> ## Documentation Index
> Fetch the complete documentation index at: https://simplex.sh/docs/llms.txt
> Use this file to discover all available pages before exploring further.

# Get Clinical Questions

> Resolve the payer-specific clinical question set for a pharmacy claim.

`get_clinical_questions` takes a pharmacy claim tuple, pins down the line of business and indication, and returns the payer's clinical question set — each question carrying a structured `citation` back to the underlying policy.

Pass the resolved questions and the user's answers as `clinical_answers` on [Fill Prior Authorization](/docs/payer-portal-api/fax/fill-pa).

## Parameters

| Name        | Type   | Required | Description                                                                                                                                                      |
| ----------- | ------ | -------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| `bin`       | string | yes      | Pharmacy claim BIN (6 digits).                                                                                                                                   |
| `state`     | string | yes      | Two-letter state code for the member (e.g. `"CA"`).                                                                                                              |
| `drug_name` | string | yes      | Drug brand (e.g. `"wegovy"`). Use [Search Drugs](/docs/prior-auth-sdk/search-drugs) if the caller only has a free-text string.                                        |
| `icd_code`  | string | yes      | ICD-10 diagnosis code (e.g. `"E66.01"`).                                                                                                                         |
| `pcn`       | string | no       | Processor control number. Tiebreaker for shared-processor BINs.                                                                                                  |
| `group_id`  | string | no       | Group ID. Tiebreaker for shared-processor BINs.                                                                                                                  |
| `member_id` | string | no       | Member ID. The leading alpha prefix often disambiguates LOBs on shared BIN/PCN pairs (e.g. BIN `003858` / PCN `A4` hosts both ESI Commercial and Humana Part D). |

## Example

<Tabs>
  <Tab title="Python">
    ```python theme={null}
    from simplex import (
        ClinicalQuestion,
        ClinicalQuestionCitation,
        ClinicalQuestionsRouting,
        GetClinicalQuestionsResponse,
        SimplexClient,
        SimplexError,
    )

    client = SimplexClient()

    try:
        response: GetClinicalQuestionsResponse = client.get_clinical_questions(
            bin="003858",
            state="CA",
            drug_name="wegovy",
            icd_code="E66.01",
            pcn="A4",
            member_id="4XS1234567",
        )

        print("matched:", response.get("matched"))
        print("coverage_status:", response.get("coverage_status"))
        print("lob_id:", response.get("lob_id"))

        routing: ClinicalQuestionsRouting = response.get("routing") or {}
        print(f"PBM: {routing.get('pbm_name')}")
        print(f"LOB: {routing.get('line_of_business')}")
        print(f"Plan/Group: {routing.get('plan_name_or_group')}")
        print(f"Confidence: {routing.get('confidence')}")

        questions: list[ClinicalQuestion] = response.get("questions") or []
        for i, q in enumerate(questions, 1):
            req = "required" if q.get("required") else "optional"
            print(f"{i}. [{q.get('input_type')}, {req}] {q.get('prompt')}")
            citation: ClinicalQuestionCitation | None = q.get("citation")
            if citation:
                print(
                    f"   ↳ {citation.get('policy_id')} "
                    f"§{citation.get('section')} "
                    f"({citation.get('effective_date')})"
                )
    except SimplexError as e:
        print(f"Simplex error: {e}")
    ```
  </Tab>

  <Tab title="TypeScript">
    ```typescript theme={null}
    import { SimplexClient, SimplexError } from "simplex-ts";

    const client = new SimplexClient();

    try {
      const response = await client.getClinicalQuestions({
        bin: "003858",
        state: "CA",
        drugName: "wegovy",
        icdCode: "E66.01",
        pcn: "A4",
        memberId: "4XS1234567",
      });

      console.log("matched:", response.matched);
      console.log("coverage_status:", response.coverageStatus);
      console.log("lob_id:", response.lobId);

      const { routing } = response;
      console.log(`PBM: ${routing?.pbmName}`);
      console.log(`LOB: ${routing?.lineOfBusiness}`);
      console.log(`Plan/Group: ${routing?.planNameOrGroup}`);
      console.log(`Confidence: ${routing?.confidence}`);

      (response.questions ?? []).forEach((q, i) => {
        const req = q.required ? "required" : "optional";
        console.log(`${i + 1}. [${q.inputType}, ${req}] ${q.prompt}`);
        if (q.citation) {
          console.log(
            `   ↳ ${q.citation.policyId} §${q.citation.section} ` +
              `(${q.citation.effectiveDate})`
          );
        }
      });
    } catch (e) {
      if (e instanceof SimplexError) {
        console.error(`Simplex error: ${e.message}`);
      }
    }
    ```
  </Tab>
</Tabs>

## Response

| Field             | Type    | Description                                                                                        |
| ----------------- | ------- | -------------------------------------------------------------------------------------------------- |
| `matched`         | boolean | Whether the tuple resolved to a specific LOB/policy.                                               |
| `coverage_status` | string  | Coverage verdict for the drug under the resolved plan (e.g. `"covered_with_pa"`, `"not_covered"`). |
| `lob_id`          | string  | Internal identifier for the resolved line of business.                                             |
| `rationale`       | string  | Human-readable explanation of how the claim tuple was routed.                                      |
| `routing`         | object  | `pbm_name`, `line_of_business`, `plan_name_or_group`, `confidence`.                                |
| `questions`       | array   | Clinical questions the payer requires for this drug + indication.                                  |
| `sources`         | array   | Policy documents consulted, with `source_name` and `fetch_timestamp`.                              |

### Question shape

Each entry in `questions` has:

| Field        | Type    | Description                                                                                          |
| ------------ | ------- | ---------------------------------------------------------------------------------------------------- |
| `prompt`     | string  | The question text, as written in payer policy.                                                       |
| `input_type` | string  | `"boolean"`, `"text"`, `"number"`, `"date"`, or `"choice"`.                                          |
| `required`   | boolean | Whether the payer treats this answer as mandatory.                                                   |
| `citation`   | object  | `policy_id`, `section`, `effective_date`, `url`, `verbatim_quote` — show to reviewers as the source. |

```json theme={null}
{
  "matched": true,
  "coverage_status": "covered_with_pa",
  "lob_id": "esi_commercial_std",
  "routing": {
    "pbm_name": "Express Scripts",
    "line_of_business": "Commercial",
    "plan_name_or_group": "ESI Commercial Standard Formulary",
    "confidence": "high"
  },
  "questions": [
    {
      "prompt": "Does the patient have a BMI ≥ 30 kg/m²?",
      "input_type": "boolean",
      "required": true,
      "citation": {
        "policy_id": "ESI-OBES-2024-03",
        "section": "Coverage Criteria §2.a",
        "effective_date": "2024-03-01"
      }
    }
  ]
}
```

## Next step

Combine the patient/prescriber/drug data with the user's answers to these questions and call [Fill Prior Authorization](/docs/payer-portal-api/fax/fill-pa).