{
  "description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
  "_filename": "Questionnaire-UPPARFQuestionnaire.json",
  "package_name": "hl7.fhir.us.cql",
  "date": "2023-10-19T00:00:00+00:00",
  "publisher": "HL7 International / Clinical Decision Support",
  "jurisdiction": [ {
    "coding": [ {
      "code": "US",
      "system": "urn:iso:std:iso:3166",
      "display": "United States of America"
    } ]
  } ],
  "name": "UPPARFQuestionnaire",
  "item": [ {
    "text": "Urgency",
    "type": "choice",
    "linkId": "urgency",
    "extension": [ {
      "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
      "valueExpression": {
        "language": "text/cql-identifier",
        "expression": "Urgency"
      }
    } ],
    "answerOption": [ {
      "valueCoding": {
        "code": "urgent",
        "system": "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
        "display": "Urgent"
      }
    }, {
      "valueCoding": {
        "code": "routine",
        "system": "http://example.org/fhir/CodeSystem/UPPARFQuestionnaire-urgency",
        "display": "Non-Urgent"
      }
    } ]
  }, {
    "item": [ {
      "text": "Requested Drug Name",
      "type": "string",
      "linkId": "drug-info|drug-name",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Most Recent Medication Name"
        }
      } ]
    }, {
      "item": [ {
        "text": "Is this a first request for prior authorization for this drug?",
        "type": "boolean",
        "linkId": "drug-info|drug-intention-opioid|first-prior-authentication",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Is First Prior Authentication"
          }
        } ],
        "enableWhen": [ {
          "operator": "=",
          "question": "drug-info|drug-intention-opioid",
          "answerBoolean": true
        } ]
      }, {
        "text": "What was the date of the first request?",
        "type": "date",
        "linkId": "drug-info|drug-intention-opioid|date-first-request",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Initial Request Date"
          }
        } ],
        "enableWhen": [ {
          "operator": "=",
          "question": "drug-info|drug-intention-opioid|first-prior-authentication",
          "answerBoolean": false
        } ]
      }, {
        "text": "Has the date of the first request been greater than twelve months ago?",
        "type": "boolean",
        "linkId": "drug-info|drug-intention-opioid|twelve-months-since-request",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Is First Request > 12 Months"
          }
        } ],
        "enableWhen": [ {
          "operator": "=",
          "question": "drug-info|drug-intention-opioid|first-prior-authentication",
          "answerBoolean": false
        } ]
      } ],
      "text": "Is this drug intended to treat opioid dependence?",
      "type": "boolean",
      "linkId": "drug-info|drug-intention-opioid",
      "extension": [ {
        "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
        "valueExpression": {
          "language": "text/cql-identifier",
          "expression": "Is Opioid Treatment"
        }
      } ]
    } ],
    "text": "Drug Information",
    "type": "group",
    "linkId": "drug-info"
  }, {
    "item": [ {
      "item": [ {
        "text": "Prescription Date",
        "type": "string",
        "linkId": "completing-form|patient-info|prescription-date",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescription Date"
          }
        } ]
      } ],
      "text": "Patient Info",
      "type": "group",
      "linkId": "completing-form|patient-info"
    }, {
      "item": [ {
        "text": "Prescriber Name",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-name",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Name"
          }
        } ]
      }, {
        "text": "Prescriber Fax",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-fax",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Fax"
          }
        } ]
      }, {
        "text": "Prescriber Phone",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-phone",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Phone"
          }
        } ]
      }, {
        "text": "Prescriber Pager",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-pager",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Pager"
          }
        } ]
      }, {
        "text": "Prescriber Address",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-address",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Address"
          }
        } ]
      }, {
        "text": "Prescriber Office Contact",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-contact",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Contact"
          }
        } ]
      }, {
        "text": "Prescriber NPI",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-npi",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber NPI"
          }
        } ]
      }, {
        "text": "Prescriber DEA",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-dea",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber DEA"
          }
        } ]
      }, {
        "text": "Prescriber Tax ID",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-tax-id",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Tax ID"
          }
        } ]
      }, {
        "text": "Specialty/Facility Name If applicable",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-specialty",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Specialty"
          }
        } ]
      }, {
        "text": "Email Address",
        "type": "string",
        "linkId": "completing-form|prescriber-info|prescriber-email",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Prescriber Email Address"
          }
        } ]
      } ],
      "text": "Prescriber Info",
      "type": "group",
      "linkId": "completing-form|prescriber-info"
    }, {
      "item": [ {
        "text": "New Request",
        "type": "choice",
        "linkId": "completing-form|drug-benefit|request-type",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Request Type"
          }
        } ],
        "answerOption": [ {
          "valueString": "New Request"
        }, {
          "valueString": "Reauthorization"
        } ]
      }, {
        "text": "Patient ICD Diagnostic Codes",
        "type": "open-choice",
        "linkId": "completing-form|drug-benefit|diagnosis-codes",
        "repeats": true,
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "ICD 10 Codes"
          }
        } ],
        "answerValueSet": "http://hl7.org/fhir/ValueSet/icd-10"
      }, {
        "text": "Patient Diagnosis",
        "type": "string",
        "linkId": "completing-form|drug-benefit|diagnosis-descriptions",
        "repeats": true,
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Diagnosis Descriptions"
          }
        } ]
      }, {
        "text": "Drugs Requested with J-Code; if applicable",
        "type": "string",
        "linkId": "completing-form|drug-benefit|drugs",
        "repeats": true
      }, {
        "text": "Strength/Route/Frequency",
        "type": "string",
        "linkId": "completing-form|drug-benefit|strength-route-frequency"
      }, {
        "text": "Unit/Volume of Named Drugs",
        "type": "string",
        "linkId": "completing-form|drug-benefit|unit-volume"
      }, {
        "text": "Start Date and Length of Therapy",
        "type": "string",
        "linkId": "completing-form|drug-benefit|start-length",
        "extension": [ {
          "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
          "valueExpression": {
            "language": "text/cql-identifier",
            "expression": "Start Date and Length"
          }
        } ]
      }, {
        "text": "Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID:",
        "type": "string",
        "linkId": "completing-form|drug-benefit|location"
      }, {
        "text": "Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response:",
        "type": "string",
        "linkId": "completing-form|drug-benefit|criteria"
      }, {
        "text": "For use in clinical trial?",
        "type": "boolean",
        "linkId": "completing-form|drug-benefit|for-trial"
      }, {
        "text": "Provide trial name and registration number",
        "type": "string",
        "linkId": "completing-form|drug-benefit|for-trial|registration-number",
        "enableWhen": [ {
          "operator": "=",
          "question": "completing-form|drug-benefit|for-trial",
          "answerBoolean": true
        } ]
      }, {
        "text": "Drug Name Brand Name and Scientific Name/Strength:",
        "type": "string",
        "linkId": "completing-form|drug-benefit|drug-name"
      }, {
        "text": "Dose",
        "type": "string",
        "linkId": "completing-form|drug-benefit|dose"
      }, {
        "text": "Route",
        "type": "string",
        "linkId": "completing-form|drug-benefit|route"
      }, {
        "text": "Frequency",
        "type": "string",
        "linkId": "completing-form|drug-benefit|frequency"
      }, {
        "text": "Quantity",
        "type": "quantity",
        "linkId": "completing-form|drug-benefit|quantity"
      }, {
        "text": "Number of Refills",
        "type": "integer",
        "linkId": "completing-form|drug-benefit|refills"
      }, {
        "text": "Product will be delivered to:",
        "type": "choice",
        "linkId": "completing-form|drug-benefit|delivery",
        "answerOption": [ {
          "valueString": "Patient's Home"
        }, {
          "valueString": "Physician Office"
        }, {
          "valueString": "Other"
        } ]
      }, {
        "text": "Prescriber or Authorized Signature:",
        "type": "attachment",
        "linkId": "completing-form|drug-benefit|signature"
      }, {
        "text": "Dispensing Pharmacy Name and Phone Number:",
        "type": "string",
        "linkId": "completing-form|drug-benefit|pharmacy"
      }, {
        "text": "Date",
        "type": "date",
        "linkId": "completing-form|drug-benefit|date"
      } ],
      "text": "Prior Authorization Request for Drug Benefit",
      "type": "group",
      "linkId": "completing-form|drug-benefit"
    } ],
    "text": "Prior authentication is required and this form needs to be completed",
    "type": "group",
    "linkId": "completing-form",
    "enableWhen": [ {
      "operator": "=",
      "question": "drug-info|drug-intention-opioid",
      "answerBoolean": false
    }, {
      "operator": "=",
      "question": "drug-info|drug-intention-opioid|twelve-months-since-request",
      "answerBoolean": false
    } ],
    "enableBehavior": "any"
  } ],
  "copyright": "This content is informed by the following source, used with permission: https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=4136509",
  "type": null,
  "experimental": "true",
  "resourceType": "Questionnaire",
  "title": "Example Uniform Pharmacy Prior Authorization Request Form",
  "package_version": "1.0.0",
  "extension": [ {
    "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
    "valueCanonical": "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions"
  }, {
    "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": "MedicationRequest",
        "system": "http://example.org/fhir/CodeSystem/additionalLaunchContext",
        "display": "MedicationRequest"
      }
    }, {
      "url": "type",
      "valueCode": "MedicationRequest"
    }, {
      "url": "description",
      "valueString": "The MedicationRequest 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": "ef425621-0370-499e-9071-f58975a53e74",
  "kind": null,
  "url": "http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire",
  "version": "1.0.0",
  "contact": [ {
    "telecom": [ {
      "value": "http://www.hl7.org/Special/committees/dss",
      "system": "url"
    } ]
  } ]
}