Examples with CarrierClaimLine gov.cms.bfd.model.rif.CarrierClaimLine used on opensource projects

Example 1 with CarrierClaimLine

use of gov.cms.bfd.model.rif.CarrierClaimLine in project beneficiary-fhir-data by CMSgov.

the class CarrierClaimTransformerV2 method transformClaim.

/**
 * @param claimGroup the CCW {@link CarrierClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     CarrierClaim}
 */
private static ExplanationOfBenefit transformClaim(CarrierClaim claimGroup, Optional<Boolean> includeTaxNumbers) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    // Required values not directly mapped
    eob.getMeta().addProfile(ProfileConstants.C4BB_EOB_NONCLINICIAN_PROFILE_URL);
    // TODO: ExplanationOfBenefit.outcome is a required field. Needs to be mapped.
    // eob.setOutcome(?)
    // Common group level fields between all claim types
    // Claim Type + Claim ID => ExplanationOfBenefit.id
    // CLM_ID => ExplanationOfBenefit.identifier
    // CLM_GRP_ID => ExplanationOfBenefit.identifier
    // BENE_ID + Coverage Type => ExplanationOfBenefit.insurance.coverage
    // (reference)
    // BENE_ID => ExplanationOfBenefit.patient (reference)
    // FINAL_ACTION => ExplanationOfBenefit.status
    // CLM_FROM_DT => ExplanationOfBenefit.billablePeriod.start
    // CLM_THRU_DT => ExplanationOfBenefit.billablePeriod.end
    // CLM_PMT_AMT => ExplanationOfBenefit.payment.amount
    TransformerUtilsV2.mapEobCommonClaimHeaderData(eob, claimGroup.getClaimId(), claimGroup.getBeneficiaryId(), ClaimTypeV2.CARRIER, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_B, Optional.of(claimGroup.getDateFrom()), Optional.of(claimGroup.getDateThrough()), Optional.of(claimGroup.getPaymentAmount()), claimGroup.getFinalAction());
    // NCH_WKLY_PROC_DT => ExplanationOfBenefit.supportinginfo.timingDate
    TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationRecievedDateSlice(eob, CcwCodebookVariable.NCH_WKLY_PROC_DT, Optional.of(claimGroup.getWeeklyProcessDate())));
    // map eob type codes into FHIR
    // NCH_CLM_TYPE_CD            => ExplanationOfBenefit.type.coding
    // EOB Type                   => ExplanationOfBenefit.type.coding
    // Claim Type (Professional)  => ExplanationOfBenefit.type.coding
    // NCH_NEAR_LINE_REC_IDENT_CD => ExplanationOfBenefit.extension
    TransformerUtilsV2.mapEobType(eob, ClaimTypeV2.CARRIER, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // CARR_CLM_PRMRY_PYR_PD_AMT => ExplanationOfBenefit.total.amount
    TransformerUtilsV2.addTotal(eob, TransformerUtilsV2.createTotalAdjudicationAmountSlice(eob, CcwCodebookVariable.CLM_TOT_CHRG_AMT, C4BBAdjudication.PRIOR_PAYER_PAID, claimGroup.getPrimaryPayerPaidAmount()));
    // Common group level fields between Carrier and DME
    // BENE_ID =>
    // CARR_NUM                       => ExplanationOfBenefit.extension
    // CLM_CLNCL_TRIL_NUM             => ExplanationOfBenefit.extension
    // CARR_CLM_CASH_DDCTBL_APLD_AMT  => ExplanationOfBenefit.benefitBalance.financial
    // CARR_CLM_PMT_DNL_CD            => ExplanationOfBenefit.extension
    // RFR_PHYSN_NPI                  => ExplanationOfBenefit.referral.identifier
    // => ExplanationOfBenefit.careteam.provider
    // RFR_PHYSN_UPIN                 => ExplanationOfBenefit.referral.identifier
    // => ExplanationOfBenefit.careteam.provider
    // CARR_CLM_PRVDR_ASGNMT_IND_SW   => ExplanationOfBenefit.extension
    // NCH_CLM_PRVDR_PMT_AMT          => ExplanationOfBenefit.benefitBalance.financial
    // NCH_CLM_BENE_PMT_AMT           => ExplanationOfBenefit.benefitBalance.financial
    // NCH_CARR_CLM_SBMTD_CHRG_AMT    => ExplanationOfBenefit.benefitBalance.financial
    // NCH_CARR_CLM_ALOWD_AMT         => ExplanationOfBenefit.benefitBalance.financial
    // CLM_DISP_CD                    => ExplanationOfBenefit.disposition
    // CARR_CLM_CNTL_NUM              => ExplanationOfBenefit.extension
    TransformerUtilsV2.mapEobCommonGroupCarrierDME(eob, claimGroup.getBeneficiaryId(), claimGroup.getCarrierNumber(), claimGroup.getClinicalTrialNumber(), claimGroup.getBeneficiaryPartBDeductAmount(), claimGroup.getPaymentDenialCode(), claimGroup.getReferringPhysicianNpi(), claimGroup.getReferringPhysicianUpin(), claimGroup.getProviderAssignmentIndicator(), claimGroup.getProviderPaymentAmount(), claimGroup.getBeneficiaryPaymentAmount(), claimGroup.getSubmittedChargeAmount(), claimGroup.getAllowedChargeAmount(), claimGroup.getClaimDispositionCode(), claimGroup.getClaimCarrierControlNumber());
    // ICD_DGNS_VRSN_CD(1-12) => diagnosis.diagnosisCodeableConcept
    for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
        DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.CARRIER);
    }
    // CARR_CLM_RFRNG_PIN_NUM => ExplanationOfBenefit.careteam.provider
    TransformerUtilsV2.addCareTeamMember(eob, C4BBPractitionerIdentifierType.NPI, C4BBClaimProfessionalAndNonClinicianCareTeamRole.REFERRING, Optional.ofNullable(claimGroup.getReferringProviderIdNumber()));
    // CARR_CLM_ENTRY_CD => ExplanationOfBenefit.extension
    eob.addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.CARR_CLM_ENTRY_CD, claimGroup.getClaimEntryCode()));
    // Process line items
    for (CarrierClaimLine line : claimGroup.getLines()) {
        ItemComponent item = eob.addItem();
        // LINE_NUM => ExplanationOfBenefit.item.sequence
        item.setSequence(line.getLineNumber().intValue());
        // PRF_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
        Optional<CareTeamComponent> performing = TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.NPI, C4BBClaimProfessionalAndNonClinicianCareTeamRole.PERFORMING, line.getPerformingPhysicianNpi());
        // Fall back to UPIN if NPI not present
        if (!line.getPerformingPhysicianNpi().isPresent()) {
            performing = TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.UPIN, C4BBClaimProfessionalAndNonClinicianCareTeamRole.PERFORMING, line.getPerformingPhysicianUpin());
        }
        // Update the responsible flag
        performing.ifPresent(p -> {
            p.setResponsible(true);
            // PRVDR_SPCLTY => ExplanationOfBenefit.careTeam.qualification
            p.setQualification(TransformerUtilsV2.createCodeableConcept(eob, CcwCodebookVariable.PRVDR_SPCLTY, line.getProviderSpecialityCode()));
            // CARR_LINE_PRVDR_TYPE_CD => ExplanationOfBenefit.careTeam.extension
            p.addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_PRVDR_TYPE_CD, line.getProviderTypeCode()));
            // PRTCPTNG_IND_CD => ExplanationOfBenefit.careTeam.extension
            p.addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.PRTCPTNG_IND_CD, line.getProviderParticipatingIndCode()));
        });
        // ORG_NPI_NUM => ExplanationOfBenefit.careTeam.provider
        TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.NPI, C4BBClaimProfessionalAndNonClinicianCareTeamRole.PRIMARY, line.getOrganizationNpi());
        // CARR_LINE_RDCD_PMT_PHYS_ASTN_C => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.CARR_LINE_RDCD_PMT_PHYS_ASTN_C, String.valueOf(line.getReducedPaymentPhysicianAsstCode())));
        // HCPCS_CD               => ExplanationOfBenefit.item.productOrService
        // HCPCS_1ST_MDFR_CD      => ExplanationOfBenefit.item.modifier
        // HCPCS_2ND_MDFR_CD      => ExplanationOfBenefit.item.modifier
        // CARR_CLM_HCPCS_YR_CD   => ExplanationOfBenefit.item.modifier.version
        TransformerUtilsV2.mapHcpcs(eob, item, line.getHcpcsCode(), claimGroup.getHcpcsYearCode(), Arrays.asList(line.getHcpcsInitialModifierCode(), line.getHcpcsSecondModifierCode()));
        // tax num should be as a extension
        if (includeTaxNumbers.orElse(false)) {
            item.addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.TAX_NUM, line.getProviderTaxNumber()));
        }
        // CARR_LINE_ANSTHSA_UNIT_CNT => ExplanationOfBenefit.item.extension
        if (line.getAnesthesiaUnitCount().compareTo(BigDecimal.ZERO) > 0) {
            item.addExtension(TransformerUtilsV2.createExtensionQuantity(CcwCodebookVariable.CARR_LINE_ANSTHSA_UNIT_CNT, line.getAnesthesiaUnitCount()));
        }
        // CARR_LINE_MTUS_CNT => ExplanationOfBenefit.item.extension
        if (!line.getMtusCount().equals(BigDecimal.ZERO)) {
            item.addExtension(TransformerUtilsV2.createExtensionQuantity(CcwCodebookVariable.CARR_LINE_MTUS_CNT, line.getMtusCount()));
        }
        // CARR_LINE_MTUS_CD => ExplanationOfBenefit.item.extension
        line.getMtusCode().ifPresent(code -> item.addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_MTUS_CNT, code)));
        // Common item level fields between Carrier and DME
        // LINE_SRVC_CNT            => ExplanationOfBenefit.item.quantity
        // LINE_CMS_TYPE_SRVC_CD    => ExplanationOfBenefit.item.category
        // LINE_PLACE_OF_SRVC_CD    => ExplanationOfBenefit.item.location
        // BETOS_CD                 => ExplanationOfBenefit.item.extension
        // LINE_1ST_EXPNS_DT        => ExplanationOfBenefit.item.servicedPeriod
        // LINE_LAST_EXPNS_DT       => ExplanationOfBenefit.item.servicedPeriod
        // LINE_NCH_PMT_AMT         => ExplanationOfBenefit.item.adjudication
        // LINE_PMT_80_100_CD       => ExplanationOfBenefit.item.adjudication.extension
        // PAID_TO_PATIENT          => ExplanationOfBenefit.item.adjudication
        // LINE_PRVDR_PMT_AMT       => ExplanationOfBenefit.item.adjudication
        // LINE_BENE_PTB_DDCTBL_AMT => ExplanationOfBenefit.item.adjudication
        // LINE_BENE_PRMRY_PYR_CD   => ExplanationOfBenefit.item.extension
        // LINE_BENE_PRMRY_PYR_PD_AMT => ExplanationOfBenefit.item.adjudication
        // LINE_COINSRNC_AMT        => ExplanationOfBenefit.item.adjudication
        // LINE_SBMTD_CHRG_AMT      => ExplanationOfBenefit.item.adjudication
        // LINE_ALOWD_CHRG_AMT      => ExplanationOfBenefit.item.adjudication
        // LINE_BENE_PRMRY_PYR_CD   => ExplanationOfBenefit.item.extension
        // LINE_SERVICE_DEDUCTIBLE  => ExplanationOfBenefit.item.extension
        // LINE_HCT_HGB_TYPE_CD     => Observation.code
        // LINE_HCT_HGB_RSLT_NUM    => Observation.value
        // LINE_NDC_CD              => ExplanationOfBenefit.item.productOrService
        TransformerUtilsV2.mapEobCommonItemCarrierDME(item, eob, claimGroup.getClaimId(), item.getSequence(), line.getServiceCount(), line.getPlaceOfServiceCode(), line.getFirstExpenseDate(), line.getLastExpenseDate(), line.getBeneficiaryPaymentAmount(), line.getProviderPaymentAmount(), line.getBeneficiaryPartBDeductAmount(), line.getPrimaryPayerCode(), line.getPrimaryPayerPaidAmount(), line.getBetosCode(), line.getPaymentAmount(), line.getPaymentCode(), line.getCoinsuranceAmount(), line.getSubmittedChargeAmount(), line.getAllowedChargeAmount(), line.getProcessingIndicatorCode(), line.getServiceDeductibleCode(), line.getHctHgbTestTypeCode(), line.getHctHgbTestResult(), line.getCmsServiceTypeCode(), line.getNationalDrugCode());
        // LINE_ICD_DGNS_CD      => ExplanationOfBenefit.item.diagnosisSequence
        // LINE_ICD_DGNS_VRSN_CD => ExplanationOfBenefit.item.diagnosisSequence
        DiagnosisUtilV2.addDiagnosisLink(eob, item, Diagnosis.from(line.getDiagnosisCode(), line.getDiagnosisCodeVersion(), DiagnosisLabel.OTHER), ClaimTypeV2.CARRIER);
        // PRVDR_STATE_CD => ExplanationOfBenefit.item.location.extension
        line.getProviderStateCode().ifPresent(code -> item.getLocation().addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.PRVDR_STATE_CD, code)));
        // PRVDR_ZIP => ExplanationOfBenefit.item.location.extension
        line.getProviderZipCode().ifPresent(code -> item.getLocation().addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.PRVDR_ZIP, code)));
        // CARR_LINE_PRCNG_LCLTY_CD => ExplanationOfBenefit.item.location.extension
        item.getLocation().addExtension(TransformerUtilsV2.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_PRCNG_LCLTY_CD, line.getLinePricingLocalityCode()));
        // CARR_LINE_CLIA_LAB_NUM => ExplanationOfBenefit.item.location.extension
        line.getCliaLabNumber().ifPresent(num -> item.getLocation().addExtension(TransformerUtilsV2.createExtensionIdentifier(CcwCodebookVariable.CARR_LINE_CLIA_LAB_NUM, num)));
    }
    TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}

Example 2 with CarrierClaimLine

use of gov.cms.bfd.model.rif.CarrierClaimLine in project beneficiary-fhir-data by CMSgov.

the class CarrierClaimTransformerTest method assertMatches.

/**
 * Verifies that the {@link ExplanationOfBenefit} "looks like" it should, if it were produced from
 * the specified {@link CarrierClaim}.
 *
 * @param claim the {@link CarrierClaim} that the {@link ExplanationOfBenefit} was generated from
 * @param eob the {@link ExplanationOfBenefit} that was generated from the specified {@link
 *     CarrierClaim}
 * @param includedTaxNumbers whether or not to include tax numbers are expected to be included in
 *     the result (see {@link
 *     ExplanationOfBenefitResourceProvider#HEADER_NAME_INCLUDE_TAX_NUMBERS}, defaults to <code>
 *     false</code>)
 * @throws FHIRException (indicates test failure)
 */
static void assertMatches(CarrierClaim claim, ExplanationOfBenefit eob, Optional<Boolean> includedTaxNumbers) throws FHIRException {
    // Test to ensure group level fields between all claim types match
    TransformerTestUtils.assertEobCommonClaimHeaderData(eob, claim.getClaimId(), claim.getBeneficiaryId(), ClaimType.CARRIER, claim.getClaimGroupId().toPlainString(), MedicareSegment.PART_B, Optional.of(claim.getDateFrom()), Optional.of(claim.getDateThrough()), Optional.of(claim.getPaymentAmount()), claim.getFinalAction());
    // Test to ensure common group fields between Carrier and DME match
    TransformerTestUtils.assertEobCommonGroupCarrierDMEEquals(eob, claim.getBeneficiaryId(), claim.getCarrierNumber(), claim.getClinicalTrialNumber(), claim.getBeneficiaryPartBDeductAmount(), claim.getPaymentDenialCode(), claim.getReferringPhysicianNpi(), claim.getProviderAssignmentIndicator(), claim.getProviderPaymentAmount(), claim.getBeneficiaryPaymentAmount(), claim.getSubmittedChargeAmount(), claim.getAllowedChargeAmount());
    assertEquals(5, eob.getDiagnosis().size());
    assertEquals(1, eob.getItem().size());
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.PRPAYAMT, claim.getPrimaryPayerPaidAmount(), eob);
    CarrierClaimLine claimLine1 = claim.getLines().get(0);
    ItemComponent eobItem0 = eob.getItem().get(0);
    assertEquals(claimLine1.getLineNumber(), new BigDecimal(eobItem0.getSequence()));
    TransformerTestUtils.assertCareTeamEquals(claimLine1.getPerformingPhysicianNpi().get(), ClaimCareteamrole.PRIMARY, eob);
    CareTeamComponent performingCareTeamEntry = TransformerTestUtils.findCareTeamEntryForProviderNpi(claimLine1.getPerformingPhysicianNpi().get(), eob.getCareTeam());
    TransformerTestUtils.assertHasCoding(CcwCodebookVariable.PRVDR_SPCLTY, claimLine1.getProviderSpecialityCode(), performingCareTeamEntry.getQualification());
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.CARR_LINE_PRVDR_TYPE_CD, claimLine1.getProviderTypeCode(), performingCareTeamEntry);
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.PRTCPTNG_IND_CD, claimLine1.getProviderParticipatingIndCode(), performingCareTeamEntry);
    TransformerTestUtils.assertExtensionCodingEquals(performingCareTeamEntry, TransformerConstants.CODING_NPI_US, TransformerConstants.CODING_NPI_US, "" + claimLine1.getOrganizationNpi().get());
    CareTeamComponent taxNumberCareTeamEntry = TransformerTestUtils.findCareTeamEntryForProviderTaxNumber(claimLine1.getProviderTaxNumber(), eob.getCareTeam());
    if (includedTaxNumbers.orElse(false)) {
        assertNotNull(taxNumberCareTeamEntry);
    } else {
        assertNull(taxNumberCareTeamEntry);
    }
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.PRVDR_STATE_CD, claimLine1.getProviderStateCode(), eobItem0.getLocation());
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.PRVDR_STATE_CD, claimLine1.getProviderStateCode(), eobItem0.getLocation());
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.CARR_LINE_PRCNG_LCLTY_CD, claimLine1.getLinePricingLocalityCode(), eobItem0.getLocation());
    TransformerTestUtils.assertHasCoding(TransformerConstants.CODING_SYSTEM_HCPCS, "" + claim.getHcpcsYearCode().get(), null, claimLine1.getHcpcsCode().get(), eobItem0.getService().getCoding());
    assertEquals(1, eobItem0.getModifier().size());
    TransformerTestUtils.assertHcpcsCodes(eobItem0, claimLine1.getHcpcsCode(), claimLine1.getHcpcsInitialModifierCode(), claimLine1.getHcpcsSecondModifierCode(), claim.getHcpcsYearCode(), 0);
    if (claimLine1.getAnesthesiaUnitCount().compareTo(BigDecimal.ZERO) > 0) {
        TransformerTestUtils.assertExtensionQuantityEquals(CcwCodebookVariable.CARR_LINE_ANSTHSA_UNIT_CNT, claimLine1.getAnesthesiaUnitCount(), eobItem0.getService());
    }
    TransformerTestUtils.assertExtensionCodingEquals(CcwCodebookVariable.CARR_LINE_MTUS_CD, claimLine1.getMtusCode(), eobItem0);
    TransformerTestUtils.assertExtensionQuantityEquals(CcwCodebookVariable.CARR_LINE_MTUS_CNT, claimLine1.getMtusCount(), eobItem0);
    TransformerTestUtils.assertAdjudicationReasonEquals(CcwCodebookVariable.CARR_LINE_RDCD_PMT_PHYS_ASTN_C, claimLine1.getReducedPaymentPhysicianAsstCode(), eobItem0.getAdjudication());
    TransformerTestUtils.assertExtensionIdentifierEquals(CcwCodebookVariable.CARR_LINE_CLIA_LAB_NUM, claimLine1.getCliaLabNumber(), eobItem0.getLocation());
    // verify {@link
    // TransformerUtils#mapEobType(CodeableConcept,ClaimType,Optional,Optional)}
    // method worked as expected for this claim type
    TransformerTestUtils.assertMapEobType(eob.getType(), ClaimType.CARRIER, Optional.of(org.hl7.fhir.dstu3.model.codesystems.ClaimType.PROFESSIONAL), Optional.of(claim.getNearLineRecordIdCode()), Optional.of(claim.getClaimTypeCode()));
    // Test to ensure common item fields between Carrier and DME match
    TransformerTestUtils.assertEobCommonItemCarrierDMEEquals(eobItem0, eob, claimLine1.getServiceCount(), claimLine1.getPlaceOfServiceCode(), claimLine1.getFirstExpenseDate(), claimLine1.getLastExpenseDate(), claimLine1.getBeneficiaryPaymentAmount(), claimLine1.getProviderPaymentAmount(), claimLine1.getBeneficiaryPartBDeductAmount(), claimLine1.getPrimaryPayerCode(), claimLine1.getPrimaryPayerPaidAmount(), claimLine1.getBetosCode(), claimLine1.getPaymentAmount(), claimLine1.getPaymentCode(), claimLine1.getCoinsuranceAmount(), claimLine1.getSubmittedChargeAmount(), claimLine1.getAllowedChargeAmount(), claimLine1.getProcessingIndicatorCode(), claimLine1.getServiceDeductibleCode(), claimLine1.getDiagnosisCode(), claimLine1.getDiagnosisCodeVersion(), claimLine1.getHctHgbTestTypeCode(), claimLine1.getHctHgbTestResult(), claimLine1.getCmsServiceTypeCode(), claimLine1.getNationalDrugCode());
    // Test lastUpdated
    TransformerTestUtils.assertLastUpdatedEquals(claim.getLastUpdated(), eob);
}

Example 3 with CarrierClaimLine

use of gov.cms.bfd.model.rif.CarrierClaimLine in project beneficiary-fhir-data by CMSgov.

the class RifFilesProcessorTest method process1CarrierClaimRecord.

/**
 * Ensures that {@link RifFilesProcessor} can correctly handle {@link
 * StaticRifResource#SAMPLE_A_CARRIER}.
 */
@Test
public void process1CarrierClaimRecord() {
    RifFilesEvent filesEvent = new RifFilesEvent(Instant.now(), StaticRifResource.SAMPLE_A_CARRIER.toRifFile());
    RifFilesProcessor processor = new RifFilesProcessor();
    RifFileRecords rifFileRecords = processor.produceRecords(filesEvent.getFileEvents().get(0));
    List<RifRecordEvent<?>> rifEventsList = rifFileRecords.getRecords().collect(Collectors.toList());
    assertEquals(StaticRifResource.SAMPLE_A_CARRIER.getRecordCount(), rifEventsList.size());
    RifRecordEvent<?> rifRecordEvent = rifEventsList.get(0);
    assertEquals(StaticRifResource.SAMPLE_A_CARRIER.getRifFileType(), rifRecordEvent.getFileEvent().getFile().getFileType());
    assertNotNull(rifRecordEvent.getRecord());
    assertTrue(rifRecordEvent.getRecord() instanceof CarrierClaim);
    // Verify the claim header.
    CarrierClaim claimGroup = (CarrierClaim) rifRecordEvent.getRecord();
    assertEquals(RecordAction.INSERT, rifRecordEvent.getRecordAction());
    assertEquals(claimGroup.getBeneficiaryId(), rifRecordEvent.getBeneficiaryId());
    assertEquals("567834", claimGroup.getBeneficiaryId());
    assertEquals("9991831999", claimGroup.getClaimId());
    assertEquals(new BigDecimal(900), claimGroup.getClaimGroupId());
    assertEquals('O', claimGroup.getNearLineRecordIdCode());
    assertEquals("71", claimGroup.getClaimTypeCode());
    assertEquals(LocalDate.of(1999, 10, 27), claimGroup.getDateFrom());
    assertEquals(LocalDate.of(1999, 10, 27), claimGroup.getDateThrough());
    assertEquals(LocalDate.of(1999, 11, 6), claimGroup.getWeeklyProcessDate());
    assertEquals('1', claimGroup.getClaimEntryCode());
    assertEquals("1", claimGroup.getClaimDispositionCode());
    assertEquals("61026", claimGroup.getCarrierNumber());
    assertEquals("1", claimGroup.getPaymentDenialCode());
    assertEquals(new BigDecimal("199.99"), claimGroup.getPaymentAmount());
    assertEquals(new BigDecimal("0"), claimGroup.getPrimaryPayerPaidAmount());
    assertEquals("1234534", claimGroup.getReferringPhysicianUpin().get());
    assertEquals("8765676", claimGroup.getReferringPhysicianNpi().get());
    assertEquals(new Character('A'), claimGroup.getProviderAssignmentIndicator().get());
    assertEquals(new BigDecimal("123.45"), claimGroup.getProviderPaymentAmount());
    assertEquals(new BigDecimal("888.00"), claimGroup.getBeneficiaryPaymentAmount());
    assertEquals(new BigDecimal("245.04"), claimGroup.getSubmittedChargeAmount());
    assertEquals(new BigDecimal("166.23"), claimGroup.getAllowedChargeAmount());
    assertEquals(new BigDecimal("777.00"), claimGroup.getBeneficiaryPartBDeductAmount());
    assertEquals(new Character('5'), claimGroup.getHcpcsYearCode().get());
    assertEquals("K25852", claimGroup.getReferringProviderIdNumber());
    assertEquals("H5555", claimGroup.getDiagnosisPrincipalCode().get());
    assertEquals(new Character('0'), claimGroup.getDiagnosisPrincipalCodeVersion().get());
    assertEquals("H5555", claimGroup.getDiagnosis1Code().get());
    assertEquals(new Character('0'), claimGroup.getDiagnosis1CodeVersion().get());
    assertEquals("H8888", claimGroup.getDiagnosis2Code().get());
    assertEquals(new Character('0'), claimGroup.getDiagnosis2CodeVersion().get());
    assertEquals("H66666", claimGroup.getDiagnosis3Code().get());
    assertEquals(new Character('0'), claimGroup.getDiagnosis3CodeVersion().get());
    assertEquals("H77777", claimGroup.getDiagnosis4Code().get());
    assertEquals(new Character('0'), claimGroup.getDiagnosis4CodeVersion().get());
    assertFalse(claimGroup.getDiagnosis5Code().isPresent());
    assertFalse(claimGroup.getDiagnosis5CodeVersion().isPresent());
    assertEquals(1, claimGroup.getLines().size());
    assertEquals("0", claimGroup.getClinicalTrialNumber().get());
    assertEquals("74655592568216", claimGroup.getClaimCarrierControlNumber().get());
    // Verify one of the claim lines.
    CarrierClaimLine claimLine = claimGroup.getLines().get(0);
    assertEquals(new BigDecimal(6), claimLine.getLineNumber());
    assertEquals("K25555", claimLine.getPerformingProviderIdNumber());
    assertFalse(claimLine.getPerformingPhysicianUpin().isPresent());
    assertEquals("1923124", claimLine.getPerformingPhysicianNpi().get());
    assertTrue(claimLine.getOrganizationNpi().isPresent());
    assertEquals('0', claimLine.getProviderTypeCode());
    assertEquals("204299999", claimLine.getProviderTaxNumber());
    assertEquals("IL", claimLine.getProviderStateCode().get());
    assertEquals("555558202", claimLine.getProviderZipCode().get());
    assertEquals("41", claimLine.getProviderSpecialityCode().get());
    assertEquals(new Character('1'), claimLine.getProviderParticipatingIndCode().get());
    assertEquals('0', claimLine.getReducedPaymentPhysicianAsstCode());
    assertEquals(new BigDecimal(1), claimLine.getServiceCount());
    assertEquals('1', claimLine.getCmsServiceTypeCode());
    assertEquals("11", claimLine.getPlaceOfServiceCode());
    assertEquals("15", claimLine.getLinePricingLocalityCode());
    assertEquals(LocalDate.of(1999, 10, 27), claimLine.getFirstExpenseDate().get());
    assertEquals(LocalDate.of(1999, 10, 27), claimLine.getLastExpenseDate().get());
    assertEquals("92999", claimLine.getHcpcsCode().get());
    assertTrue(claimLine.getHcpcsInitialModifierCode().isPresent());
    assertFalse(claimLine.getHcpcsSecondModifierCode().isPresent());
    assertEquals("T2D", claimLine.getBetosCode().get());
    assertEquals(new BigDecimal("37.5"), claimLine.getPaymentAmount());
    assertEquals(new BigDecimal("0"), claimLine.getBeneficiaryPaymentAmount());
    assertEquals(new BigDecimal("37.5"), claimLine.getProviderPaymentAmount());
    assertEquals(new BigDecimal("0"), claimLine.getBeneficiaryPartBDeductAmount());
    assertTrue(claimLine.getPrimaryPayerCode().isPresent());
    assertEquals(new BigDecimal("0"), claimLine.getPrimaryPayerPaidAmount());
    assertEquals(new BigDecimal("9.57"), claimLine.getCoinsuranceAmount());
    assertEquals(new BigDecimal("75"), claimLine.getSubmittedChargeAmount());
    assertEquals(new BigDecimal("47.84"), claimLine.getAllowedChargeAmount());
    assertEquals("A", claimLine.getProcessingIndicatorCode().get());
    assertEquals(new Character('0'), claimLine.getPaymentCode().get());
    assertEquals(new Character('0'), claimLine.getServiceDeductibleCode().get());
    assertEquals(new BigDecimal("1"), claimLine.getMtusCount());
    assertEquals(new Character('3'), claimLine.getMtusCode().get());
    assertEquals("H12345", claimLine.getDiagnosisCode().get());
    assertEquals(new Character('0'), claimLine.getDiagnosisCodeVersion().get());
    assertFalse(claimLine.getHpsaScarcityCode().isPresent());
    assertFalse(claimLine.getRxNumber().isPresent());
    assertEquals(new BigDecimal("42.0"), claimLine.getHctHgbTestResult());
    assertEquals("R1", claimLine.getHctHgbTestTypeCode().get());
    assertEquals("49035044700", claimLine.getNationalDrugCode().get());
    assertEquals("BB889999AA", claimLine.getCliaLabNumber().get());
    assertEquals(new BigDecimal(0), claimLine.getAnesthesiaUnitCount());
}

Example 4 with CarrierClaimLine

use of gov.cms.bfd.model.rif.CarrierClaimLine in project beneficiary-fhir-data by CMSgov.

the class RifLoaderIT method loadSampleU.

/**
 * Runs {@link RifLoader} against the {@link StaticRifResourceGroup#SAMPLE_U} data.
 */
@Test
@Disabled
public void loadSampleU() {
    loadSample(Arrays.asList(StaticRifResourceGroup.SAMPLE_A.getResources()));
    loadSample(Arrays.asList(StaticRifResourceGroup.SAMPLE_U.getResources()));
    verifyRecordPrimaryKeysPresent(Arrays.asList(StaticRifResourceGroup.SAMPLE_U.getResources()));
    // Ensure no records were skipped
    validateBeneficiaryAndSkippedCountsInDatabase(1, 0);
    /*
     * Verify that the updates worked as expected by manually checking some fields.
     */
    EntityManagerFactory entityManagerFactory = PipelineTestUtils.get().getPipelineApplicationState().getEntityManagerFactory();
    EntityManager entityManager = null;
    try {
        entityManager = entityManagerFactory.createEntityManager();
        CriteriaQuery<BeneficiaryHistory> beneficiaryHistoryCriteria = entityManager.getCriteriaBuilder().createQuery(BeneficiaryHistory.class);
        List<BeneficiaryHistory> beneficiaryHistoryEntries = entityManager.createQuery(beneficiaryHistoryCriteria.select(beneficiaryHistoryCriteria.from(BeneficiaryHistory.class))).getResultList();
        for (BeneficiaryHistory beneHistory : beneficiaryHistoryEntries) {
            assertEquals("567834", beneHistory.getBeneficiaryId());
            // A recent lastUpdated timestamp
            assertTrue(beneHistory.getLastUpdated().isPresent(), "Expected a lastUpdated field");
            beneHistory.getLastUpdated().ifPresent(lastUpdated -> {
                assertTrue(lastUpdated.isAfter(Instant.now().minus(10, ChronoUnit.MINUTES)), "Expected a recent lastUpdated timestamp");
            });
        }
        assertEquals(4, beneficiaryHistoryEntries.size());
        Beneficiary beneficiaryFromDb = entityManager.find(Beneficiary.class, "567834");
        // Last Name inserted with value of "Johnson"
        assertEquals("Johnson", beneficiaryFromDb.getNameSurname());
        // Following fields were NOT changed in update record
        assertEquals("John", beneficiaryFromDb.getNameGiven());
        assertEquals(new Character('A'), beneficiaryFromDb.getNameMiddleInitial().get());
        assertEquals(Optional.of("SSSS"), beneficiaryFromDb.getMedicareBeneficiaryId(), "Beneficiary has MBI");
        assertEquals(Optional.of("401441595efcc68bc5b26f4e88bd9fa550004e068d69ff75761ab946ec553a02"), beneficiaryFromDb.getMbiHash(), "Beneficiary has mbiHash");
        // A recent lastUpdated timestamp
        assertTrue(beneficiaryFromDb.getLastUpdated().isPresent(), "Expected a lastUpdated field");
        beneficiaryFromDb.getLastUpdated().ifPresent(lastUpdated -> {
            assertTrue(lastUpdated.isAfter(Instant.now().minus(1, ChronoUnit.MINUTES)), "Expected a recent lastUpdated timestamp");
        });
        CarrierClaim carrierRecordFromDb = entityManager.find(CarrierClaim.class, "9991831999");
        assertEquals('N', carrierRecordFromDb.getFinalAction());
        // DateThrough inserted with value 10-27-1999
        assertEquals(LocalDate.of(2000, Month.OCTOBER, 27), carrierRecordFromDb.getDateThrough());
        assertEquals(1, carrierRecordFromDb.getLines().size());
        // A recent lastUpdated timestamp
        assertTrue(carrierRecordFromDb.getLastUpdated().isPresent(), "Expected a lastUpdated field");
        carrierRecordFromDb.getLastUpdated().ifPresent(lastUpdated -> {
            assertTrue(lastUpdated.isAfter(Instant.now().minus(1, ChronoUnit.MINUTES)), "Expected a recent lastUpdated timestamp");
        });
        CarrierClaimLine carrierLineRecordFromDb = carrierRecordFromDb.getLines().get(0);
        // CliaLabNumber inserted with value BB889999AA
        assertEquals("GG443333HH", carrierLineRecordFromDb.getCliaLabNumber().get());
    } finally {
        if (entityManager != null)
            entityManager.close();
    }
}

Example 5 with CarrierClaimLine

use of gov.cms.bfd.model.rif.CarrierClaimLine in project beneficiary-fhir-data by CMSgov.

the class CarrierClaimTransformer method transformClaim.

/**
 * @param claimGroup the CCW {@link CarrierClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     CarrierClaim}
 */
private static ExplanationOfBenefit transformClaim(CarrierClaim claimGroup, Optional<Boolean> includeTaxNumbers) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    // Common group level fields between all claim types
    TransformerUtils.mapEobCommonClaimHeaderData(eob, claimGroup.getClaimId(), claimGroup.getBeneficiaryId(), ClaimType.CARRIER, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_B, Optional.of(claimGroup.getDateFrom()), Optional.of(claimGroup.getDateThrough()), Optional.of(claimGroup.getPaymentAmount()), claimGroup.getFinalAction());
    TransformerUtils.mapEobWeeklyProcessDate(eob, claimGroup.getWeeklyProcessDate());
    // map eob type codes into FHIR
    TransformerUtils.mapEobType(eob, ClaimType.CARRIER, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    TransformerUtils.addAdjudicationTotal(eob, CcwCodebookVariable.PRPAYAMT, claimGroup.getPrimaryPayerPaidAmount());
    // Common group level fields between Carrier and DME
    TransformerUtils.mapEobCommonGroupCarrierDME(eob, claimGroup.getBeneficiaryId(), claimGroup.getCarrierNumber(), claimGroup.getClinicalTrialNumber(), claimGroup.getBeneficiaryPartBDeductAmount(), claimGroup.getPaymentDenialCode(), claimGroup.getReferringPhysicianNpi(), claimGroup.getProviderAssignmentIndicator(), claimGroup.getProviderPaymentAmount(), claimGroup.getBeneficiaryPaymentAmount(), claimGroup.getSubmittedChargeAmount(), claimGroup.getAllowedChargeAmount(), claimGroup.getClaimDispositionCode(), claimGroup.getClaimCarrierControlNumber());
    for (Diagnosis diagnosis : TransformerUtils.extractDiagnoses1Thru12(claimGroup.getDiagnosisPrincipalCode(), claimGroup.getDiagnosisPrincipalCodeVersion(), claimGroup.getDiagnosis1Code(), claimGroup.getDiagnosis1CodeVersion(), claimGroup.getDiagnosis2Code(), claimGroup.getDiagnosis2CodeVersion(), claimGroup.getDiagnosis3Code(), claimGroup.getDiagnosis3CodeVersion(), claimGroup.getDiagnosis4Code(), claimGroup.getDiagnosis4CodeVersion(), claimGroup.getDiagnosis5Code(), claimGroup.getDiagnosis5CodeVersion(), claimGroup.getDiagnosis6Code(), claimGroup.getDiagnosis6CodeVersion(), claimGroup.getDiagnosis7Code(), claimGroup.getDiagnosis7CodeVersion(), claimGroup.getDiagnosis8Code(), claimGroup.getDiagnosis8CodeVersion(), claimGroup.getDiagnosis9Code(), claimGroup.getDiagnosis9CodeVersion(), claimGroup.getDiagnosis10Code(), claimGroup.getDiagnosis10CodeVersion(), claimGroup.getDiagnosis11Code(), claimGroup.getDiagnosis11CodeVersion(), claimGroup.getDiagnosis12Code(), claimGroup.getDiagnosis12CodeVersion())) TransformerUtils.addDiagnosisCode(eob, diagnosis);
    for (CarrierClaimLine claimLine : claimGroup.getLines()) {
        ItemComponent item = eob.addItem();
        item.setSequence(claimLine.getLineNumber().intValue());
        /*
       * Per Michelle at GDIT, and also Tony Dean at OEDA, the performing provider _should_ always
       * be present. However, we've found some examples in production where it's not for some claim
       * lines. (This is annoying, as it's present on other lines in the same claim, and the data
       * indicates that the same NPI probably applies to the lines where it's not specified. Still,
       * it's not safe to guess at this, so we'll leave it blank.)
       */
        if (claimLine.getPerformingPhysicianNpi().isPresent()) {
            ExplanationOfBenefit.CareTeamComponent performingCareTeamMember = TransformerUtils.addCareTeamPractitioner(eob, item, TransformerConstants.CODING_NPI_US, claimLine.getPerformingPhysicianNpi().get(), ClaimCareteamrole.PRIMARY);
            performingCareTeamMember.setResponsible(true);
            /*
         * The provider's "specialty" and "type" code are equivalent. However, the "specialty" codes
         * are more granular, and seem to better match the example FHIR
         * `http://hl7.org/fhir/ex-providerqualification` code set. Accordingly, we map the
         * "specialty" codes to the `qualification` field here, and stick the "type" code into an
         * extension. TODO: suggest that the spec allows more than one `qualification` entry.
         */
            performingCareTeamMember.setQualification(TransformerUtils.createCodeableConcept(eob, CcwCodebookVariable.PRVDR_SPCLTY, claimLine.getProviderSpecialityCode()));
            performingCareTeamMember.addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_PRVDR_TYPE_CD, claimLine.getProviderTypeCode()));
            performingCareTeamMember.addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.PRTCPTNG_IND_CD, claimLine.getProviderParticipatingIndCode()));
            // addExtensionReference
            if (claimLine.getOrganizationNpi().isPresent()) {
                TransformerUtils.addExtensionCoding(performingCareTeamMember, TransformerConstants.CODING_NPI_US, TransformerConstants.CODING_NPI_US, TransformerUtils.retrieveNpiCodeDisplay(claimLine.getOrganizationNpi().get()), "" + claimLine.getOrganizationNpi().get());
            }
        }
        /*
       * FIXME This value seems to be just a "synonym" for the performing physician NPI and should
       * probably be mapped as an extra identifier with it (if/when that lands in a contained
       * Practitioner resource).
       */
        if (includeTaxNumbers.orElse(false)) {
            ExplanationOfBenefit.CareTeamComponent providerTaxNumber = TransformerUtils.addCareTeamPractitioner(eob, item, IdentifierType.TAX.getSystem(), claimLine.getProviderTaxNumber(), ClaimCareteamrole.OTHER);
            providerTaxNumber.setResponsible(true);
        }
        item.addAdjudication(TransformerUtils.createAdjudicationWithReason(eob, CcwCodebookVariable.CARR_LINE_RDCD_PMT_PHYS_ASTN_C, claimLine.getReducedPaymentPhysicianAsstCode()));
        TransformerUtils.mapHcpcs(eob, item, claimGroup.getHcpcsYearCode(), claimLine.getHcpcsCode(), Arrays.asList(claimLine.getHcpcsInitialModifierCode(), claimLine.getHcpcsSecondModifierCode()));
        if (claimLine.getAnesthesiaUnitCount().compareTo(BigDecimal.ZERO) > 0) {
            item.getService().addExtension(TransformerUtils.createExtensionQuantity(CcwCodebookVariable.CARR_LINE_ANSTHSA_UNIT_CNT, claimLine.getAnesthesiaUnitCount()));
        }
        if (claimLine.getMtusCode().isPresent()) {
            item.addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_MTUS_CD, claimLine.getMtusCode()));
        }
        if (!claimLine.getMtusCount().equals(BigDecimal.ZERO)) {
            item.addExtension(TransformerUtils.createExtensionQuantity(CcwCodebookVariable.CARR_LINE_MTUS_CNT, claimLine.getMtusCount()));
        }
        // Common item level fields between Carrier and DME
        TransformerUtils.mapEobCommonItemCarrierDME(item, eob, claimGroup.getClaimId(), claimLine.getServiceCount(), claimLine.getPlaceOfServiceCode(), claimLine.getFirstExpenseDate(), claimLine.getLastExpenseDate(), claimLine.getBeneficiaryPaymentAmount(), claimLine.getProviderPaymentAmount(), claimLine.getBeneficiaryPartBDeductAmount(), claimLine.getPrimaryPayerCode(), claimLine.getPrimaryPayerPaidAmount(), claimLine.getBetosCode(), claimLine.getPaymentAmount(), claimLine.getPaymentCode(), claimLine.getCoinsuranceAmount(), claimLine.getSubmittedChargeAmount(), claimLine.getAllowedChargeAmount(), claimLine.getProcessingIndicatorCode(), claimLine.getServiceDeductibleCode(), claimLine.getDiagnosisCode(), claimLine.getDiagnosisCodeVersion(), claimLine.getHctHgbTestTypeCode(), claimLine.getHctHgbTestResult(), claimLine.getCmsServiceTypeCode(), claimLine.getNationalDrugCode());
        if (claimLine.getProviderStateCode().isPresent()) {
            item.getLocation().addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.PRVDR_STATE_CD, claimLine.getProviderStateCode()));
        }
        if (claimLine.getProviderZipCode().isPresent()) {
            item.getLocation().addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.PRVDR_ZIP, claimLine.getProviderZipCode()));
        }
        item.getLocation().addExtension(TransformerUtils.createExtensionCoding(eob, CcwCodebookVariable.CARR_LINE_PRCNG_LCLTY_CD, claimLine.getLinePricingLocalityCode()));
        if (claimLine.getCliaLabNumber().isPresent()) {
            item.getLocation().addExtension(TransformerUtils.createExtensionIdentifier(CcwCodebookVariable.CARR_LINE_CLIA_LAB_NUM, claimLine.getCliaLabNumber()));
        }
    }
    TransformerUtils.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}