | Value Set:
history|patient-history|diagnosis | Diagnosis | 0..1 | string | Value Set:
history|patient-history|age-at-onset | Age at onset | 0..1 | string | Value Set:
history|patient-history|abatement | Abatement | 0..1 | string | Value Set:
history|family-history | 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 | 0..1 | string | Value Set:
history|other-findings | Other findings/testing completed - previous genetic testing for condition | 0..1 | string | Value Set:
history|treatment-relation | How will testing be used in relation to treatment or management of the patient? | 0..1 | string | Value Set:
person-filling-out-form | Person filling out form | 0..1 | group | Value Set:
person-filling-out-form|name | Name | 0..1 | string | Value Set:
person-filling-out-form|phone-number | Phone number | 0..1 | string | Value Set:
person-filling-out-form|facility | Phone number | 0..1 | string | Value Set:
Documentation for this format

Is the billing provider/referring lab different from servicing provider?

- linkId: billing-provider-question
- Answers:

Billing provider/referring lab information

- linkId: billing-provider-info
- Enable When: todo
- Answers:

Requesting provider name

- linkId: billing-provider-info|name
- Answers:

Phone

- linkId: billing-provider-info|phone-number
- Answers:

Ordering provider address

- linkId: billing-provider-info|address
- Answers:

Ordering provider Tax ID/NPI #

- linkId: billing-provider-info|npi
- Answers:

Fax

- linkId: billing-provider-info|fax
- Answers:

Test requested

- linkId: test-requested
- Answers:

Date of service

- linkId: test-requested|service-date
- Answers:

Test ID

- linkId: test-requested|test-id
- Answers:

Test name

- linkId: test-requested|test-name
- Answers:

Diagnosis description

- linkId: test-requested|diagnosis-description
- Answers:

ICD-10 code(s)

- linkId: test-requested|diagnosis-icd-code
- Answers: ICD-10 Codes

CPT code(s)

- linkId: test-requested|diagnosis-cpt-code
- Answers: AMA CPT All Codes

Clinical Trial Information

- linkId: clinical-trial
- Answers:

Is the requested test part of a clinical trial?

- linkId: clinical-trial-question
- Answers:

If Yes, provide the registration or ID number for the specific trial in which this test is being studied.

- linkId: clinical-trial|yes-clinial-trial
- Enable When: todo
- Answers:

Patient history and related findings

- linkId: history
- Answers:

Patient history including age at diagnosis

- linkId: history|patient-history
- Answers:

Diagnosis

- linkId: history|patient-history|diagnosis
- Answers:

Age at onset

- linkId: history|patient-history|age-at-onset
- Answers:

Abatement

- linkId: history|patient-history|abatement
- Answers:

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

- linkId: history|family-history
- Answers:

Other findings/testing completed - previous genetic testing for condition

- linkId: history|other-findings
- Answers:

How will testing be used in relation to treatment or management of the patient?

- linkId: history|treatment-relation
- Answers:

Person filling out form

- linkId: person-filling-out-form
- Answers:

Name

- linkId: person-filling-out-form|name
- Answers:

Phone number

- linkId: person-filling-out-form|phone-number
- Answers:

Phone number

- linkId: person-filling-out-form|facility
- Answers:

LinkID | Description & Constraints
--- | ---
billing-provider-question | Value Set:
billing-provider-info | Enable When: Not done yet Value Set:
billing-provider-info|name | Value Set:
billing-provider-info|phone-number | Value Set:
billing-provider-info|address | Value Set:
billing-provider-info|npi | Value Set:
billing-provider-info|fax | Value Set:
test-requested | Value Set:
test-requested|service-date | Value Set:
test-requested|test-id | Value Set:
test-requested|test-name | Value Set:
test-requested|diagnosis-description | Value Set:
test-requested|diagnosis-icd-code | Value Set: ICD-10 Codes
test-requested|diagnosis-cpt-code | Value Set: AMA CPT All Codes
clinical-trial | Value Set:
clinical-trial-question | Value Set:
clinical-trial|yes-clinial-trial | Enable When: Not done yet Value Set:
history | Value Set:
history|patient-history | Value Set:
history|patient-history|diagnosis | Value Set:
history|patient-history|age-at-onset | Value Set:
history|patient-history|abatement | Value Set:
history|family-history | Value Set:
history|other-findings | Value Set:
history|treatment-relation | Value Set:
person-filling-out-form | Value Set:
person-filling-out-form|name | Value Set:
person-filling-out-form|phone-number | Value Set:
person-filling-out-form|facility | 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.