{
  "description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "_filename": "Questionnaire-MBODAQuestionnaire.json",
  "package_name": "hl7.fhir.us.cql",
  "date": "2023-08-14T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166",
      "display": "United States of America"
    } ]
  } ],
  "name": "MBODAQuestionnaire",
  "item": [ {
    "item": [ {
      "text": "Diagnosis/ICD-10 code(s)",
      "type": "open-choice",
      "linkId": "diagnosis-info|diagnosis-code",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Diagnosis Codes"
        }
      } ]
    }, {
      "text": "Diagnosis description",
      "type": "string",
      "linkId": "diagnosis-info|diagnosis-description",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Diagnosis Descriptions"
        }
      } ]
    } ],
    "text": "Diagnosis Information",
    "type": "group",
    "linkId": "diagnosis-info"
  }, {
    "item": [ {
      "text": "Medication name",
      "type": "string",
      "linkId": "medication-info|name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Medication Name"
        }
      } ]
    }, {
      "text": "Dose",
      "type": "quantity",
      "linkId": "medication-info|dose",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "ug",
          "system": "http://unitsofmeasure.org",
          "display": "ug"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "mg",
          "system": "http://unitsofmeasure.org",
          "display": "mg"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "g",
          "system": "http://unitsofmeasure.org",
          "display": "g"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "ml",
          "system": "http://unitsofmeasure.org",
          "display": "ml"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Medication Dose"
        }
      } ]
    }, {
      "text": "Route",
      "type": "open-choice",
      "linkId": "medication-info|route",
      "repeats": true,
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Medication Route"
        }
      } ]
    }, {
      "text": "Frequency",
      "type": "quantity",
      "linkId": "medication-info|frequency",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "h",
          "system": "http://unitsofmeasure.org",
          "display": "h"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "d",
          "system": "http://unitsofmeasure.org",
          "display": "d"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "wk",
          "system": "http://unitsofmeasure.org",
          "display": "wk"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "mo",
          "system": "http://unitsofmeasure.org",
          "display": "mo"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Medication Frequency"
        }
      } ]
    }, {
      "text": "Expected length of therapy",
      "type": "quantity",
      "linkId": "medication-info|therapy-leng",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "h",
          "system": "http://unitsofmeasure.org",
          "display": "h"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "d",
          "system": "http://unitsofmeasure.org",
          "display": "d"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "wk",
          "system": "http://unitsofmeasure.org",
          "display": "wk"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "mo",
          "system": "http://unitsofmeasure.org",
          "display": "mo"
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unitOption",
        "valueCoding": {
          "code": "a",
          "system": "http://unitsofmeasure.org",
          "display": "a"
        }
      }, {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Expected Therapy Length"
        }
      } ]
    }, {
      "text": "Quantity/number of requested visits",
      "type": "integer",
      "linkId": "medication-info|num-visits"
    }, {
      "text": "Anticipated/actual date of service",
      "type": "date",
      "linkId": "medication-info|service-date",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Anticipated/actual date of service"
        }
      } ]
    }, {
      "text": "New Medication or Continued Therapy",
      "type": "choice",
      "linkId": "medication-info|new-med",
      "answerOption": [ {
        "valueCoding": {
          "code": "NewMedication",
          "system": "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med",
          "display": "New Medication"
        }
      }, {
        "valueCoding": {
          "code": "ContinuedTherapy",
          "system": "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med",
          "display": "Continuation of therapy"
        }
      } ]
    }, {
      "text": "Date therapy initially started",
      "type": "date",
      "linkId": "medication-info|date-initiallized",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Initial date of therapy"
        }
      } ],
      "enableWhen": [ {
        "operator": "=",
        "question": "medication-info|new-med",
        "answerCoding": {
          "code": "ContinuedTherapy",
          "system": "http://example.org/fhir/CodeSystem/MBODAQuestionnaire-medication-info-new-med"
        }
      } ]
    }, {
      "text": "HCPCS/CPT code/J code/NDC code of requested drug",
      "type": "string",
      "linkId": "medication-info|requested-drug-code"
    }, {
      "text": "Associated procedure codes requiring prior auth",
      "type": "string",
      "linkId": "medication-info|associated-procedure"
    } ],
    "text": "Medication Information",
    "type": "group",
    "linkId": "medication-info"
  }, {
    "item": [ {
      "item": [ {
        "text": "URGENT - rationale",
        "type": "string",
        "linkId": "request-for-expedited-review|rationale"
      } ],
      "text": "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.",
      "type": "group",
      "linkId": "request-for-expedited-review|para"
    } ],
    "text": "Request for Expedited Review",
    "type": "group",
    "linkId": "request-for-expedited-review"
  }, {
    "item": [ {
      "text": "Signature:",
      "type": "attachment",
      "linkId": "ordering-provider-signature|author-signature",
      "extension": [ {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired",
        "valueCodeableConcept": {
          "coding": [ {
            "code": "1.2.840.10065.1.12.1.1",
            "system": "urn:iso-astm:E1762-95:2013",
            "display": "Author's Signature"
          } ]
        }
      }, {
        "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-usageMode",
        "valueCode": "capture"
      } ]
    } ],
    "text": "Ordering Provider Signature",
    "type": "group",
    "linkId": "ordering-provider-signature"
  } ],
  "copyright": "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",
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Example Medical Benefit Outpatient Drug Authorization Questionnaire",
  "package_version": "1.0.0",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical": "http://hl7.org/fhir/us/cql/Library/MBODAInitialExpressions"
  }, {
    "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/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": "89cf1b33-b722-4e85-ae7f-5e00967df0ba",
  "kind": null,
  "url": "http://hl7.org/fhir/us/cql/Questionnaire/MBODAQuestionnaire",
  "version": "1.0.0",
  "contact": [ {
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}