{
  "resourceType": "Parameters",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-qpackage-output-parameters"
    ]
  },
  "parameter": [
    {
      "name": "packagebundle",
      "resource": {
        "resourceType": "Bundle",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/DTR-QPackageBundle"
          ]
        },
        "type": "collection",
        "entry": [
          {
            "fullUrl": "https://interop.hn1.com/fhir/Questionnaire/therapy-intake",
            "resource": {
              "resourceType": "Questionnaire",
              "id": "therapy-intake",
              "meta": {
                "profile": [
                  "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-std-questionnaire"
                ]
              },
              "url": "https://interop.hn1.com/fhir/Questionnaire/therapy-intake",
              "version": "1.0.0",
              "name": "HN1TherapyIntake",
              "title": "HN1 Therapy Intake Questionnaire",
              "status": "active",
              "subjectType": [
                "Patient"
              ],
              "item": [
                {
                  "linkId": "therapy-intake-pdf",
                  "text": "Reference Form",
                  "type": "display",
                  "extension": [
                    {
                      "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-supportHyperlink",
                      "extension": [
                        {
                          "url": "label",
                          "valueString": "View the Therapy Intake Form (PDF)"
                        },
                        {
                          "url": "link",
                          "valueUri": "https://interop.hn1.com/docs/therapy-intake.pdf"
                        }
                      ]
                    }
                  ]
                },
                {
                  "linkId": "request-information",
                  "text": "Request Information",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "request-priority",
                      "text": "Request Priority",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueCoding": {
                            "system": "http://hl7.org/fhir/request-priority",
                            "code": "routine",
                            "display": "Routine"
                          }
                        },
                        {
                          "valueCoding": {
                            "system": "http://hl7.org/fhir/request-priority",
                            "code": "urgent",
                            "display": "Urgent"
                          }
                        }
                      ]
                    },
                    {
                      "linkId": "request-date",
                      "text": "Request Date",
                      "type": "date",
                      "required": true
                    }
                  ]
                },
                {
                  "linkId": "member-information",
                  "text": "Member Information",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "member-id",
                      "text": "Member ID Number",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "member-health-plan",
                      "text": "Member Health Plan",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "member-last-name",
                      "text": "Member Last Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "member-first-name",
                      "text": "Member First Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "member-telephone",
                      "text": "Member Telephone Number",
                      "type": "string"
                    },
                    {
                      "linkId": "member-date-of-birth",
                      "text": "Member Date of Birth",
                      "type": "date",
                      "required": true
                    },
                    {
                      "linkId": "member-sex",
                      "text": "Sex",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueCoding": {
                            "system": "http://hl7.org/fhir/administrative-gender",
                            "code": "male",
                            "display": "Male"
                          }
                        },
                        {
                          "valueCoding": {
                            "system": "http://hl7.org/fhir/administrative-gender",
                            "code": "female",
                            "display": "Female"
                          }
                        }
                      ]
                    }
                  ]
                },
                {
                  "linkId": "referring-provider",
                  "text": "Referring Provider",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "referring-provider-name",
                      "text": "Referring Provider Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "referring-provider-phone",
                      "text": "Phone Number",
                      "type": "string"
                    },
                    {
                      "linkId": "referring-provider-fax",
                      "text": "Fax Number",
                      "type": "string"
                    },
                    {
                      "linkId": "referring-provider-npi",
                      "text": "Referring Provider NPI",
                      "type": "string",
                      "required": true
                    }
                  ]
                },
                {
                  "linkId": "rendering-provider",
                  "text": "Rendering Provider",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "facility-name",
                      "text": "Facility/Group Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "facility-tin",
                      "text": "Facility/Group TIN Number",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-address",
                      "text": "Facility/Group Address",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-city",
                      "text": "City",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-zip",
                      "text": "Zip Code",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-npi",
                      "text": "Facility/Group NPI",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "facility-contact-name",
                      "text": "Contact Person Name",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-phone",
                      "text": "Phone Number",
                      "type": "string"
                    },
                    {
                      "linkId": "facility-fax",
                      "text": "Fax Number",
                      "type": "string"
                    }
                  ]
                },
                {
                  "linkId": "treating-therapist",
                  "text": "Treating Therapist",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "therapist-last-name",
                      "text": "Treating Therapist Last Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "therapist-first-name",
                      "text": "Treating Therapist First Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "therapist-npi",
                      "text": "Treating Therapist NPI",
                      "type": "string",
                      "required": true
                    }
                  ]
                },
                {
                  "linkId": "clinical-information",
                  "text": "Clinical Information",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "line-of-business",
                      "text": "Line of Business",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueString": "Medicare"
                        }
                      ]
                    },
                    {
                      "linkId": "place-of-service",
                      "text": "Place of Service",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueString": "11 - Office"
                        },
                        {
                          "valueString": "12 - Home"
                        },
                        {
                          "valueString": "22 - Outpatient Hospital"
                        },
                        {
                          "valueString": "49 - Independent Clinic"
                        },
                        {
                          "valueString": "Other"
                        }
                      ]
                    },
                    {
                      "linkId": "other-place-of-service",
                      "text": "Other Place of Service",
                      "type": "string",
                      "enableWhen": [
                        {
                          "question": "place-of-service",
                          "operator": "=",
                          "answerString": "Other"
                        }
                      ]
                    },
                    {
                      "linkId": "primary-diagnosis-description",
                      "text": "Primary Diagnosis Description",
                      "type": "text",
                      "required": true
                    },
                    {
                      "linkId": "icd-code",
                      "text": "ICD Code",
                      "type": "string",
                      "required": true,
                      "repeats": true
                    },
                    {
                      "linkId": "cpt-code",
                      "text": "CPT Code",
                      "type": "string",
                      "required": true,
                      "repeats": true
                    },
                    {
                      "linkId": "status-post-surgery",
                      "text": "Status Post Surgery",
                      "type": "boolean"
                    },
                    {
                      "linkId": "surgery-procedure",
                      "text": "If Status Post Surgery, List Procedure",
                      "type": "string",
                      "enableWhen": [
                        {
                          "question": "status-post-surgery",
                          "operator": "=",
                          "answerBoolean": true
                        }
                      ]
                    },
                    {
                      "linkId": "surgery-date",
                      "text": "Date of Surgery",
                      "type": "date",
                      "enableWhen": [
                        {
                          "question": "status-post-surgery",
                          "operator": "=",
                          "answerBoolean": true
                        }
                      ]
                    },
                    {
                      "linkId": "cva-date",
                      "text": "Date of CVA",
                      "type": "date"
                    }
                  ]
                },
                {
                  "linkId": "plan-of-care",
                  "text": "Plan of Care",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "plan-of-care-approved",
                      "text": "The Plan of Care has been submitted and approved by the ordering provider.",
                      "type": "boolean",
                      "required": true
                    },
                    {
                      "linkId": "frequency-per-week",
                      "text": "Frequency: Times per Week",
                      "type": "integer",
                      "required": true
                    },
                    {
                      "linkId": "duration-weeks",
                      "text": "Duration: Number of Weeks",
                      "type": "integer",
                      "required": true
                    },
                    {
                      "linkId": "plan-reviewed-with-member",
                      "text": "The servicing provider reviewed the approved Plan of Care with the enrollee.",
                      "type": "boolean",
                      "required": true
                    },
                    {
                      "linkId": "ordering-provider-notification",
                      "text": "The ordering provider will be notified when therapy is completed or stopped.",
                      "type": "boolean",
                      "required": true
                    }
                  ]
                },
                {
                  "linkId": "therapy-information",
                  "text": "Therapy Information",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "therapy-discipline",
                      "text": "Therapy Discipline",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueString": "Physical Therapy"
                        },
                        {
                          "valueString": "Occupational Therapy"
                        },
                        {
                          "valueString": "Speech Therapy"
                        },
                        {
                          "valueString": "Aquatic Therapy"
                        },
                        {
                          "valueString": "Vestibular"
                        },
                        {
                          "valueString": "Lymphedema"
                        }
                      ]
                    },
                    {
                      "linkId": "evaluation-date",
                      "text": "Evaluation Date",
                      "type": "date",
                      "required": true
                    },
                    {
                      "linkId": "episode-type",
                      "text": "Episode Type",
                      "type": "choice",
                      "required": true,
                      "answerOption": [
                        {
                          "valueString": "Initial Review"
                        },
                        {
                          "valueString": "Subsequent Episode"
                        }
                      ]
                    },
                    {
                      "linkId": "episode-number",
                      "text": "Episode Number",
                      "type": "integer",
                      "enableWhen": [
                        {
                          "question": "episode-type",
                          "operator": "=",
                          "answerString": "Subsequent Episode"
                        }
                      ]
                    },
                    {
                      "linkId": "previous-evaluation-date",
                      "text": "Previous Evaluation Date",
                      "type": "date",
                      "repeats": true
                    },
                    {
                      "linkId": "notes-comments",
                      "text": "Note/Comments",
                      "type": "text"
                    }
                  ]
                },
                {
                  "linkId": "attestation",
                  "text": "Attestation",
                  "type": "group",
                  "item": [
                    {
                      "linkId": "attestation-confirmed",
                      "text": "I attest that the information provided is accurate and truthful.",
                      "type": "boolean",
                      "required": true
                    },
                    {
                      "linkId": "authorized-representative-name",
                      "text": "Provider or Authorized Representative Print Name",
                      "type": "string",
                      "required": true
                    },
                    {
                      "linkId": "attestation-date",
                      "text": "Attestation Date",
                      "type": "date",
                      "required": true
                    }
                  ]
                }
              ],
              "publisher": "HN1",
              "copyright": "Copyright HN1. All rights reserved.",
              "date": "2026-07-29",
              "description": "Collects the therapy intake information required to support HN1 utilization management and prior authorization workflows.",
              "purpose": "Provide a standardized electronic representation of the HN1 therapy intake form for use in the Da Vinci DTR workflow.",
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/artifact-versionAlgorithm",
                  "valueCoding": {
                    "system": "http://hl7.org/fhir/version-algorithm",
                    "code": "semver"
                  }
                }
              ],
              "text": {
                "status": "generated",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>HN1 Therapy Intake Questionnaire</b></p><p>Electronic therapy intake questionnaire for HN1 utilization-management and prior-authorization workflows.</p></div>"
              }
            }
          },
          {
            "fullUrl": "urn:uuid:72bd17bc-51f1-4c0d-93c8-0f9242fcd18b",
            "resource": {
              "resourceType": "QuestionnaireResponse",
              "id": "therapy-intake-draft",
              "meta": {
                "profile": [
                  "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse"
                ]
              },
              "extension": [
                {
                  "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-coverage",
                  "valueReference": {
                    "type": "Coverage",
                    "identifier": {
                      "system": "https://interop.hn1.com/fhir/identifier/coverage-id",
                      "value": "coverage-12345"
                    },
                    "display": "Coverage identified in the provider's questionnaire-package request"
                  }
                },
                {
                  "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse",
                  "valueCodeableConcept": {
                    "coding": [
                      {
                        "system": "http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes",
                        "code": "withpa",
                        "display": "Include in prior authorization"
                      }
                    ]
                  }
                },
                {
                  "url": "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context",
                  "valueReference": {
                    "type": "ServiceRequest",
                    "identifier": {
                      "system": "https://interop.hn1.com/fhir/identifier/service-request-id",
                      "value": "therapy-order-98765"
                    },
                    "display": "Therapy order identified in the provider's questionnaire-package request"
                  }
                }
              ],
              "identifier": {
                "system": "https://interop.hn1.com/fhir/identifier/questionnaire-response",
                "value": "therapy-intake-draft-example"
              },
              "questionnaire": "https://interop.hn1.com/fhir/Questionnaire/therapy-intake|1.0.0",
              "status": "in-progress",
              "subject": {
                "type": "Patient",
                "identifier": {
                  "system": "https://interop.hn1.com/fhir/identifier/member-id",
                  "value": "member-12345"
                },
                "display": "Patient identified in the provider's questionnaire-package request"
              },
              "authored": "2026-07-29T18:00:00+00:00",
              "text": {
                "status": "generated",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>HN1 Therapy Intake QuestionnaireResponse</b></p><p>Initial draft response supplied with the DTR questionnaire package.</p></div>"
              }
            }
          }
        ],
        "timestamp": "2026-07-29T18:00:00+00:00"
      }
    }
  ]
}