{
  "description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "_filename": "Questionnaire-GMTPQuestionnaire.json",
  "package_name": "hl7.fhir.us.cql.r4b",
  "date": "2023-10-12T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166",
      "display": "United States of America"
    } ]
  } ],
  "name": "GMTPQuestionnaire",
  "item": [ {
    "item": [ {
      "item": [ {
        "text": "Requesting provider name",
        "type": "string",
        "linkId": "billing-provider-info|name",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Billing Provider Name"
          }
        } ]
      }, {
        "text": "Phone",
        "type": "string",
        "linkId": "billing-provider-info|phone-number",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Billing Provider Phone"
          }
        } ]
      }, {
        "text": "Ordering provider address",
        "type": "string",
        "linkId": "billing-provider-info|address",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Billing Provider Address"
          }
        } ]
      }, {
        "text": "Ordering provider Tax ID/NPI #",
        "type": "string",
        "linkId": "billing-provider-info|npi",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Billing Provider NPI"
          }
        } ]
      }, {
        "text": "Fax",
        "type": "string",
        "linkId": "billing-provider-info|fax",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Billing Provider Fax"
          }
        } ]
      } ],
      "text": "Billing provider/referring lab information",
      "type": "group",
      "linkId": "billing-provider-info",
      "enableWhen": [ {
        "operator": "=",
        "question": "billing-provider-question",
        "answerBoolean": true
      } ]
    } ],
    "text": "Is the billing provider/referring lab different from servicing provider?",
    "type": "boolean",
    "linkId": "billing-provider-question",
    "extension": [ {
      "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
      "valueExpression": {
        "language": "text/cql-identifier",
        "expression": "Billing Provider different from Servicing Provider"
      }
    } ]
  }, {
    "item": [ {
      "text": "Date of service",
      "type": "date",
      "linkId": "test-requested|service-date",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Date of Service"
        }
      } ]
    }, {
      "text": "Test ID",
      "type": "string",
      "linkId": "test-requested|test-id",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Test ID"
        }
      } ]
    }, {
      "text": "Test name",
      "type": "string",
      "linkId": "test-requested|test-name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Test name"
        }
      } ]
    }, {
      "text": "Diagnosis description",
      "type": "string",
      "linkId": "test-requested|diagnosis-description",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Diagnosis Descriptions"
        }
      } ]
    }, {
      "text": "ICD-10 code(s)",
      "type": "open-choice",
      "linkId": "test-requested|diagnosis-icd-code",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Test ICD Codes"
        }
      } ],
      "answerValueSet": "http://hl7.org/fhir/ValueSet/icd-10"
    }, {
      "text": "CPT code(s)",
      "type": "open-choice",
      "linkId": "test-requested|diagnosis-cpt-code",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Test CPT Codes"
        }
      } ],
      "answerValueSet": "http://terminology.hl7.org/ValueSet/cpt-all"
    } ],
    "text": "Test requested",
    "type": "group",
    "linkId": "test-requested"
  }, {
    "item": [ {
      "item": [ {
        "text": "If Yes, provide the registration or ID number for the specific trial in which this test is being studied.",
        "type": "string",
        "linkId": "clinical-trial|yes-clinial-trial",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Clinical Trial ID"
          }
        } ],
        "enableWhen": [ {
          "operator": "=",
          "question": "clinical-trial-question",
          "answerBoolean": true
        } ]
      } ],
      "text": "Is the requested test part of a clinical trial?",
      "type": "boolean",
      "linkId": "clinical-trial-question",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Part of clinical trial"
        }
      } ]
    } ],
    "text": "Clinical Trial Information",
    "type": "group",
    "linkId": "clinical-trial"
  }, {
    "item": [ {
      "item": [ {
        "text": "Diagnosis",
        "type": "string",
        "linkId": "history|patient-history|diagnosis",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-expression",
            "expression": "%PatientHistory.diagnosis"
          }
        } ]
      }, {
        "text": "Age at onset",
        "type": "string",
        "linkId": "history|patient-history|age-at-onset",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-expression",
            "expression": "%PatientHistory.ageAtOnset"
          }
        } ]
      }, {
        "text": "Abatement",
        "type": "string",
        "linkId": "history|patient-history|abatement",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-expression",
            "expression": "%PatientHistory.abatement"
          }
        } ]
      } ],
      "text": "Patient history including age at diagnosis",
      "type": "group",
      "linkId": "history|patient-history",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext",
        "valueExpression": {
          "name": "PatientHistory",
          "language": "text/cql-identifier",
          "expression": "Patient history"
        }
      } ]
    }, {
      "text": "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",
      "type": "string",
      "linkId": "history|family-history"
    }, {
      "text": "Other findings/testing completed - previous genetic testing for condition",
      "type": "string",
      "linkId": "history|other-findings",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Previous genetic testing for condition"
        }
      } ]
    }, {
      "text": "How will testing be used in relation to treatment or management of the patient?",
      "type": "string",
      "linkId": "history|treatment-relation"
    } ],
    "text": "Patient history and related findings",
    "type": "group",
    "linkId": "history"
  }, {
    "item": [ {
      "text": "Name",
      "type": "string",
      "linkId": "person-filling-out-form|name"
    }, {
      "text": "Phone number",
      "type": "string",
      "linkId": "person-filling-out-form|phone-number"
    }, {
      "text": "Phone number",
      "type": "string",
      "linkId": "person-filling-out-form|facility"
    } ],
    "text": "Person filling out form",
    "type": "group",
    "linkId": "person-filling-out-form"
  } ],
  "copyright": "This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=1986712",
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Example Genetic/Molecular Testing Preauthorization Questionnaire",
  "package_version": "1.0.0",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical": "http://hl7.org/fhir/us/cql/Library/GMTPInitialExpressions"
  }, {
    "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext",
    "extension": [ {
      "url": "name",
      "valueCoding": {
        "code": "patient",
        "system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
        "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": {
        "code": "Coverage",
        "system": "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "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": {
        "code": "ServiceRequest",
        "system": "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "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/StructureDefinition/structuredefinition-wg",
    "valueCode": "cds"
  }, {
    "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"
      } ]
    }
  } ],
  "status": "active",
  "id": "0ed36e5e-5f8f-49df-a96f-614e2d6302a0",
  "kind": null,
  "url": "http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire",
  "version": "1.0.0",
  "contact": [ {
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}