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 Patient and Coverage Questionnaire (Experimental)

Official URL: http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Informative Active as of 2024-09-16 | Computable Name: ExamplePatientAndCoverageQuestionnaire

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
- Sample Rendering
- Form Logic

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
ExamplePatientAndCoverageQuestionnaire | 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. |  | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/ExamplePatientAndCoverageQuestionnaire#2.0.0-ballot
patient-info | Patient Information | 0..1 | group | Value Set:
patient-info|patient-name | Name | 0..1 | string | Value Set:
patient-info|date-of-birth | Date of Birth | 0..1 | date | Value Set:
patient-info|birth-sex | Birth Sex | 0..1 | choice | Value Set: Birth Sex
patient-info|medical-record-number | Medical Record Number | 0..1 | string | Value Set:
patient-info|phone-number | Phone Number | 0..1 | string | Value Set:
patient-info|email-address | Email Address | 0..1 | string | Value Set:
patient-info|address | Address | 0..1 | string | Value Set:
patient-info|city | City | 0..1 | string | Value Set:
patient-info|state | State | 0..1 | string | Value Set:
patient-info|postal-code | Postal Code | 0..1 | string | Value Set:
coverage-info | Coverage Information | 0..1 | group | Value Set:
coverage-info|member-id | Member ID | 0..1 | string | Value Set:
completing-form|patient-info|policy-number | Policy Number | 0..1 | string | Value Set:
provider-info | Requesting Provider Information | 0..1 | group | Value Set:
provider-info|name | Requesting provider name | 0..1 | string | Value Set:
provider-info|phone-number | Phone | 0..1 | string | Value Set:
provider-info|address | Ordering provider address | 0..1 | string | Value Set:
provider-info|npi | Ordering provider Tax ID/NPI # | 0..1 | string | Value Set:
provider-info|fax | Fax | 0..1 | string | Value Set:
servicing-provider | Laboratory performing testing/Servicing Provider | 0..1 | group | Value Set:
servicing-provider|name | Servicing Provider name | 0..1 | string | Value Set:
servicing-provider|phone-number | Phone | 0..1 | string | Value Set:
servicing-provider|address | Ordering provider address | 0..1 | string | Value Set:
servicing-provider|npi | Ordering provider Tax ID/NPI # | 0..1 | string | Value Set:
servicing-provider|fax | Fax | 0..1 | string | Value Set:
Documentation for this format

Patient Information

- linkId: patient-info
- Answers:

Name

- linkId: patient-info|patient-name
- Answers:

Date of Birth

- linkId: patient-info|date-of-birth
- Answers:

Birth Sex

- linkId: patient-info|birth-sex
- Answers: Birth Sex

Medical Record Number

- linkId: patient-info|medical-record-number
- Answers:

Phone Number

- linkId: patient-info|phone-number
- Answers:

Email Address

- linkId: patient-info|email-address
- Answers:

Address

- linkId: patient-info|address
- Answers:

City

- linkId: patient-info|city
- Answers:

State

- linkId: patient-info|state
- Answers:

Postal Code

- linkId: patient-info|postal-code
- Answers:

Coverage Information

- linkId: coverage-info
- Answers:

Member ID

- linkId: coverage-info|member-id
- Answers:

Policy Number

- linkId: completing-form|patient-info|policy-number
- Answers:

Requesting Provider Information

- linkId: provider-info
- Answers:

Requesting provider name

- linkId: provider-info|name
- Answers:

Phone

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

Ordering provider address

- linkId: provider-info|address
- Answers:

Ordering provider Tax ID/NPI #

- linkId: provider-info|npi
- Answers:

Fax

- linkId: provider-info|fax
- Answers:

Laboratory performing testing/Servicing Provider

- linkId: servicing-provider
- Answers:

Servicing Provider name

- linkId: servicing-provider|name
- Answers:

Phone

- linkId: servicing-provider|phone-number
- Answers:

Ordering provider address

- linkId: servicing-provider|address
- Answers:

Ordering provider Tax ID/NPI #

- linkId: servicing-provider|npi
- Answers:

Fax

- linkId: servicing-provider|fax
- Answers:

LinkID | Description & Constraints
--- | ---
patient-info | Value Set:
patient-info|patient-name | Value Set:
patient-info|date-of-birth | Value Set:
patient-info|birth-sex | Value Set: Birth Sex
patient-info|medical-record-number | Value Set:
patient-info|phone-number | Value Set:
patient-info|email-address | Value Set:
patient-info|address | Value Set:
patient-info|city | Value Set:
patient-info|state | Value Set:
patient-info|postal-code | Value Set:
coverage-info | Value Set:
coverage-info|member-id | Value Set:
completing-form|patient-info|policy-number | Value Set:
provider-info | Value Set:
provider-info|name | Value Set:
provider-info|phone-number | Value Set:
provider-info|address | Value Set:
provider-info|npi | Value Set:
provider-info|fax | Value Set:
servicing-provider | Value Set:
servicing-provider|name | Value Set:
servicing-provider|phone-number | Value Set:
servicing-provider|address | Value Set:
servicing-provider|npi | Value Set:
servicing-provider|fax | 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.