# Example Patient and Coverage Questionnaire - Common CQL Artifacts for FHIR (US-Based) v2.0.0-ballot

## Questionnaire: Example Patient and Coverage Questionnaire (Experimental) 

 
For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed. 

*  [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" : "ExamplePatientAndCoverageQuestionnaire",
  "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/ExamplePatientAndCoverageInitialExpressions"
  },
  {
    "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" : "Coverage",
        "display" : "Coverage"
      }
    },
    {
      "url" : "type",
      "valueCode" : "Coverage"
    },
    {
      "url" : "description",
      "valueString" : "The coverage 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" : "ServiceRequest",
        "display" : "ServiceRequest"
      }
    },
    {
      "url" : "type",
      "valueCode" : "ServiceRequest"
    },
    {
      "url" : "description",
      "valueString" : "The ServiceRequest 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/ExamplePatientAndCoverageQuestionnaire",
  "version" : "2.0.0-ballot",
  "name" : "ExamplePatientAndCoverageQuestionnaire",
  "title" : "Example Patient and Coverage Questionnaire",
  "status" : "active",
  "experimental" : true,
  "date" : "2024-09-16T00:00:00+00:00",
  "publisher" : "HL7 International / Clinical Decision Support",
  "contact" : [{
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/dss"
    }]
  }],
  "description" : "For the Prior Authorization Questionnaire Use Case, this type of in-context information is expected to be known already so it wouldn't typically be in a Questionnaire. This example illustrates how to get this information if it is needed.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US",
      "display" : "United States of America"
    }]
  }],
  "item" : [{
    "linkId" : "patient-info",
    "text" : "Patient Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Patient Name"
        }
      }],
      "linkId" : "patient-info|patient-name",
      "text" : "Name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Date of Birth"
        }
      }],
      "linkId" : "patient-info|date-of-birth",
      "text" : "Date of Birth",
      "type" : "date"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Birth Sex"
        }
      }],
      "linkId" : "patient-info|birth-sex",
      "text" : "Birth Sex",
      "type" : "choice",
      "answerValueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.24"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Medical Record Number"
        }
      }],
      "linkId" : "patient-info|medical-record-number",
      "text" : "Medical Record Number",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Phone Number"
        }
      }],
      "linkId" : "patient-info|phone-number",
      "text" : "Phone Number",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Email Address"
        }
      }],
      "linkId" : "patient-info|email-address",
      "text" : "Email Address",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Address"
        }
      }],
      "linkId" : "patient-info|address",
      "text" : "Address",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "City"
        }
      }],
      "linkId" : "patient-info|city",
      "text" : "City",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "State"
        }
      }],
      "linkId" : "patient-info|state",
      "text" : "State",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Postal Code"
        }
      }],
      "linkId" : "patient-info|postal-code",
      "text" : "Postal Code",
      "type" : "string"
    }]
  },
  {
    "linkId" : "coverage-info",
    "text" : "Coverage Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Member ID"
        }
      }],
      "linkId" : "coverage-info|member-id",
      "text" : "Member ID",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Policy Number"
        }
      }],
      "linkId" : "completing-form|patient-info|policy-number",
      "text" : "Policy Number",
      "type" : "string"
    }]
  },
  {
    "linkId" : "provider-info",
    "text" : "Requesting Provider Information",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Requesting Provider Name"
        }
      }],
      "linkId" : "provider-info|name",
      "text" : "Requesting provider name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Requesting Provider Phone"
        }
      }],
      "linkId" : "provider-info|phone-number",
      "text" : "Phone",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Requesting Provider Address"
        }
      }],
      "linkId" : "provider-info|address",
      "text" : "Ordering provider address",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Requesting Provider NPI"
        }
      }],
      "linkId" : "provider-info|npi",
      "text" : "Ordering provider Tax ID/NPI #",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Requesting Provider Fax"
        }
      }],
      "linkId" : "provider-info|fax",
      "text" : "Fax",
      "type" : "string"
    }]
  },
  {
    "linkId" : "servicing-provider",
    "text" : "Laboratory performing testing/Servicing Provider",
    "type" : "group",
    "item" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Servicing Provider Name"
        }
      }],
      "linkId" : "servicing-provider|name",
      "text" : "Servicing Provider name",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Servicing Provider Phone"
        }
      }],
      "linkId" : "servicing-provider|phone-number",
      "text" : "Phone",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Servicing Provider Address"
        }
      }],
      "linkId" : "servicing-provider|address",
      "text" : "Ordering provider address",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Servicing Provider NPI"
        }
      }],
      "linkId" : "servicing-provider|npi",
      "text" : "Ordering provider Tax ID/NPI #",
      "type" : "string"
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression" : {
          "language" : "text/cql-identifier",
          "expression" : "Servicing Provider Fax"
        }
      }],
      "linkId" : "servicing-provider|fax",
      "text" : "Fax",
      "type" : "string"
    }]
  }]
}

```
