HN1 Therapy Intake Questionnaire

Electronic therapy intake questionnaire for HN1 utilization-management and prior-authorization workflows.

 <status value="active" /> <subjectType value="Patient" /> <date value="2026-07-29" /> <publisher value="HN1" /> <description value="Collects the therapy intake information required to support HN1 utilization management and prior authorization workflows." /> <purpose value="Provide a standardized electronic representation of the HN1 therapy intake form for use in the Da Vinci DTR workflow." /> <copyright value="Copyright HN1. All rights reserved." /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-supportHyperlink"> <extension url="label"> <valueString value="View the Therapy Intake Form (PDF)" /> </extension> <extension url="link"> <valueUri value="https://interop.hn1.com/docs/therapy-intake.pdf" /> </extension> </extension> <linkId value="therapy-intake-pdf" /> <text value="Reference Form" /> <type value="display" /> </item> <item> <linkId value="request-information" /> <text value="Request Information" /> <type value="group" /> <item> <linkId value="request-priority" /> <text value="Request Priority" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="routine" /> <display value="Routine" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="urgent" /> <display value="Urgent" /> </valueCoding> </answerOption> </item> <item> <linkId value="request-date" /> <text value="Request Date" /> <type value="date" /> <required value="true" /> </item> </item> <item> <linkId value="member-information" /> <text value="Member Information" /> <type value="group" /> <item> <linkId value="member-id" /> <text value="Member ID Number" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="member-health-plan" /> <text value="Member Health Plan" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="member-last-name" /> <text value="Member Last Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="member-first-name" /> <text value="Member First Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="member-telephone" /> <text value="Member Telephone Number" /> <type value="string" /> </item> <item> <linkId value="member-date-of-birth" /> <text value="Member Date of Birth" /> <type value="date" /> <required value="true" /> </item> <item> <linkId value="member-sex" /> <text value="Sex" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="male" /> <display value="Male" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="female" /> <display value="Female" /> </valueCoding> </answerOption> </item> </item> <item> <linkId value="referring-provider" /> <text value="Referring Provider" /> <type value="group" /> <item> <linkId value="referring-provider-name" /> <text value="Referring Provider Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="referring-provider-phone" /> <text value="Phone Number" /> <type value="string" /> </item> <item> <linkId value="referring-provider-fax" /> <text value="Fax Number" /> <type value="string" /> </item> <item> <linkId value="referring-provider-npi" /> <text value="Referring Provider NPI" /> <type value="string" /> <required value="true" /> </item> </item> <item> <linkId value="rendering-provider" /> <text value="Rendering Provider" /> <type value="group" /> <item> <linkId value="facility-name" /> <text value="Facility/Group Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="facility-tin" /> <text value="Facility/Group TIN Number" /> <type value="string" /> </item> <item> <linkId value="facility-address" /> <text value="Facility/Group Address" /> <type value="string" /> </item> <item> <linkId value="facility-city" /> <text value="City" /> <type value="string" /> </item> <item> <linkId value="facility-zip" /> <text value="Zip Code" /> <type value="string" /> </item> <item> <linkId value="facility-npi" /> <text value="Facility/Group NPI" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="facility-contact-name" /> <text value="Contact Person Name" /> <type value="string" /> </item> <item> <linkId value="facility-phone" /> <text value="Phone Number" /> <type value="string" /> </item> <item> <linkId value="facility-fax" /> <text value="Fax Number" /> <type value="string" /> </item> </item> <item> <linkId value="treating-therapist" /> <text value="Treating Therapist" /> <type value="group" /> <item> <linkId value="therapist-last-name" /> <text value="Treating Therapist Last Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="therapist-first-name" /> <text value="Treating Therapist First Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="therapist-npi" /> <text value="Treating Therapist NPI" /> <type value="string" /> <required value="true" /> </item> </item> <item> <linkId value="clinical-information" /> <text value="Clinical Information" /> <type value="group" /> <item> <linkId value="line-of-business" /> <text value="Line of Business" /> <type value="choice" /> <required value="true" /> <answerOption> <valueString value="Medicare" /> </answerOption> </item> <item> <linkId value="place-of-service" /> <text value="Place of Service" /> <type value="choice" /> <required value="true" /> <answerOption> <valueString value="11 - Office" /> </answerOption> <answerOption> <valueString value="12 - Home" /> </answerOption> <answerOption> <valueString value="22 - Outpatient Hospital" /> </answerOption> <answerOption> <valueString value="49 - Independent Clinic" /> </answerOption> <answerOption> <valueString value="Other" /> </answerOption> </item> <item> <linkId value="other-place-of-service" /> <text value="Other Place of Service" /> <type value="string" /> <enableWhen> <question value="place-of-service" /> <operator value="=" /> <answerString value="Other" /> </enableWhen> </item> <item> <linkId value="primary-diagnosis-description" /> <text value="Primary Diagnosis Description" /> <type value="text" /> <required value="true" /> </item> <item> <linkId value="icd-code" /> <text value="ICD Code" /> <type value="string" /> <required value="true" /> <repeats value="true" /> </item> <item> <linkId value="cpt-code" /> <text value="CPT Code" /> <type value="string" /> <required value="true" /> <repeats value="true" /> </item> <item> <linkId value="status-post-surgery" /> <text value="Status Post Surgery" /> <type value="boolean" /> </item> <item> <linkId value="surgery-procedure" /> <text value="If Status Post Surgery, List Procedure" /> <type value="string" /> <enableWhen> <question value="status-post-surgery" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> </item> <item> <linkId value="surgery-date" /> <text value="Date of Surgery" /> <type value="date" /> <enableWhen> <question value="status-post-surgery" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> </item> <item> <linkId value="cva-date" /> <text value="Date of CVA" /> <type value="date" /> </item> </item> <item> <linkId value="plan-of-care" /> <text value="Plan of Care" /> <type value="group" /> <item> <linkId value="plan-of-care-approved" /> <text value="The Plan of Care has been submitted and approved by the ordering provider." /> <type value="boolean" /> <required value="true" /> </item> <item> <linkId value="frequency-per-week" /> <text value="Frequency: Times per Week" /> <type value="integer" /> <required value="true" /> </item> <item> <linkId value="duration-weeks" /> <text value="Duration: Number of Weeks" /> <type value="integer" /> <required value="true" /> </item> <item> <linkId value="plan-reviewed-with-member" /> <text value="The servicing provider reviewed the approved Plan of Care with the enrollee." /> <type value="boolean" /> <required value="true" /> </item> <item> <linkId value="ordering-provider-notification" /> <text value="The ordering provider will be notified when therapy is completed or stopped." /> <type value="boolean" /> <required value="true" /> </item> </item> <item> <linkId value="therapy-information" /> <text value="Therapy Information" /> <type value="group" /> <item> <linkId value="therapy-discipline" /> <text value="Therapy Discipline" /> <type value="choice" /> <required value="true" /> <answerOption> <valueString value="Physical Therapy" /> </answerOption> <answerOption> <valueString value="Occupational Therapy" /> </answerOption> <answerOption> <valueString value="Speech Therapy" /> </answerOption> <answerOption> <valueString value="Aquatic Therapy" /> </answerOption> <answerOption> <valueString value="Vestibular" /> </answerOption> <answerOption> <valueString value="Lymphedema" /> </answerOption> </item> <item> <linkId value="evaluation-date" /> <text value="Evaluation Date" /> <type value="date" /> <required value="true" /> </item> <item> <linkId value="episode-type" /> <text value="Episode Type" /> <type value="choice" /> <required value="true" /> <answerOption> <valueString value="Initial Review" /> </answerOption> <answerOption> <valueString value="Subsequent Episode" /> </answerOption> </item> <item> <linkId value="episode-number" /> <text value="Episode Number" /> <type value="integer" /> <enableWhen> <question value="episode-type" /> <operator value="=" /> <answerString value="Subsequent Episode" /> </enableWhen> </item> <item> <linkId value="previous-evaluation-date" /> <text value="Previous Evaluation Date" /> <type value="date" /> <repeats value="true" /> </item> <item> <linkId value="notes-comments" /> <text value="Note/Comments" /> <type value="text" /> </item> </item> <item> <linkId value="attestation" /> <text value="Attestation" /> <type value="group" /> <item> <linkId value="attestation-confirmed" /> <text value="I attest that the information provided is accurate and truthful." /> <type value="boolean" /> <required value="true" /> </item> <item> <linkId value="authorized-representative-name" /> <text value="Provider or Authorized Representative Print Name" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="attestation-date" /> <text value="Attestation Date" /> <type value="date" /> <required value="true" /> </item> </item> </Questionnaire> </resource> </entry> <entry> <fullUrl value="urn:uuid:72bd17bc-51f1-4c0d-93c8-0f9242fcd18b" /> <resource> <QuestionnaireResponse> <id value="therapy-intake-draft" /> <meta> <profile value="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaireresponse" /> </meta> <text> <status value="generated" /> <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> </text> <extension url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-coverage"> <valueReference> <type value="Coverage" /> <identifier> <system value="https://interop.hn1.com/fhir/identifier/coverage-id" /> <value value="coverage-12345" /> </identifier> <display value="Coverage identified in the provider's questionnaire-package request" /> </valueReference> </extension> <extension url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/intendedUse"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/us/davinci-crd/CodeSystem/coverage-information-codes" /> <code value="withpa" /> <display value="Include in prior authorization" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/qr-context"> <valueReference> <type value="ServiceRequest" /> <identifier> <system value="https://interop.hn1.com/fhir/identifier/service-request-id" /> <value value="therapy-order-98765" /> </identifier> <display value="Therapy order identified in the provider's questionnaire-package request" /> </valueReference> </extension> <identifier> <system value="https://interop.hn1.com/fhir/identifier/questionnaire-response" /> <value value="therapy-intake-draft-example" /> </identifier> <questionnaire value="https://interop.hn1.com/fhir/Questionnaire/therapy-intake|1.0.0" /> <status value="in-progress" /> <subject> <type value="Patient" /> <identifier> <system value="https://interop.hn1.com/fhir/identifier/member-id" /> <value value="member-12345" /> </identifier> <display value="Patient identified in the provider's questionnaire-package request" /> </subject> <authored value="2026-07-29T14:00:00-04:00" /> </QuestionnaireResponse> </resource> </entry> </Bundle> </resource> </parameter> </Parameters>