| Package | hl7.fhir.us.cql |
| Resource Type | Questionnaire |
| Id | GMTPQuestionnaire |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/cql/https://build.fhir.org/ig/HL7/us-cql-ig/Questionnaire-GMTPQuestionnaire.html |
| URL | http://hl7.org/fhir/us/cql/Questionnaire/GMTPQuestionnaire |
| Version | 1.0.0-ballot |
| Status | active |
| Date | 2023-10-12T00:00:00+00:00 |
| Name | GMTPQuestionnaire |
| Title | Example Genetic/Molecular Testing Preauthorization Questionnaire |
| 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=1986712 |
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Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire GMTPQuestionnaire
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  GMTPQuestionnaire | 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/GMTPQuestionnaire#1.0.0-ballot | |
  billing-provider-question | Is the billing provider/referring lab different from servicing provider? | 0..1 | choice | Options: 2 options |
   billing-provider-info | Billing provider/referring lab information | 0..1 | group | Enable When: billing-provider-question = |
  billing-provider-info|name | Requesting provider name | 0..1 | string | |
| billing-provider-info|phone-number | Phone | 0..1 | string | |
| billing-provider-info|address | Ordering provider address | 0..1 | string | |
| billing-provider-info|npi | Ordering provider Tax ID/NPI # | 0..1 | string | |
| billing-provider-info|fax | Fax | 0..1 | string | |
| test-requested | Test requested | 0..1 | group | |
 test-requested|service-date | Date of service | 0..1 | date | |
| test-requested|test-id | Test ID | 0..1 | string | |
| test-requested|test-name | Test name | 0..1 | string | |
| test-requested|diagnosis-description | Diagnosis description | 0..1 | string | |
| test-requested|diagnosis-icd-code | ICD-10 code(s) | 0..* | open-choice | Value Set: ICD-10 Codes |
| test-requested|diagnosis-cpt-code | CPT code(s) | 0..* | open-choice | Value Set: AMA CPT All Codes |
| clinical-trial | Clinical Trial Information | 0..1 | group | |
| clinical-trial-question | Is the requested test part of a clinical trial? | 0..1 | choice | Options: 2 options |
| clinical-trial|yes-clinial-trial | If Yes, provide the registration or ID number for the specific trial in which this test is being studied. | 0..1 | string | Enable When: clinical-trial-question = |
| history | Patient history and related findings | 0..1 | group | |
| history|patient-history | Patient history including age at diagnosis | 0..1 | group | |
| history|patient-history|diagnosis | Diagnosis | 0..1 | string | |
| history|patient-history|age-at-onset | Age at onset | 0..1 | string | |
| history|patient-history|abatement | Abatement | 0..1 | string | |
| history|family-history | 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 | 0..1 | string | |
| history|other-findings | Other findings/testing completed - previous genetic testing for condition | 0..1 | string | |
| history|treatment-relation | How will testing be used in relation to treatment or management of the patient? | 0..1 | string | |
| person-filling-out-form | Person filling out form | 0..1 | group | |
| person-filling-out-form|name | Name | 0..1 | string | |
| person-filling-out-form|phone-number | Phone number | 0..1 | string | |
| person-filling-out-form|facility | Phone number | 0..1 | string | |
| Documentation for this format | ||||
Options Sets
Answer options for billing-provider-question
Answer options for clinical-trial-question
FHIR{
"resourceType": "Questionnaire",
"id": "GMTPQuestionnaire",
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
"valueCanonical": "http://hl7.org/fhir/us/cql/Library/GMTPInitialExpressions"
},
{
"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": "Coverage",
"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": {
"system": "http://hl7.org/fhir/uv/sdc/CodeSystem/launchContext",
"code": "ServiceRequest",
"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/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/GMTPQuestionnaire",
"version": "1.0.0-ballot",
"name": "GMTPQuestionnaire",
"title": "Example Genetic/Molecular Testing Preauthorization Questionnaire",
"status": "active",
"experimental": true,
"date": "2023-10-12T00:00:00+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=1986712",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider different from Servicing Provider"
}
}
],
"linkId": "billing-provider-question",
"text": "Is the billing provider/referring lab different from servicing provider?",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "Y",
"display": "Yes"
}
},
{
"valueCoding": {
"code": "N",
"display": "No"
}
}
],
"item": [
{
"linkId": "billing-provider-info",
"text": "Billing provider/referring lab information",
"type": "group",
"enableWhen": [
{
"question": "billing-provider-question",
"operator": "=",
"answerCoding": {
"code": "Y"
}
}
],
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider Name"
}
}
],
"linkId": "billing-provider-info|name",
"text": "Requesting provider name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider Phone"
}
}
],
"linkId": "billing-provider-info|phone-number",
"text": "Phone",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider Address"
}
}
],
"linkId": "billing-provider-info|address",
"text": "Ordering provider address",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider NPI"
}
}
],
"linkId": "billing-provider-info|npi",
"text": "Ordering provider Tax ID/NPI #",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Billing Provider Fax"
}
}
],
"linkId": "billing-provider-info|fax",
"text": "Fax",
"type": "string"
}
]
}
]
},
{
"linkId": "test-requested",
"text": "Test requested",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Date of Service"
}
}
],
"linkId": "test-requested|service-date",
"text": "Date of service",
"type": "date"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Test ID"
}
}
],
"linkId": "test-requested|test-id",
"text": "Test ID",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Test name"
}
}
],
"linkId": "test-requested|test-name",
"text": "Test name",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Diagnosis Descriptions"
}
}
],
"linkId": "test-requested|diagnosis-description",
"text": "Diagnosis description",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Test ICD Codes"
}
}
],
"linkId": "test-requested|diagnosis-icd-code",
"text": "ICD-10 code(s)",
"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": "Test CPT Codes"
}
}
],
"linkId": "test-requested|diagnosis-cpt-code",
"text": "CPT code(s)",
"type": "open-choice",
"repeats": true,
"answerValueSet": "http://terminology.hl7.org/ValueSet/cpt-all"
}
]
},
{
"linkId": "clinical-trial",
"text": "Clinical Trial Information",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Part of clinical trial"
}
}
],
"linkId": "clinical-trial-question",
"text": "Is the requested test part of a clinical trial?",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "Y",
"display": "Yes"
}
},
{
"valueCoding": {
"code": "N",
"display": "No"
}
}
],
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Clinical Trial ID"
}
}
],
"linkId": "clinical-trial|yes-clinial-trial",
"text": "If Yes, provide the registration or ID number for the specific trial in which this test is being studied.",
"type": "string",
"enableWhen": [
{
"question": "clinical-trial-question",
"operator": "=",
"answerCoding": {
"code": "Y"
}
}
]
}
]
}
]
},
{
"linkId": "history",
"text": "Patient history and related findings",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-itemPopulationContext",
"valueExpression": {
"name": "PatientHistory",
"language": "text/cql-identifier",
"expression": "Patient history including age at diagnosis"
}
}
],
"linkId": "history|patient-history",
"text": "Patient history including age at diagnosis",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-expression",
"expression": "PatientHistory.diagnosis"
}
}
],
"linkId": "history|patient-history|diagnosis",
"text": "Diagnosis",
"type": "string"
},
{
"linkId": "history|patient-history|age-at-onset",
"text": "Age at onset",
"type": "string"
},
{
"linkId": "history|patient-history|abatement",
"text": "Abatement",
"type": "string"
}
]
},
{
"linkId": "history|family-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"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "Previous genetic testing for condition"
}
}
],
"linkId": "history|other-findings",
"text": "Other findings/testing completed - previous genetic testing for condition",
"type": "string"
},
{
"linkId": "history|treatment-relation",
"text": "How will testing be used in relation to treatment or management of the patient?",
"type": "string"
}
]
},
{
"linkId": "person-filling-out-form",
"text": "Person filling out form",
"type": "group",
"item": [
{
"linkId": "person-filling-out-form|name",
"text": "Name",
"type": "string"
},
{
"linkId": "person-filling-out-form|phone-number",
"text": "Phone number",
"type": "string"
},
{
"linkId": "person-filling-out-form|facility",
"text": "Phone number",
"type": "string"
}
]
}
]
}