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

Example 1 with SNFClaimLine

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

the class SNFClaimTransformer method transformClaim.

/**
 * @param claimGroup the CCW {@link SNFClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     SNFClaim}
 */
private static ExplanationOfBenefit transformClaim(SNFClaim claimGroup) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    // Common group level fields between all claim types
    TransformerUtils.mapEobCommonClaimHeaderData(eob, claimGroup.getClaimId(), claimGroup.getBeneficiaryId(), ClaimType.SNF, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, 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.SNF, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // set the provider number which is common among several claim types
    TransformerUtils.setProviderNumber(eob, claimGroup.getProviderNumber());
    // add EOB information to fields that are common between the Inpatient and SNF claim types
    TransformerUtils.addCommonEobInformationInpatientSNF(eob, claimGroup.getAdmissionTypeCd(), claimGroup.getSourceAdmissionCd(), claimGroup.getNoncoveredStayFromDate(), claimGroup.getNoncoveredStayThroughDate(), claimGroup.getCoveredCareThroughDate(), claimGroup.getMedicareBenefitsExhaustedDate(), claimGroup.getDiagnosisRelatedGroupCd());
    if (claimGroup.getPatientStatusCd().isPresent()) {
        TransformerUtils.addInformationWithCode(eob, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, claimGroup.getPatientStatusCd().get());
    }
    // Common group level fields between Inpatient, HHA, Hospice and SNF
    TransformerUtils.mapEobCommonGroupInpHHAHospiceSNF(eob, claimGroup.getClaimAdmissionDate(), claimGroup.getBeneficiaryDischargeDate(), Optional.of(claimGroup.getUtilizationDayCount()));
    /*
     * add field values to the benefit balances that are common between the
     * Inpatient and SNF claim types
     */
    TransformerUtils.addCommonGroupInpatientSNF(eob, claimGroup.getCoinsuranceDayCount(), claimGroup.getNonUtilizationDayCount(), claimGroup.getDeductibleAmount(), claimGroup.getPartACoinsuranceLiabilityAmount(), claimGroup.getBloodPintsFurnishedQty(), claimGroup.getNoncoveredCharge(), claimGroup.getTotalDeductionAmount(), claimGroup.getClaimPPSCapitalDisproportionateShareAmt(), claimGroup.getClaimPPSCapitalExceptionAmount(), claimGroup.getClaimPPSCapitalFSPAmount(), claimGroup.getClaimPPSCapitalIMEAmount(), claimGroup.getClaimPPSCapitalOutlierAmount(), claimGroup.getClaimPPSOldCapitalHoldHarmlessAmount());
    if (claimGroup.getQualifiedStayFromDate().isPresent() || claimGroup.getQualifiedStayThroughDate().isPresent()) {
        TransformerUtils.validatePeriodDates(claimGroup.getQualifiedStayFromDate(), claimGroup.getQualifiedStayThroughDate());
        SupportingInformationComponent nchQlfydStayInfo = TransformerUtils.addInformation(eob, CcwCodebookVariable.NCH_QLFYD_STAY_FROM_DT);
        Period nchQlfydStayPeriod = new Period();
        if (claimGroup.getQualifiedStayFromDate().isPresent())
            nchQlfydStayPeriod.setStart(TransformerUtils.convertToDate((claimGroup.getQualifiedStayFromDate().get())), TemporalPrecisionEnum.DAY);
        if (claimGroup.getQualifiedStayThroughDate().isPresent())
            nchQlfydStayPeriod.setEnd(TransformerUtils.convertToDate((claimGroup.getQualifiedStayThroughDate().get())), TemporalPrecisionEnum.DAY);
        nchQlfydStayInfo.setTiming(nchQlfydStayPeriod);
    }
    // Common group level fields between Inpatient, Outpatient and SNF
    TransformerUtils.mapEobCommonGroupInpOutSNF(eob, claimGroup.getBloodDeductibleLiabilityAmount(), claimGroup.getOperatingPhysicianNpi(), claimGroup.getOtherPhysicianNpi(), claimGroup.getClaimQueryCode(), claimGroup.getMcoPaidSw());
    // Common group level fields between Inpatient, Outpatient Hospice, HHA and SNF
    TransformerUtils.mapEobCommonGroupInpOutHHAHospiceSNF(eob, claimGroup.getOrganizationNpi(), claimGroup.getClaimFacilityTypeCode(), claimGroup.getClaimFrequencyCode(), claimGroup.getClaimNonPaymentReasonCode(), claimGroup.getPatientDischargeStatusCode(), claimGroup.getClaimServiceClassificationTypeCode(), claimGroup.getClaimPrimaryPayerCode(), claimGroup.getAttendingPhysicianNpi(), claimGroup.getTotalChargeAmount(), claimGroup.getPrimaryPayerPaidAmount(), claimGroup.getFiscalIntermediaryNumber(), claimGroup.getFiDocumentClaimControlNumber(), claimGroup.getFiOriginalClaimControlNumber());
    for (Diagnosis diagnosis : TransformerUtils.extractDiagnoses1Thru12(claimGroup.getDiagnosisAdmittingCode(), claimGroup.getDiagnosisAdmittingCodeVersion(), 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 (Diagnosis diagnosis : TransformerUtils.extractDiagnoses13Thru25(claimGroup.getDiagnosis13Code(), claimGroup.getDiagnosis13CodeVersion(), claimGroup.getDiagnosis14Code(), claimGroup.getDiagnosis14CodeVersion(), claimGroup.getDiagnosis15Code(), claimGroup.getDiagnosis15CodeVersion(), claimGroup.getDiagnosis16Code(), claimGroup.getDiagnosis16CodeVersion(), claimGroup.getDiagnosis17Code(), claimGroup.getDiagnosis17CodeVersion(), claimGroup.getDiagnosis18Code(), claimGroup.getDiagnosis18CodeVersion(), claimGroup.getDiagnosis19Code(), claimGroup.getDiagnosis19CodeVersion(), claimGroup.getDiagnosis20Code(), claimGroup.getDiagnosis20CodeVersion(), claimGroup.getDiagnosis21Code(), claimGroup.getDiagnosis21CodeVersion(), claimGroup.getDiagnosis22Code(), claimGroup.getDiagnosis22CodeVersion(), claimGroup.getDiagnosis23Code(), claimGroup.getDiagnosis23CodeVersion(), claimGroup.getDiagnosis24Code(), claimGroup.getDiagnosis24CodeVersion(), claimGroup.getDiagnosis25Code(), claimGroup.getDiagnosis25CodeVersion())) TransformerUtils.addDiagnosisCode(eob, diagnosis);
    for (Diagnosis diagnosis : TransformerUtils.extractExternalDiagnoses1Thru12(claimGroup.getDiagnosisExternalFirstCode(), claimGroup.getDiagnosisExternalFirstCodeVersion(), claimGroup.getDiagnosisExternal1Code(), claimGroup.getDiagnosisExternal1CodeVersion(), claimGroup.getDiagnosisExternal2Code(), claimGroup.getDiagnosisExternal2CodeVersion(), claimGroup.getDiagnosisExternal3Code(), claimGroup.getDiagnosisExternal3CodeVersion(), claimGroup.getDiagnosisExternal4Code(), claimGroup.getDiagnosisExternal4CodeVersion(), claimGroup.getDiagnosisExternal5Code(), claimGroup.getDiagnosisExternal5CodeVersion(), claimGroup.getDiagnosisExternal6Code(), claimGroup.getDiagnosisExternal6CodeVersion(), claimGroup.getDiagnosisExternal7Code(), claimGroup.getDiagnosisExternal7CodeVersion(), claimGroup.getDiagnosisExternal8Code(), claimGroup.getDiagnosisExternal8CodeVersion(), claimGroup.getDiagnosisExternal9Code(), claimGroup.getDiagnosisExternal9CodeVersion(), claimGroup.getDiagnosisExternal10Code(), claimGroup.getDiagnosisExternal10CodeVersion(), claimGroup.getDiagnosisExternal11Code(), claimGroup.getDiagnosisExternal11CodeVersion(), claimGroup.getDiagnosisExternal12Code(), claimGroup.getDiagnosisExternal12CodeVersion())) TransformerUtils.addDiagnosisCode(eob, diagnosis);
    for (CCWProcedure procedure : TransformerUtils.extractCCWProcedures(claimGroup.getProcedure1Code(), claimGroup.getProcedure1CodeVersion(), claimGroup.getProcedure1Date(), claimGroup.getProcedure2Code(), claimGroup.getProcedure2CodeVersion(), claimGroup.getProcedure2Date(), claimGroup.getProcedure3Code(), claimGroup.getProcedure3CodeVersion(), claimGroup.getProcedure3Date(), claimGroup.getProcedure4Code(), claimGroup.getProcedure4CodeVersion(), claimGroup.getProcedure4Date(), claimGroup.getProcedure5Code(), claimGroup.getProcedure5CodeVersion(), claimGroup.getProcedure5Date(), claimGroup.getProcedure6Code(), claimGroup.getProcedure6CodeVersion(), claimGroup.getProcedure6Date(), claimGroup.getProcedure7Code(), claimGroup.getProcedure7CodeVersion(), claimGroup.getProcedure7Date(), claimGroup.getProcedure8Code(), claimGroup.getProcedure8CodeVersion(), claimGroup.getProcedure8Date(), claimGroup.getProcedure9Code(), claimGroup.getProcedure9CodeVersion(), claimGroup.getProcedure9Date(), claimGroup.getProcedure10Code(), claimGroup.getProcedure10CodeVersion(), claimGroup.getProcedure10Date(), claimGroup.getProcedure11Code(), claimGroup.getProcedure11CodeVersion(), claimGroup.getProcedure11Date(), claimGroup.getProcedure12Code(), claimGroup.getProcedure12CodeVersion(), claimGroup.getProcedure12Date(), claimGroup.getProcedure13Code(), claimGroup.getProcedure13CodeVersion(), claimGroup.getProcedure13Date(), claimGroup.getProcedure14Code(), claimGroup.getProcedure14CodeVersion(), claimGroup.getProcedure14Date(), claimGroup.getProcedure15Code(), claimGroup.getProcedure15CodeVersion(), claimGroup.getProcedure15Date(), claimGroup.getProcedure16Code(), claimGroup.getProcedure16CodeVersion(), claimGroup.getProcedure16Date(), claimGroup.getProcedure17Code(), claimGroup.getProcedure17CodeVersion(), claimGroup.getProcedure17Date(), claimGroup.getProcedure18Code(), claimGroup.getProcedure18CodeVersion(), claimGroup.getProcedure18Date(), claimGroup.getProcedure19Code(), claimGroup.getProcedure19CodeVersion(), claimGroup.getProcedure19Date(), claimGroup.getProcedure20Code(), claimGroup.getProcedure20CodeVersion(), claimGroup.getProcedure20Date(), claimGroup.getProcedure21Code(), claimGroup.getProcedure21CodeVersion(), claimGroup.getProcedure21Date(), claimGroup.getProcedure22Code(), claimGroup.getProcedure22CodeVersion(), claimGroup.getProcedure22Date(), claimGroup.getProcedure23Code(), claimGroup.getProcedure23CodeVersion(), claimGroup.getProcedure23Date(), claimGroup.getProcedure24Code(), claimGroup.getProcedure24CodeVersion(), claimGroup.getProcedure24Date(), claimGroup.getProcedure25Code(), claimGroup.getProcedure25CodeVersion(), claimGroup.getProcedure25Date())) TransformerUtils.addProcedureCode(eob, procedure);
    for (SNFClaimLine claimLine : claimGroup.getLines()) {
        ItemComponent item = eob.addItem();
        item.setSequence(claimLine.getLineNumber().intValue());
        item.setLocation(new Address().setState((claimGroup.getProviderStateCode())));
        TransformerUtils.mapHcpcs(eob, item, Optional.empty(), claimLine.getHcpcsCode(), Collections.emptyList());
        // Common item level fields between Inpatient, Outpatient, HHA, Hospice and SNF
        TransformerUtils.mapEobCommonItemRevenue(item, eob, claimLine.getRevenueCenter(), claimLine.getRateAmount(), claimLine.getTotalChargeAmount(), claimLine.getNonCoveredChargeAmount(), BigDecimal.valueOf(claimLine.getUnitCount()), claimLine.getNationalDrugCodeQuantity(), claimLine.getNationalDrugCodeQualifierCode(), claimLine.getRevenueCenterRenderingPhysicianNPI());
        // Common group level field coinsurance between Inpatient, HHA, Hospice and SNF
        TransformerUtils.mapEobCommonGroupInpHHAHospiceSNFCoinsurance(eob, item, claimLine.getDeductibleCoinsuranceCd());
    }
    TransformerUtils.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}

Example 2 with SNFClaimLine

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

the class RifFilesProcessorTest method process1SNFClaimRecord.

/**
 * Ensures that {@link RifFilesProcessor} can correctly handle {@link
 * StaticRifResource#SAMPLE_A_SNF}.
 */
@Test
public void process1SNFClaimRecord() {
    RifFilesEvent filesEvent = new RifFilesEvent(Instant.now(), StaticRifResource.SAMPLE_A_SNF.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_SNF.getRecordCount(), rifEventsList.size());
    RifRecordEvent<?> rifRecordEvent = rifEventsList.get(0);
    assertEquals(StaticRifResource.SAMPLE_A_SNF.getRifFileType(), rifRecordEvent.getFileEvent().getFile().getFileType());
    assertNotNull(rifRecordEvent.getRecord());
    assertTrue(rifRecordEvent.getRecord() instanceof SNFClaim);
    // Verify the claim header.
    SNFClaim claimGroup = (SNFClaim) rifRecordEvent.getRecord();
    assertEquals(RecordAction.INSERT, rifRecordEvent.getRecordAction());
    assertEquals(claimGroup.getBeneficiaryId(), rifRecordEvent.getBeneficiaryId());
    assertEquals("567834", claimGroup.getBeneficiaryId());
    assertEquals("777777777", claimGroup.getClaimId());
    assertEquals(new BigDecimal(900), claimGroup.getClaimGroupId());
    assertEquals('V', claimGroup.getNearLineRecordIdCode());
    assertEquals("20", claimGroup.getClaimTypeCode());
    assertEquals(LocalDate.of(2013, 12, 01), claimGroup.getDateFrom());
    assertEquals(LocalDate.of(2013, 12, 18), claimGroup.getDateThrough());
    assertEquals('3', claimGroup.getClaimQueryCode());
    assertEquals("299999", claimGroup.getProviderNumber());
    assertEquals("B", claimGroup.getClaimNonPaymentReasonCode().get());
    assertEquals('1', claimGroup.getClaimServiceClassificationTypeCode());
    assertEquals(new BigDecimal("3333.33"), claimGroup.getPaymentAmount());
    assertEquals(new BigDecimal("11.00"), claimGroup.getPrimaryPayerPaidAmount());
    assertEquals("FL", claimGroup.getProviderStateCode());
    assertEquals("1111111111", claimGroup.getOrganizationNpi().get());
    assertEquals("2222222222", claimGroup.getAttendingPhysicianNpi().get());
    assertEquals("3333333333", claimGroup.getOperatingPhysicianNpi().get());
    assertEquals("4444444444", claimGroup.getOtherPhysicianNpi().get());
    assertEquals("1", claimGroup.getPatientDischargeStatusCode());
    assertEquals(new BigDecimal("5555.03"), claimGroup.getTotalChargeAmount());
    assertEquals(LocalDate.of(2013, 11, 5), claimGroup.getClaimAdmissionDate().get());
    assertEquals('3', claimGroup.getAdmissionTypeCd());
    assertEquals('4', claimGroup.getSourceAdmissionCd().get().charValue());
    assertEquals(new BigDecimal("112.00"), claimGroup.getDeductibleAmount());
    assertEquals(new BigDecimal("5.00"), claimGroup.getPartACoinsuranceLiabilityAmount());
    assertEquals(new BigDecimal("6.00"), claimGroup.getBloodDeductibleLiabilityAmount());
    assertEquals(new BigDecimal("33.00"), claimGroup.getNoncoveredCharge());
    assertEquals(new BigDecimal("14.00"), claimGroup.getTotalDeductionAmount());
    assertEquals(new BigDecimal("9.00"), claimGroup.getClaimPPSCapitalFSPAmount().get());
    assertEquals(new BigDecimal("8.00"), claimGroup.getClaimPPSCapitalOutlierAmount().get());
    assertEquals(new BigDecimal("7.00"), claimGroup.getClaimPPSCapitalDisproportionateShareAmt().get());
    assertEquals(new BigDecimal("6.00"), claimGroup.getClaimPPSCapitalIMEAmount().get());
    assertEquals(new BigDecimal("5.00"), claimGroup.getClaimPPSCapitalExceptionAmount().get());
    assertEquals(new BigDecimal("4.00"), claimGroup.getClaimPPSOldCapitalHoldHarmlessAmount().get());
    assertEquals(new BigDecimal(17), claimGroup.getUtilizationDayCount());
    assertEquals(new BigDecimal(17), claimGroup.getCoinsuranceDayCount());
    assertEquals(new BigDecimal(0), claimGroup.getNonUtilizationDayCount());
    assertEquals(new BigDecimal(19), claimGroup.getBloodPintsFurnishedQty());
    assertEquals(LocalDate.of(2013, 9, 23), claimGroup.getQualifiedStayFromDate().get());
    assertEquals(LocalDate.of(2013, 11, 5), claimGroup.getQualifiedStayThroughDate().get());
    assertEquals(LocalDate.of(2002, 1, 11), claimGroup.getNoncoveredStayFromDate().get());
    assertEquals(LocalDate.of(2002, 1, 21), claimGroup.getNoncoveredStayThroughDate().get());
    assertFalse(claimGroup.getCoveredCareThroughDate().isPresent());
    assertEquals(LocalDate.of(2002, 1, 31), claimGroup.getMedicareBenefitsExhaustedDate().get());
    assertEquals(LocalDate.of(2013, 12, 18), claimGroup.getBeneficiaryDischargeDate().get());
    assertEquals("R4444", claimGroup.getDiagnosisAdmittingCode().get());
    assertEquals('9', claimGroup.getDiagnosisAdmittingCodeVersion().get().charValue());
    assertEquals("R2222", claimGroup.getDiagnosisExternal1Code().get());
    assertEquals('9', claimGroup.getDiagnosisExternal1CodeVersion().get().charValue());
    assertEquals("23443453453", claimGroup.getFiDocumentClaimControlNumber().get());
    assertEquals("34534535535", claimGroup.getFiOriginalClaimControlNumber().get());
    assertEquals(1, claimGroup.getLines().size());
    // Verify one of the claim lines.
    SNFClaimLine claimLine = claimGroup.getLines().get(0);
    assertEquals("MMM", claimLine.getHcpcsCode().get());
    assertEquals(new BigDecimal("95.00"), claimLine.getTotalChargeAmount());
    assertEquals(new BigDecimal("88.00"), claimLine.getNonCoveredChargeAmount());
    assertEquals("345345345", claimLine.getRevenueCenterRenderingPhysicianNPI().get());
}

Example 3 with SNFClaimLine

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

the class SNFClaimTransformerV2 method transformClaim.

/**
 * @param claimGroup the CCW {@link SNFClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     SNFClaim}
 */
private static ExplanationOfBenefit transformClaim(SNFClaim claimGroup) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    // Required values not directly mapped
    eob.getMeta().addProfile(ProfileConstants.C4BB_EOB_INPATIENT_PROFILE_URL);
    // 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
    // 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.SNF, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, 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.SNF, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // PRVDR_NUM => ExplanationOfBenefit.provider.identifier
    TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
    // add EOB information to fields that are common between the Inpatient and SNF claim types
    // CLM_IP_ADMSN_TYPE_CD             => ExplanationOfBenefit.supportingInfo.code
    // CLM_SRC_IP_ADMSN_CD              => ExplanationOfBenefit.supportingInfo.code
    // NCH_VRFD_NCVRD_STAY_FROM_DT      => ExplanationOfBenefit.supportingInfo.timingPeriod
    // NCH_VRFD_NCVRD_STAY_THRU_DT      => ExplanationOfBenefit.supportingInfo.timingPeriod
    // NCH_ACTV_OR_CVRD_LVL_CARE_THRU   => ExplanationOfBenefit.supportingInfo.timingDate
    // NCH_BENE_MDCR_BNFTS_EXHTD_DT_I   => ExplanationOfBenefit.supportingInfo.timingDate
    // CLM_DRG_CD                       => ExplanationOfBenefit.supportingInfo.code
    TransformerUtilsV2.addCommonEobInformationInpatientSNF(eob, claimGroup.getAdmissionTypeCd(), claimGroup.getSourceAdmissionCd(), claimGroup.getNoncoveredStayFromDate(), claimGroup.getNoncoveredStayThroughDate(), claimGroup.getCoveredCareThroughDate(), claimGroup.getMedicareBenefitsExhaustedDate(), claimGroup.getDiagnosisRelatedGroupCd());
    // NCH_PTNT_STUS_IND_CD => ExplanationOfBenefit.supportingInfo.code
    claimGroup.getPatientStatusCd().ifPresent(c -> TransformerUtilsV2.addInformationWithCode(eob, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, c));
    // CLM_ADMSN_DT       => ExplanationOfBenefit.supportingInfo:admissionperiod
    // NCH_BENE_DSCHRG_DT => ExplanationOfBenefit.supportingInfo:admissionperiod
    TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationAdmPeriodSlice(eob, claimGroup.getClaimAdmissionDate(), claimGroup.getBeneficiaryDischargeDate()));
    // CLM_UTLZTN_DAY_CNT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_UTLZTN_DAY_CNT, claimGroup.getUtilizationDayCount());
    // NCH_QLFYD_STAY_THRU_DT => ExplanationOfBenefit.supportingInfo
    if (claimGroup.getQualifiedStayFromDate().isPresent() || claimGroup.getQualifiedStayThroughDate().isPresent()) {
        TransformerUtilsV2.validatePeriodDates(claimGroup.getQualifiedStayFromDate(), claimGroup.getQualifiedStayThroughDate());
        Period period = new Period();
        // NCH_QLFYD_STAY_FROM_DT
        claimGroup.getQualifiedStayFromDate().ifPresent(c -> period.setStart(TransformerUtilsV2.convertToDate(c), TemporalPrecisionEnum.DAY));
        // NCH_QLFYD_STAY_THRU_DT
        claimGroup.getQualifiedStayThroughDate().ifPresent(c -> period.setEnd(TransformerUtilsV2.convertToDate(c), TemporalPrecisionEnum.DAY));
        // Add to EOB
        TransformerUtilsV2.addInformation(eob, CcwCodebookVariable.NCH_QLFYD_STAY_FROM_DT).setTiming(period);
    }
    // CLM_PPS_IND_CODE => ExplanationOfBenefit.supportingInfo
    claimGroup.getProspectivePaymentCode().ifPresent(c -> TransformerUtilsV2.addInformationWithCode(eob, CcwCodebookVariable.CLM_PPS_IND_CD, CcwCodebookVariable.CLM_PPS_IND_CD, c));
    /*
     * add field values to the benefit balances that are common between the
     * Inpatient and SNF claim types
     */
    // BENE_TOT_COINSRNC_DAYS_CNT       => ExplanationOfBenefit.benefitBalance.financial
    // CLM_NON_UTLZTN_DAYS_CNT          => ExplanationOfBenefit.benefitBalance.financial
    // NCH_BENE_IP_DDCTBL_AMT           => ExplanationOfBenefit.benefitBalance.financial
    // NCH_BENE_PTA_COINSRNC_LBLTY_AMT  => ExplanationOfBenefit.benefitBalance.financial
    // NCH_BLOOD_PNTS_FRNSHD_QTY        => ExplanationOfBenefit.supportingInfo.valueQuantity
    // NCH_IP_NCVRD_CHRG_AMT            => ExplanationOfBenefit.benefitBalance.financial
    // NCH_IP_TOT_DDCTN_AMT             => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT   => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_CPTL_EXCPTN_AMT          => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_CPTL_FSP_AMT             => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_CPTL_IME_AMT             => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_CPTL_OUTLIER_AMT         => ExplanationOfBenefit.benefitBalance.financial
    // CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT   => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addCommonGroupInpatientSNF(eob, claimGroup.getCoinsuranceDayCount(), claimGroup.getNonUtilizationDayCount(), claimGroup.getDeductibleAmount(), claimGroup.getPartACoinsuranceLiabilityAmount(), claimGroup.getBloodPintsFurnishedQty(), claimGroup.getNoncoveredCharge(), claimGroup.getTotalDeductionAmount(), claimGroup.getClaimPPSCapitalDisproportionateShareAmt(), claimGroup.getClaimPPSCapitalExceptionAmount(), claimGroup.getClaimPPSCapitalFSPAmount(), claimGroup.getClaimPPSCapitalIMEAmount(), claimGroup.getClaimPPSCapitalOutlierAmount(), claimGroup.getClaimPPSOldCapitalHoldHarmlessAmount());
    // Map care team
    // AT_PHYSN_NPI     => ExplanationOfBenefit.careTeam.provider (Primary)
    // AT_PHYSN_UPIN    => ExplanationOfBenefit.careTeam.provider
    // OP_PHYSN_NPI     => ExplanationOfBenefit.careTeam.provider (Assisting)
    // OP_PHYSN_NPI     => ExplanationOfBenefit.careTeam.provider
    // OT_PHYSN_NPI     => ExplanationOfBenefit.careTeam.provider (Other)
    // OT_PHYSN_UPIN    => ExplanationOfBenefit.careTeam.provider
    TransformerUtilsV2.mapCareTeam(eob, claimGroup.getAttendingPhysicianNpi(), claimGroup.getOperatingPhysicianNpi(), claimGroup.getOtherPhysicianNpi(), claimGroup.getAttendingPhysicianUpin(), claimGroup.getOperatingPhysicianUpin(), claimGroup.getOtherPhysicianUpin());
    // Common group level fields between Inpatient, Outpatient and SNF
    // NCH_BENE_BLOOD_DDCTBL_LBLTY_AM   => ExplanationOfBenefit.benefitBalance.financial
    // CLAIM_QUERY_CODE                 => ExplanationOfBenefit.billablePeriod.extension
    // CLM_MCO_PD_SW                    => ExplanationOfBenefit.supportingInfo.code
    TransformerUtilsV2.mapEobCommonGroupInpOutSNF(eob, claimGroup.getBloodDeductibleLiabilityAmount(), claimGroup.getClaimQueryCode(), claimGroup.getMcoPaidSw());
    // Common group level fields between Inpatient, Outpatient Hospice, HHA and SNF
    // ORG_NPI_NUM              => ExplanationOfBenefit.provider
    // CLM_FAC_TYPE_CD          => ExplanationOfBenefit.facility.extension
    // CLM_FREQ_CD              => ExplanationOfBenefit.supportingInfo
    // CLM_MDCR_NON_PMT_RSN_CD  => ExplanationOfBenefit.extension
    // PTNT_DSCHRG_STUS_CD      => ExplanationOfBenefit.supportingInfo
    // CLM_SRVC_CLSFCTN_TYPE_CD => ExplanationOfBenefit.extension
    // NCH_PRMRY_PYR_CD         => ExplanationOfBenefit.supportingInfo
    // CLM_TOT_CHRG_AMT         => ExplanationOfBenefit.total.amount
    // NCH_PRMRY_PYR_CLM_PD_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.mapEobCommonGroupInpOutHHAHospiceSNF(eob, claimGroup.getOrganizationNpi(), claimGroup.getClaimFacilityTypeCode(), claimGroup.getClaimFrequencyCode(), claimGroup.getClaimNonPaymentReasonCode(), claimGroup.getPatientDischargeStatusCode(), claimGroup.getClaimServiceClassificationTypeCode(), claimGroup.getClaimPrimaryPayerCode(), claimGroup.getTotalChargeAmount(), claimGroup.getPrimaryPayerPaidAmount(), claimGroup.getFiscalIntermediaryNumber(), claimGroup.getLastUpdated());
    // ICD_DGNS_E_VRSN_CD(1-12) => diagnosis.diagnosisCodeableConcept
    for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
        DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.SNF);
    }
    // Handle Procedures
    // ICD_PRCDR_CD(1-25)        => ExplanationOfBenefit.procedure.procedureCodableConcept
    // ICD_PRCDR_VRSN_CD(1-25)   => ExplanationOfBenefit.procedure.procedureCodableConcept
    // PRCDR_DT(1-25)            => ExplanationOfBenefit.procedure.date
    final int FIRST_PROCEDURE = 1;
    final int LAST_PROCEDURE = 25;
    IntStream.range(FIRST_PROCEDURE, LAST_PROCEDURE + 1).mapToObj(i -> TransformerUtilsV2.extractCCWProcedure(i, claimGroup)).filter(p -> p.isPresent()).forEach(p -> TransformerUtilsV2.addProcedureCode(eob, p.get()));
    for (SNFClaimLine line : claimGroup.getLines()) {
        ItemComponent item = eob.addItem();
        // Override the default sequence
        // CLM_LINE_NUM => item.sequence
        item.setSequence(line.getLineNumber().intValue());
        // PRVDR_STATE_CD => item.location
        TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
        // HCPCS_CD => ExplanationOfBenefit.item.productOrService
        TransformerUtilsV2.mapHcpcs(eob, item, line.getHcpcsCode(), Optional.empty(), Collections.emptyList());
        // REV_CNTR                   => ExplanationOfBenefit.item.revenue
        // REV_CNTR_RATE_AMT          => ExplanationOfBenefit.item.adjudication
        // REV_CNTR_TOT_CHRG_AMT      => ExplanationOfBenefit.item.adjudication
        // REV_CNTR_NCVRD_CHRG_AMT    => ExplanationOfBenefit.item.adjudication
        // REV_CNTR_NDC_QTY           => ExplanationOfBenefit.item.quantity
        // REV_CNTR_NDC_QTY_QLFR_CD   => ExplanationOfBenefit.modifier
        TransformerUtilsV2.mapEobCommonItemRevenue(item, eob, line.getRevenueCenter(), line.getRateAmount(), line.getTotalChargeAmount(), Optional.of(line.getNonCoveredChargeAmount()), line.getNationalDrugCodeQuantity(), line.getNationalDrugCodeQualifierCode());
        // REV_CNTR_DDCTBL_COINSRNC_CD => item.revenue
        TransformerUtilsV2.addItemRevenue(item, eob, CcwCodebookVariable.REV_CNTR_DDCTBL_COINSRNC_CD, line.getDeductibleCoinsuranceCd());
        // RNDRNG_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
        TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.UPIN, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianUPIN());
        // RNDRNG_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
        TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.NPI, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianNPI());
    }
    // Last Updated => ExplanationOfBenefit.meta.lastUpdated
    TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}

Example 4 with SNFClaimLine

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

the class SNFClaimTransformerTest method assertMatches.

/**
 * Verifies that the {@link ExplanationOfBenefit} "looks like" it should, if it were produced from
 * the specified {@link SNFClaim}.
 *
 * @param claim the {@link SNFClaim} that the {@link ExplanationOfBenefit} was generated from
 * @param eob the {@link ExplanationOfBenefit} that was generated from the specified {@link
 *     SNFClaim}
 * @throws FHIRException (indicates test failure)
 */
static void assertMatches(SNFClaim claim, ExplanationOfBenefit eob) throws FHIRException {
    // Test to ensure group level fields between all claim types match
    TransformerTestUtils.assertEobCommonClaimHeaderData(eob, claim.getClaimId(), claim.getBeneficiaryId(), ClaimType.SNF, claim.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, Optional.of(claim.getDateFrom()), Optional.of(claim.getDateThrough()), Optional.of(claim.getPaymentAmount()), claim.getFinalAction());
    // test the common field provider number is set as expected in the EOB
    TransformerTestUtils.assertProviderNumber(eob, claim.getProviderNumber());
    // test common benefit components between SNF and Inpatient claims are set as expected
    TransformerTestUtils.assertCommonGroupInpatientSNF(eob, claim.getCoinsuranceDayCount(), claim.getNonUtilizationDayCount(), claim.getDeductibleAmount(), claim.getPartACoinsuranceLiabilityAmount(), claim.getBloodPintsFurnishedQty(), claim.getNoncoveredCharge(), claim.getTotalDeductionAmount(), claim.getClaimPPSCapitalDisproportionateShareAmt(), claim.getClaimPPSCapitalExceptionAmount(), claim.getClaimPPSCapitalFSPAmount(), claim.getClaimPPSCapitalIMEAmount(), claim.getClaimPPSCapitalOutlierAmount(), claim.getClaimPPSOldCapitalHoldHarmlessAmount());
    if (claim.getQualifiedStayFromDate().isPresent() || claim.getQualifiedStayThroughDate().isPresent()) {
        SupportingInformationComponent nchQlyfdStayInfo = TransformerTestUtils.assertHasInfo(CcwCodebookVariable.NCH_QLFYD_STAY_FROM_DT, eob);
        TransformerTestUtils.assertPeriodEquals(claim.getQualifiedStayFromDate(), claim.getQualifiedStayThroughDate(), (Period) nchQlyfdStayInfo.getTiming());
    }
    // test common eob information between SNF and Inpatient claims are set as expected
    TransformerTestUtils.assertCommonEobInformationInpatientSNF(eob, claim.getNoncoveredStayFromDate(), claim.getNoncoveredStayThroughDate(), claim.getCoveredCareThroughDate(), claim.getMedicareBenefitsExhaustedDate(), claim.getDiagnosisRelatedGroupCd());
    TransformerTestUtils.assertDateEquals(claim.getClaimAdmissionDate().get(), eob.getHospitalization().getStartElement());
    TransformerTestUtils.assertDateEquals(claim.getBeneficiaryDischargeDate().get(), eob.getHospitalization().getEndElement());
    // test common eob information between Inpatient, HHA, Hospice and SNF claims are set as
    // expected
    TransformerTestUtils.assertEobCommonGroupInpHHAHospiceSNFEquals(eob, claim.getClaimAdmissionDate(), claim.getBeneficiaryDischargeDate(), Optional.of(claim.getUtilizationDayCount()));
    // Test to ensure common group fields between Inpatient, Outpatient and SNF
    TransformerTestUtils.assertEobCommonGroupInpOutSNFEquals(eob, claim.getBloodDeductibleLiabilityAmount(), claim.getOperatingPhysicianNpi(), claim.getOtherPhysicianNpi(), claim.getClaimQueryCode(), claim.getMcoPaidSw());
    // Test to ensure common group fields between Inpatient, Outpatient HHA, Hospice
    // and SNF match
    TransformerTestUtils.assertEobCommonGroupInpOutHHAHospiceSNFEquals(eob, claim.getOrganizationNpi(), claim.getClaimFacilityTypeCode(), claim.getClaimFrequencyCode(), claim.getClaimNonPaymentReasonCode(), claim.getPatientDischargeStatusCode(), claim.getClaimServiceClassificationTypeCode(), claim.getClaimPrimaryPayerCode(), claim.getAttendingPhysicianNpi(), claim.getTotalChargeAmount(), claim.getPrimaryPayerPaidAmount(), claim.getFiscalIntermediaryNumber(), claim.getFiDocumentClaimControlNumber(), claim.getFiOriginalClaimControlNumber());
    assertEquals(6, eob.getDiagnosis().size());
    CCWProcedure ccwProcedure = new CCWProcedure(claim.getProcedure1Code(), claim.getProcedure1CodeVersion(), claim.getProcedure1Date());
    TransformerTestUtils.assertHasCoding(ccwProcedure.getFhirSystem().toString(), claim.getProcedure1Code().get(), eob.getProcedure().get(0).getProcedureCodeableConcept().getCoding());
    assertEquals(TransformerUtils.convertToDate(claim.getProcedure1Date().get()), eob.getProcedure().get(0).getDate());
    assertEquals(1, eob.getItem().size());
    SNFClaimLine claimLine1 = claim.getLines().get(0);
    ItemComponent eobItem0 = eob.getItem().get(0);
    assertEquals(claimLine1.getLineNumber(), new BigDecimal(eobItem0.getSequence()));
    assertEquals(claim.getProviderStateCode(), eobItem0.getLocationAddress().getState());
    TransformerTestUtils.assertHasCoding(CcwCodebookVariable.REV_CNTR, claimLine1.getRevenueCenter(), eobItem0.getRevenue());
    TransformerTestUtils.assertHcpcsCodes(eobItem0, claimLine1.getHcpcsCode(), Optional.empty(), Optional.empty(), Optional.empty(), 0);
    // Test to ensure common group field coinsurance between Inpatient, HHA, Hospice and SNF match
    TransformerTestUtils.assertEobCommonGroupInpHHAHospiceSNFCoinsuranceEquals(eobItem0, claimLine1.getDeductibleCoinsuranceCd());
    String claimControlNumber = "0000000000";
    // Test to ensure item level fields between Inpatient, Outpatient, HHA, Hopsice
    // and SNF match
    TransformerTestUtils.assertEobCommonItemRevenueEquals(eobItem0, eob, claimLine1.getRevenueCenter(), claimLine1.getRateAmount(), claimLine1.getTotalChargeAmount(), claimLine1.getNonCoveredChargeAmount(), BigDecimal.valueOf(claimLine1.getUnitCount()), claimControlNumber, claimLine1.getNationalDrugCodeQuantity(), claimLine1.getNationalDrugCodeQualifierCode(), claimLine1.getRevenueCenterRenderingPhysicianNPI(), 1);
    // verify {@link
    // TransformerUtils#mapEobType(CodeableConcept,ClaimType,Optional,Optional)}
    // method worked as expected for this claim type
    TransformerTestUtils.assertMapEobType(eob.getType(), ClaimType.SNF, Optional.of(org.hl7.fhir.dstu3.model.codesystems.ClaimType.INSTITUTIONAL), Optional.of(claim.getNearLineRecordIdCode()), Optional.of(claim.getClaimTypeCode()));
    // Test lastUpdated
    TransformerTestUtils.assertLastUpdatedEquals(claim.getLastUpdated(), eob);
}