| Package | hl7.fhir.us.cql |
| Resource Type | Questionnaire |
| Id | UPPARFQuestionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/cql/https://build.fhir.org/ig/HL7/us-cql-ig/Questionnaire-UPPARFQuestionnaire.html |
| URL | http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire |
| Version | 1.0.0-ballot |
| Status | active |
| Date | 2023-10-19T00:00:00+00:00 |
| Name | UPPARFQuestionnaire |
| Title | Example Uniform Pharmacy Prior Authorization Request Form |
| Realm | us |
| Authority | hl7 |
| Description | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization 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=4136509 |
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Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire UPPARFQuestionnaire
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  UPPARFQuestionnaire | This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form. | Questionnaire | http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire#1.0.0-ballot | |
  urgency | Urgency | 0..1 | choice | Options: 2 options |
 drug-info | Drug Information | 0..1 | group | |
  drug-info|drug-name | Requested Drug Name | 0..1 | string | |
  drug-info|drug-intention-opioid | Is this drug intended to treat opioid dependence? | 0..1 | boolean | |
 drug-info|drug-intention-opioid|first-prior-authentication | Is this a first request for prior authorization for this drug? | 0..1 | boolean | Enable When: drug-info|drug-intention-opioid = |
 drug-info|drug-intention-opioid|date-first-request | What was the date of the first request? | 0..1 | date | Enable When: drug-info|drug-intention-opioid|first-prior-authentication = |
| drug-info|drug-intention-opioid|twelve-months-since-request | Has the date of the first request been greater than twelve months ago? | 0..1 | boolean | Enable When: drug-info|drug-intention-opioid|first-prior-authentication = |
| completing-form | Prior authentication is required and this form needs to be completed | 0..1 | group | Enable When: |
| completing-form|patient-info | Patient Info | 0..1 | group | |
| completing-form|patient-info|prescription-date | Prescription Date | 0..1 | string | |
| completing-form|prescriber-info | Prescriber Info | 0..1 | group | |
| completing-form|prescriber-info|prescriber-name | Prescriber Name | 0..1 | string | |
| completing-form|prescriber-info|prescriber-fax | Prescriber Fax | 0..1 | string | |
| completing-form|prescriber-info|prescriber-phone | Prescriber Phone | 0..1 | string | |
| completing-form|prescriber-info|prescriber-pager | Prescriber Pager | 0..1 | string | |
| completing-form|prescriber-info|prescriber-address | Prescriber Address | 0..1 | string | |
| completing-form|prescriber-info|prescriber-contact | Prescriber Office Contact | 0..1 | string | |
| completing-form|prescriber-info|prescriber-npi | Prescriber NPI | 0..1 | string | |
| completing-form|prescriber-info|prescriber-dea | Prescriber DEA | 0..1 | string | |
| completing-form|prescriber-info|prescriber-tax-id | Prescriber Tax ID | 0..1 | string | |
| completing-form|prescriber-info|prescriber-specialty | Specialty/Facility Name If applicable | 0..1 | string | |
| completing-form|prescriber-info|prescriber-email | Email Address | 0..1 | string | |
| completing-form|drug-benefit | Prior Authorization Request for Drug Benefit | 0..1 | group | |
| completing-form|drug-benefit|request-type | New Request | 0..1 | choice | Options: 2 options |
| completing-form|drug-benefit|diagnosis-codes | Patient ICD Diagnostic Codes | 0..* | open-choice | Value Set: ICD-10 Codes |
| completing-form|drug-benefit|diagnosis-descriptions | Patient Diagnosis | 0..* | string | |
| completing-form|drug-benefit|drugs | Drugs Requested with J-Code; if applicable | 0..* | string | |
| completing-form|drug-benefit|strength-route-frequency | Strength/Route/Frequency | 0..1 | string | |
| completing-form|drug-benefit|unit-volume | Unit/Volume of Named Drugs | 0..1 | string | |
| completing-form|drug-benefit|start-length | Start Date and Length of Therapy | 0..1 | string | |
| completing-form|drug-benefit|location | Location of Treatment e.g. provider office; facility; home health; etc. including name; Type 2 NPI if applicable; address and tax ID: | 0..1 | string | |
| completing-form|drug-benefit|criteria | Clinical Criteria for Approval; Including other Pertinent Information to Support the Request; other Medications Tried; Their Names; Duration; and Patient Response: | 0..1 | string | |
| completing-form|drug-benefit|for-trial | For use in clinical trial? | 0..1 | boolean | |
| completing-form|drug-benefit|for-trial|registration-number | Provide trial name and registration number | 0..1 | string | Enable When: completing-form|drug-benefit|for-trial = |
| completing-form|drug-benefit|drug-name | Drug Name Brand Name and Scientific Name/Strength: | 0..1 | string | |
| completing-form|drug-benefit|dose | Dose | 0..1 | string | |
| completing-form|drug-benefit|route | Route | 0..1 | string | |
| completing-form|drug-benefit|frequency | Frequency | 0..1 | string | |
 completing-form|drug-benefit|quantity | Quantity | 0..1 | quantity | |
 completing-form|drug-benefit|refills | Number of Refills | 0..1 | integer | |
| completing-form|drug-benefit|delivery | Product will be delivered to: | 0..1 | choice | Options: 3 options |
 completing-form|drug-benefit|signature | Prescriber or Authorized Signature: | 0..1 | attachment | |
| completing-form|drug-benefit|pharmacy | Dispensing Pharmacy Name and Phone Number: | 0..1 | string | |
| completing-form|drug-benefit|date | Date | 0..1 | date | |
| Documentation for this format | ||||
Options Sets
Answer options for urgency
Answer options for completing-form|drug-benefit|request-type
Answer options for completing-form|drug-benefit|delivery
FHIR{
"resourceType": "Questionnaire",
"id": "UPPARFQuestionnaire",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
"valueCanonical": "http://hl7.org/fhir/us/cql/Library/UPPARFInitialExpressions"
},
{
"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://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "MedicationRequest",
"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/uv/sdc/StructureDefinition/sdc-questionnaire-launchContext"
},
{
"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"
}
]
}
}
],
"url": "http://hl7.org/fhir/us/cql/Questionnaire/UPPARFQuestionnaire",
"version": "1.0.0-ballot",
"name": "UPPARFQuestionnaire",
"title": "Example Uniform Pharmacy Prior Authorization Request Form",
"status": "active",
"experimental": true,
"date": "2023-10-19T00:00:00+00:00",
"publisher": "HL7 International / Clinical Decision Support",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/dss"
}
]
}
],
"description": "This is an example of a prior authorization questionnaire developed based on an existing industry prior-authorization form.",
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US",
"display": "United States of America"
}
]
}
],
"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",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Urgency"
}
}
],
"linkId": "urgency",
"text": "Urgency",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "urgent",
"display": "Urgent"
}
},
{
"valueCoding": {
"code": "routine",
"display": "Non-Urgent"
}
}
]
},
{
"linkId": "drug-info",
"text": "Drug Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Most Recent Medication Name"
}
}
],
"linkId": "drug-info|drug-name",
"text": "Requested Drug Name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Is Opioid Treatment"
}
}
],
"linkId": "drug-info|drug-intention-opioid",
"text": "Is this drug intended to treat opioid dependence?",
"type": "boolean",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Is First Prior Authentication"
}
}
],
"linkId": "drug-info|drug-intention-opioid|first-prior-authentication",
"text": "Is this a first request for prior authorization for this drug?",
"type": "boolean",
"enableWhen": [
{
"question": "drug-info|drug-intention-opioid",
"operator": "=",
"answerBoolean": true
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Initial Request Date"
}
}
],
"linkId": "drug-info|drug-intention-opioid|date-first-request",
"text": "What was the date of the first request?",
"type": "date",
"enableWhen": [
{
"question": "drug-info|drug-intention-opioid|first-prior-authentication",
"operator": "=",
"answerBoolean": false
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Is First Request > 12 Months"
}
}
],
"linkId": "drug-info|drug-intention-opioid|twelve-months-since-request",
"text": "Has the date of the first request been greater than twelve months ago?",
"type": "boolean",
"enableWhen": [
{
"question": "drug-info|drug-intention-opioid|first-prior-authentication",
"operator": "=",
"answerBoolean": false
}
]
}
]
}
]
},
{
"linkId": "completing-form",
"text": "Prior authentication is required and this form needs to be completed",
"type": "group",
"enableWhen": [
{
"question": "drug-info|drug-intention-opioid",
"operator": "=",
"answerBoolean": false
},
{
"question": "drug-info|drug-intention-opioid|twelve-months-since-request",
"operator": "=",
"answerBoolean": false
}
],
"enableBehavior": "any",
"item": [
{
"linkId": "completing-form|patient-info",
"text": "Patient Info",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescription Date"
}
}
],
"linkId": "completing-form|patient-info|prescription-date",
"text": "Prescription Date",
"type": "string"
}
]
},
{
"linkId": "completing-form|prescriber-info",
"text": "Prescriber Info",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Name"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-name",
"text": "Prescriber Name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Fax"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-fax",
"text": "Prescriber Fax",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Phone"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-phone",
"text": "Prescriber Phone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Pager"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-pager",
"text": "Prescriber Pager",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Address"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-address",
"text": "Prescriber Address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Contact"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-contact",
"text": "Prescriber Office Contact",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber NPI"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-npi",
"text": "Prescriber NPI",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber DEA"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-dea",
"text": "Prescriber DEA",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Tax ID"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-tax-id",
"text": "Prescriber Tax ID",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Specialty"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-specialty",
"text": "Specialty/Facility Name If applicable",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Prescriber Email Address"
}
}
],
"linkId": "completing-form|prescriber-info|prescriber-email",
"text": "Email Address",
"type": "string"
}
]
},
{
"linkId": "completing-form|drug-benefit",
"text": "Prior Authorization Request for Drug Benefit",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Request Type"
}
}
],
"linkId": "completing-form|drug-benefit|request-type",
"text": "New Request",
"type": "choice",
"answerOption": [
{
"valueString": "New Request"
},
{
"valueString": "Reauthorization"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "ICD 10 Codes"
}
}
],
"linkId": "completing-form|drug-benefit|diagnosis-codes",
"text": "Patient ICD Diagnostic Codes",
"type": "open-choice",
"repeats": true,
"answerValueSet": "http://hl7.org/fhir/ValueSet/icd-10"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Diagnosis Descriptions"
}
}
],
"linkId": "completing-form|drug-benefit|diagnosis-descriptions",
"text": "Patient Diagnosis",
"type": "string",
"repeats": true
},
{
"linkId": "completing-form|drug-benefit|drugs",
"text": "Drugs Requested with J-Code; if applicable",
"type": "string",
"repeats": true
},
{
"linkId": "completing-form|drug-benefit|strength-route-frequency",
"text": "Strength/Route/Frequency",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|unit-volume",
"text": "Unit/Volume of Named Drugs",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Start Date and Length"
}
}
],
"linkId": "completing-form|drug-benefit|start-length",
"text": "Start Date and Length of Therapy",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|location",
"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|criteria",
"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|for-trial",
"text": "For use in clinical trial?",
"type": "boolean"
},
{
"linkId": "completing-form|drug-benefit|for-trial|registration-number",
"text": "Provide trial name and registration number",
"type": "string",
"enableWhen": [
{
"question": "completing-form|drug-benefit|for-trial",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "completing-form|drug-benefit|drug-name",
"text": "Drug Name Brand Name and Scientific Name/Strength:",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|dose",
"text": "Dose",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|route",
"text": "Route",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|frequency",
"text": "Frequency",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|quantity",
"text": "Quantity",
"type": "quantity"
},
{
"linkId": "completing-form|drug-benefit|refills",
"text": "Number of Refills",
"type": "integer"
},
{
"linkId": "completing-form|drug-benefit|delivery",
"text": "Product will be delivered to:",
"type": "choice",
"answerOption": [
{
"valueString": "Patient's Home"
},
{
"valueString": "Physician Office"
},
{
"valueString": "Other"
}
]
},
{
"linkId": "completing-form|drug-benefit|signature",
"text": "Prescriber or Authorized Signature:",
"type": "attachment"
},
{
"linkId": "completing-form|drug-benefit|pharmacy",
"text": "Dispensing Pharmacy Name and Phone Number:",
"type": "string"
},
{
"linkId": "completing-form|drug-benefit|date",
"text": "Date",
"type": "date"
}
]
}
]
}
]
}