use of org.hl7.fhir.dstu3.model.Claim.ProcedureComponent in project beneficiary-fhir-data by CMSgov.
the class TransformerUtils method addProcedureCode.
/**
* @param eob the {@link ExplanationOfBenefit} to (possibly) modify
* @param diagnosis the {@link Diagnosis} to add, if it's not already present
* @return the {@link ProcedureComponent#getSequence()} of the existing or newly-added entry
*/
static int addProcedureCode(ExplanationOfBenefit eob, CCWProcedure procedure) {
Optional<ProcedureComponent> existingProcedure = eob.getProcedure().stream().filter(pc -> pc.getProcedure() instanceof CodeableConcept).filter(pc -> isCodeInConcept((CodeableConcept) pc.getProcedure(), procedure.getFhirSystem(), procedure.getCode())).findAny();
if (existingProcedure.isPresent())
return existingProcedure.get().getSequenceElement().getValue();
ProcedureComponent procedureComponent = new ProcedureComponent().setSequence(eob.getProcedure().size() + 1);
procedureComponent.setProcedure(createCodeableConcept(procedure.getFhirSystem(), null, retrieveProcedureCodeDisplay(procedure.getCode()), procedure.getCode()));
if (procedure.getProcedureDate().isPresent()) {
procedureComponent.setDate(convertToDate(procedure.getProcedureDate().get()));
}
eob.getProcedure().add(procedureComponent);
return procedureComponent.getSequenceElement().getValue();
}
use of org.hl7.fhir.dstu3.model.Claim.ProcedureComponent in project beneficiary-fhir-data by CMSgov.
the class SNFClaimTransformerV2Test method shouldHaveProcedureMembers.
@Test
public void shouldHaveProcedureMembers() {
ProcedureComponent proc1 = TransformerTestUtilsV2.findProcedureByCode("0TCCCCC", eob.getProcedure());
ProcedureComponent cmp1 = TransformerTestUtilsV2.createProcedure(proc1.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-9-cm", "0TCCCCC", null), "2016-01-16T00:00:00-08:00");
assertTrue(cmp1.equalsDeep(proc1), "Comparing Procedure code 0TCCCCC");
}
use of org.hl7.fhir.dstu3.model.Claim.ProcedureComponent in project synthea by synthetichealth.
the class FhirStu3 method encounterClaim.
/**
* Create an entry for the given Claim, associated to an Encounter.
*
* @param rand Source of randomness to use when generating ids etc
* @param personEntry Entry for the person
* @param bundle The Bundle to add to
* @param encounterEntry The current Encounter
* @param claim the Claim object
* @return the added Entry
*/
private static BundleEntryComponent encounterClaim(RandomNumberGenerator rand, BundleEntryComponent personEntry, Bundle bundle, BundleEntryComponent encounterEntry, Claim claim) {
org.hl7.fhir.dstu3.model.Claim claimResource = new org.hl7.fhir.dstu3.model.Claim();
org.hl7.fhir.dstu3.model.Encounter encounterResource = (org.hl7.fhir.dstu3.model.Encounter) encounterEntry.getResource();
claimResource.setStatus(ClaimStatus.ACTIVE);
claimResource.setUse(org.hl7.fhir.dstu3.model.Claim.Use.COMPLETE);
// duration of encounter
claimResource.setBillablePeriod(encounterResource.getPeriod());
claimResource.setPatient(new Reference(personEntry.getFullUrl()));
claimResource.setOrganization(encounterResource.getServiceProvider());
// add item for encounter
claimResource.addItem(new ItemComponent(new PositiveIntType(1)).addEncounter(new Reference(encounterEntry.getFullUrl())));
int itemSequence = 2;
int conditionSequence = 1;
int procedureSequence = 1;
int informationSequence = 1;
for (Claim.ClaimEntry claimEntry : claim.items) {
HealthRecord.Entry item = claimEntry.entry;
if (Costs.hasCost(item)) {
// update claimItems list
ItemComponent claimItem = new ItemComponent(new PositiveIntType(itemSequence));
Code primaryCode = item.codes.get(0);
String system = ExportHelper.getSystemURI(primaryCode.system);
CodeableConcept serviceProvided = new CodeableConcept().addCoding(new Coding().setCode(primaryCode.code).setVersion("v1").setSystem(system));
claimItem.setService(serviceProvided);
// calculate the cost of the procedure
Money moneyResource = new Money();
moneyResource.setCode("USD");
moneyResource.setSystem("urn:iso:std:iso:4217");
moneyResource.setValue(item.getCost());
claimItem.setNet(moneyResource);
if (item instanceof HealthRecord.Procedure) {
Type procedureReference = new Reference(item.fullUrl);
ProcedureComponent claimProcedure = new ProcedureComponent(new PositiveIntType(procedureSequence), procedureReference);
claimResource.addProcedure(claimProcedure);
claimItem.addProcedureLinkId(procedureSequence);
procedureSequence++;
} else {
Reference informationReference = new Reference(item.fullUrl);
SpecialConditionComponent informationComponent = new SpecialConditionComponent();
informationComponent.setSequence(informationSequence);
informationComponent.setValue(informationReference);
CodeableConcept category = new CodeableConcept();
category.getCodingFirstRep().setSystem("http://hl7.org/fhir/claiminformationcategory").setCode("info");
informationComponent.setCategory(category);
claimResource.addInformation(informationComponent);
claimItem.addInformationLinkId(informationSequence);
claimItem.setService(claimResource.getType());
informationSequence++;
}
claimResource.addItem(claimItem);
} else {
// assume it's a Condition, we don't have a Condition class specifically
// add diagnosisComponent to claim
Reference diagnosisReference = new Reference(item.fullUrl);
org.hl7.fhir.dstu3.model.Claim.DiagnosisComponent diagnosisComponent = new org.hl7.fhir.dstu3.model.Claim.DiagnosisComponent(new PositiveIntType(conditionSequence), diagnosisReference);
claimResource.addDiagnosis(diagnosisComponent);
// update claimItems with diagnosis
ItemComponent diagnosisItem = new ItemComponent(new PositiveIntType(itemSequence));
diagnosisItem.addDiagnosisLinkId(conditionSequence);
claimResource.addItem(diagnosisItem);
conditionSequence++;
}
itemSequence++;
}
Money moneyResource = new Money();
moneyResource.setCode("USD");
moneyResource.setSystem("urn:iso:std:iso:4217");
moneyResource.setValue(claim.getTotalClaimCost());
claimResource.setTotal(moneyResource);
return newEntry(rand, bundle, claimResource);
}
use of org.hl7.fhir.dstu3.model.Claim.ProcedureComponent in project synthea by synthetichealth.
the class FhirStu3 method explanationOfBenefit.
/**
* Create an explanation of benefit resource for each claim, detailing insurance
* information.
*
* @param personEntry Entry for the person
* @param bundle The Bundle to add to
* @param encounterEntry The current Encounter
* @param claimEntry the Claim object
* @param person the person the health record belongs to
* @param encounter the current Encounter as an object
* @return the added entry
*/
private static BundleEntryComponent explanationOfBenefit(BundleEntryComponent personEntry, Bundle bundle, BundleEntryComponent encounterEntry, Person person, BundleEntryComponent claimEntry, Encounter encounter) {
boolean inpatient = false;
boolean outpatient = false;
EncounterType type = EncounterType.fromString(encounter.type);
if (type == EncounterType.INPATIENT) {
inpatient = true;
// Provider enum doesn't include outpatient, but it can still be
// an encounter type.
} else if (type == EncounterType.AMBULATORY || type == EncounterType.WELLNESS) {
outpatient = true;
}
ExplanationOfBenefit eob = new ExplanationOfBenefit();
org.hl7.fhir.dstu3.model.Encounter encounterResource = (org.hl7.fhir.dstu3.model.Encounter) encounterEntry.getResource();
// will have to deal with different claim types (e.g. inpatient vs outpatient)
if (inpatient) {
// https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Indirect-Medical-Education-IME
// Extra cost for educational hospitals
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-ime-op-clm-val-amt-extension", 400));
// DSH payment-- Massachusetts does not make DSH payments at all, so set to 0 for now
// https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dsh
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-dsh-op-clm-val-amt-extension", 0));
// The pass through per diem rate
// not really defined by CMS
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pass-thru-per-diem-amt-extension", 0));
// Professional charge
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-profnl-cmpnt-chrg-amt-extension", 0));
// total claim PPS charge
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-tot-pps-cptl-amt-extension", 0));
// Deductible Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-ip-ddctbl-amt-extension", 0));
// Coinsurance Liability
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-pta-coinsrnc-lblty-amt-extension", 0));
// Non-covered Charge Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-ncvrd-chrg-amt-extension", 0));
// Total Deductible/Coinsurance Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-tot-ddctn-amt-extension", 0));
// PPS Capital DSH Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-dsprprtnt-shr-amt-extension", 0));
// PPS Capital Exception Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-excptn-amt-extension", 0));
// PPS FSP
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-fsp-amt-extension", 0));
// PPS IME
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-ime-amt-extension", 400));
// PPS Capital Outlier Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-outlier-amt-extension", 0));
// Old capital hold harmless amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-old-cptl-hld-hrmls-amt-extension", 0));
// NCH DRG Outlier Approved Payment Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-drg-outlier-aprvd-pmt-amt-extension", 0));
// NCH Beneficiary Blood Deductible Liability Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-blood-ddctbl-lblty-am-extension", 0));
// Non-payment reason
eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-mdcr-non-pmt-rsn-cd-extension").setValue(new Coding().setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd").setDisplay("All other reasons for non-payment").setCode("N"));
// Prepayment
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-prpayamt-extension", 0));
// FI or MAC number
eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-fi-num-extension").setValue(new Identifier().setValue("002000").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"));
} else if (outpatient) {
// Professional component charge amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension", 0));
// Deductible amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension", 0));
// Coinsurance amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension", 0));
// Provider Payment
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension", 0));
// Beneficiary payment
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension", 0));
// Beneficiary Blood Deductible Liability Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension", 0));
// Claim Medicare Non Payment Reason Code
eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension").setValue(new Coding().setDisplay("All other reasons for non-payment").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd").setCode("N"));
// NCH Primary Payer Claim Paid Amount
eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension", 0));
// FI or MAC number
eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension").setValue(new Identifier().setValue("002000").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"));
}
// according to CMS guidelines claims have 12 months to be
// billed, so we set the billable period to 1 year after
// services have ended (the encounter ends).
Calendar cal = Calendar.getInstance();
cal.setTime(encounterResource.getPeriod().getEnd());
cal.add(Calendar.YEAR, 1);
Period billablePeriod = new Period().setStart(encounterResource.getPeriod().getEnd()).setEnd(cal.getTime());
if (inpatient) {
billablePeriod.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-claim-query-cd-extension").setValue(new Coding().setCode("3").setSystem("https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd").setDisplay("Final Bill")));
} else if (outpatient) {
billablePeriod.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension").setValue(new Coding().setCode("3").setSystem("https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd").setDisplay("Final Bill")));
}
eob.setBillablePeriod(billablePeriod);
// cost is hardcoded to be USD in claim so this should be fine as well
Money totalCost = new Money();
totalCost.setSystem("urn:iso:std:iso:4217");
totalCost.setCode("USD");
totalCost.setValue(encounter.claim.getTotalClaimCost());
eob.setTotalCost(totalCost);
// Set References
eob.setPatient(new Reference(personEntry.getFullUrl()));
if (encounter.provider != null) {
// This is what should happen if BlueButton 2.0 wasn't needlessly restrictive
// String providerUrl = findProviderUrl(encounter.provider, bundle);
// eob.setOrganization(new Reference().setReference(providerUrl));
// Instead, we'll create the BlueButton 2.0 reference via identifier...
Identifier identifier = new Identifier();
identifier.setValue(encounter.provider.getResourceID());
eob.setOrganization(new Reference().setIdentifier(identifier));
}
// Get the insurance info at the time that the encounter happened.
Payer payer = encounter.claim.payer;
Coverage coverage = new Coverage();
coverage.setId("coverage");
coverage.setType(new CodeableConcept().setText(payer.getName()));
eob.addContained(coverage);
ExplanationOfBenefit.InsuranceComponent insuranceComponent = new ExplanationOfBenefit.InsuranceComponent();
insuranceComponent.setCoverage(new Reference("#coverage"));
eob.setInsurance(insuranceComponent);
org.hl7.fhir.dstu3.model.Claim claim = (org.hl7.fhir.dstu3.model.Claim) claimEntry.getResource();
eob.addIdentifier().setSystem("https://bluebutton.cms.gov/resources/variables/clm_id").setValue(claim.getId());
// Hardcoded group id
eob.addIdentifier().setSystem("https://bluebutton.cms.gov/resources/identifier/claim-group").setValue("99999999999");
eob.setStatus(org.hl7.fhir.dstu3.model.ExplanationOfBenefit.ExplanationOfBenefitStatus.ACTIVE);
if (!inpatient && !outpatient) {
eob.setClaim(new Reference().setReference(claimEntry.getFullUrl()));
eob.setReferral(new Reference("#1"));
eob.setCreated(encounterResource.getPeriod().getEnd());
}
eob.setType(claim.getType());
List<ExplanationOfBenefit.DiagnosisComponent> eobDiag = new ArrayList<>();
for (org.hl7.fhir.dstu3.model.Claim.DiagnosisComponent claimDiagnosis : claim.getDiagnosis()) {
ExplanationOfBenefit.DiagnosisComponent diagnosisComponent = new ExplanationOfBenefit.DiagnosisComponent();
diagnosisComponent.setDiagnosis(claimDiagnosis.getDiagnosis());
diagnosisComponent.getType().add(new CodeableConcept().addCoding(new Coding().setCode("principal").setSystem("https://bluebutton.cms.gov/resources/codesystem/diagnosis-type")));
diagnosisComponent.setSequence(claimDiagnosis.getSequence());
diagnosisComponent.setPackageCode(claimDiagnosis.getPackageCode());
diagnosisComponent.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension").setValue(new Coding().setCode("Y").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1").setDisplay("Diagnosis present at time of admission"));
eobDiag.add(diagnosisComponent);
}
eob.setDiagnosis(eobDiag);
List<ExplanationOfBenefit.ProcedureComponent> eobProc = new ArrayList<>();
for (ProcedureComponent proc : claim.getProcedure()) {
ExplanationOfBenefit.ProcedureComponent p = new ExplanationOfBenefit.ProcedureComponent();
p.setDate(proc.getDate());
p.setSequence(proc.getSequence());
p.setProcedure(proc.getProcedure());
}
eob.setProcedure(eobProc);
List<ExplanationOfBenefit.ItemComponent> eobItem = new ArrayList<>();
double totalPayment = 0;
for (ItemComponent item : claim.getItem()) {
ExplanationOfBenefit.ItemComponent itemComponent = new ExplanationOfBenefit.ItemComponent();
itemComponent.setSequence(item.getSequence());
itemComponent.setQuantity(item.getQuantity());
itemComponent.setUnitPrice(item.getUnitPrice());
itemComponent.setCareTeamLinkId(item.getCareTeamLinkId());
if (item.hasService()) {
itemComponent.setService(item.getService());
}
if (!inpatient && !outpatient) {
itemComponent.setDiagnosisLinkId(item.getDiagnosisLinkId());
itemComponent.setInformationLinkId(item.getInformationLinkId());
itemComponent.setNet(item.getNet());
itemComponent.setEncounter(item.getEncounter());
itemComponent.setServiced(encounterResource.getPeriod());
itemComponent.setCategory(new CodeableConcept().addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd").setCode("1").setDisplay("Medical care")));
}
if (inpatient) {
itemComponent.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-rev-cntr-ndc-qty-extension").setValue(new Quantity().setValue(0)));
} else if (outpatient) {
itemComponent.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension").setValue(new Quantity().setValue(0)));
if (itemComponent.hasService()) {
itemComponent.getService().addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension").setValue(new Coding().setSystem("https://www.accessdata.fda.gov/scripts/cder/ndc").setDisplay("Dummy").setCode("0624")));
}
}
// Location of service, can use switch statement based on
// encounter type
String code;
String display;
CodeableConcept location = new CodeableConcept();
EncounterType encounterType = EncounterType.fromString(encounter.type);
switch(encounterType) {
case AMBULATORY:
code = "21";
display = "Inpatient Hospital";
break;
case EMERGENCY:
code = "23";
display = "Emergency Room";
break;
case INPATIENT:
code = "21";
display = "Inpatient Hospital";
break;
case URGENTCARE:
code = "20";
display = "Urgent Care Facility";
break;
case WELLNESS:
code = "22";
display = "Outpatient Hospital";
break;
default:
code = "21";
display = "Inpatient Hospital";
}
location.addCoding().setCode(code).setSystem("https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd").setDisplay(display);
itemComponent.setLocation(location);
// Adjudication
if (item.hasNet()) {
// Assume that the patient has already paid deductible and
// has 20/80 coinsurance
ExplanationOfBenefit.AdjudicationComponent coinsuranceAmount = new ExplanationOfBenefit.AdjudicationComponent();
coinsuranceAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Beneficiary Coinsurance Amount"));
coinsuranceAmount.getAmount().setValue(// 20% coinsurance
0.2 * item.getNet().getValue().doubleValue()).setSystem(// USD
"urn:iso:std:iso:4217").setCode("USD");
ExplanationOfBenefit.AdjudicationComponent lineProviderAmount = new ExplanationOfBenefit.AdjudicationComponent();
lineProviderAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Provider Payment Amount"));
lineProviderAmount.getAmount().setValue(0.8 * item.getNet().getValue().doubleValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
// assume the allowed and submitted amounts are the same for now
ExplanationOfBenefit.AdjudicationComponent submittedAmount = new ExplanationOfBenefit.AdjudicationComponent();
submittedAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Submitted Charge Amount"));
submittedAmount.getAmount().setValue(item.getNet().getValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
ExplanationOfBenefit.AdjudicationComponent allowedAmount = new ExplanationOfBenefit.AdjudicationComponent();
allowedAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Allowed Charge Amount"));
allowedAmount.getAmount().setValue(item.getNet().getValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
ExplanationOfBenefit.AdjudicationComponent indicatorCode = new ExplanationOfBenefit.AdjudicationComponent();
indicatorCode.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Processing Indicator Code"));
if (!inpatient && !outpatient) {
indicatorCode.getReason().addCoding().setCode("A").setSystem("https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd");
indicatorCode.getReason().getCodingFirstRep().setDisplay("Allowed");
}
// assume deductible is 0
ExplanationOfBenefit.AdjudicationComponent deductibleAmount = new ExplanationOfBenefit.AdjudicationComponent();
deductibleAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Beneficiary Part B Deductible Amount"));
deductibleAmount.getAmount().setValue(0).setSystem("urn:iso:std:iso:4217").setCode("USD");
List<ExplanationOfBenefit.AdjudicationComponent> adjudicationComponents = new ArrayList<>();
adjudicationComponents.add(coinsuranceAmount);
adjudicationComponents.add(lineProviderAmount);
adjudicationComponents.add(submittedAmount);
adjudicationComponents.add(allowedAmount);
adjudicationComponents.add(deductibleAmount);
adjudicationComponents.add(indicatorCode);
itemComponent.setAdjudication(adjudicationComponents);
// the total payment is what the insurance ends up paying
totalPayment += 0.8 * item.getNet().getValue().doubleValue();
}
eobItem.add(itemComponent);
}
eob.setItem(eobItem);
// This will throw a validation error no matter what. The
// payment section is required, and it requires a value.
// The validator will complain that if there is a value, the payment
// needs a code, but it will also complain if there is a code.
// There is no way to resolve this error.
Money payment = new Money();
payment.setValue(totalPayment).setSystem("urn:iso:std:iso:4217").setCode("USD");
eob.setPayment(new ExplanationOfBenefit.PaymentComponent().setAmount(payment));
// Hardcoded
String npi = "9999999999";
if (encounter.clinician != null) {
npi = encounter.clinician.npi;
} else if (encounter.provider != null) {
npi = encounter.provider.npi;
}
List<Reference> recipientList = new ArrayList<>();
recipientList.add(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi)));
eob.addContained(new ReferralRequest().setStatus(ReferralRequest.ReferralRequestStatus.COMPLETED).setIntent(ReferralRequest.ReferralCategory.ORDER).setSubject(new Reference(personEntry.getFullUrl())).setRequester(new ReferralRequest.ReferralRequestRequesterComponent().setAgent(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi)))).setRecipient(recipientList).setId("1"));
if (encounter.clinician != null) {
// This is what should happen if BlueButton 2.0 wasn't needlessly restrictive
// String practitionerFullUrl = findPractitioner(encounter.clinician, bundle);
// eob.setProvider(new Reference().setReference(practitionerFullUrl));
// Instead, we'll create the BlueButton 2.0 reference via identifier...
Identifier identifier = new Identifier();
identifier.setValue(encounter.clinician.getResourceID());
eob.setProvider(new Reference().setIdentifier(identifier));
} else {
Identifier identifier = new Identifier();
identifier.setValue("Unknown");
eob.setProvider(new Reference().setIdentifier(identifier));
}
eob.addCareTeam(new ExplanationOfBenefit.CareTeamComponent().setSequence(1).setProvider(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi))).setRole(new CodeableConcept().addCoding(new Coding().setCode("primary").setSystem("http://hl7.org/fhir/claimcareteamrole").setDisplay("Primary Care Practitioner"))));
eob.setType(new CodeableConcept().addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd").setCode("71").setDisplay("Local carrier non-durable medical equipment, prosthetics, orthotics, " + "and supplies (DMEPOS) claim")).addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/codesystem/eob-type").setCode("CARRIER").setDisplay("EOB Type")).addCoding(new Coding().setSystem("http://hl7.org/fhir/ex-claimtype").setCode("professional").setDisplay("Claim Type")).addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd").setCode("O").setDisplay("Part B physician/supplier claim record (processed by local " + "carriers; can include DMEPOS services)")));
return newEntry(person, bundle, eob);
}
use of org.hl7.fhir.dstu3.model.Claim.ProcedureComponent in project synthea by synthetichealth.
the class FhirR4 method encounterClaim.
/**
* Create an entry for the given Claim, associated to an Encounter.
*
* @param person The patient having the encounter.
* @param personEntry Entry for the person
* @param bundle The Bundle to add to
* @param encounterEntry The current Encounter
* @param claim the Claim object
* @return the added Entry
*/
private static BundleEntryComponent encounterClaim(Person person, BundleEntryComponent personEntry, Bundle bundle, BundleEntryComponent encounterEntry, Claim claim) {
org.hl7.fhir.r4.model.Claim claimResource = new org.hl7.fhir.r4.model.Claim();
org.hl7.fhir.r4.model.Encounter encounterResource = (org.hl7.fhir.r4.model.Encounter) encounterEntry.getResource();
claimResource.setStatus(ClaimStatus.ACTIVE);
CodeableConcept type = new CodeableConcept();
type.getCodingFirstRep().setSystem("http://terminology.hl7.org/CodeSystem/claim-type").setCode("institutional");
claimResource.setType(type);
claimResource.setUse(org.hl7.fhir.r4.model.Claim.Use.CLAIM);
InsuranceComponent insuranceComponent = new InsuranceComponent();
insuranceComponent.setSequence(1);
insuranceComponent.setFocal(true);
insuranceComponent.setCoverage(new Reference().setDisplay(claim.payer.getName()));
claimResource.addInsurance(insuranceComponent);
// duration of encounter
claimResource.setBillablePeriod(encounterResource.getPeriod());
claimResource.setCreated(encounterResource.getPeriod().getEnd());
claimResource.setPatient(new Reference().setReference(personEntry.getFullUrl()).setDisplay((String) person.attributes.get(Person.NAME)));
claimResource.setProvider(encounterResource.getServiceProvider());
if (USE_US_CORE_IG) {
claimResource.setFacility(encounterResource.getLocationFirstRep().getLocation());
}
// set the required priority
CodeableConcept priority = new CodeableConcept();
priority.getCodingFirstRep().setSystem("http://terminology.hl7.org/CodeSystem/processpriority").setCode("normal");
claimResource.setPriority(priority);
// add item for encounter
claimResource.addItem(new ItemComponent(new PositiveIntType(1), encounterResource.getTypeFirstRep()).addEncounter(new Reference(encounterEntry.getFullUrl())));
int itemSequence = 2;
int conditionSequence = 1;
int procedureSequence = 1;
int informationSequence = 1;
for (Claim.ClaimEntry claimEntry : claim.items) {
HealthRecord.Entry item = claimEntry.entry;
if (Costs.hasCost(item)) {
// update claimItems list
Code primaryCode = item.codes.get(0);
String system = ExportHelper.getSystemURI(primaryCode.system);
ItemComponent claimItem = new ItemComponent(new PositiveIntType(itemSequence), mapCodeToCodeableConcept(primaryCode, system));
// calculate the cost of the procedure
Money moneyResource = new Money();
moneyResource.setCurrency("USD");
moneyResource.setValue(item.getCost());
claimItem.setNet(moneyResource);
claimResource.addItem(claimItem);
if (item instanceof Procedure) {
Type procedureReference = new Reference(item.fullUrl);
ProcedureComponent claimProcedure = new ProcedureComponent(new PositiveIntType(procedureSequence), procedureReference);
claimResource.addProcedure(claimProcedure);
claimItem.addProcedureSequence(procedureSequence);
procedureSequence++;
} else {
Reference informationReference = new Reference(item.fullUrl);
SupportingInformationComponent informationComponent = new SupportingInformationComponent();
informationComponent.setSequence(informationSequence);
informationComponent.setValue(informationReference);
CodeableConcept category = new CodeableConcept();
category.getCodingFirstRep().setSystem("http://terminology.hl7.org/CodeSystem/claiminformationcategory").setCode("info");
informationComponent.setCategory(category);
claimResource.addSupportingInfo(informationComponent);
claimItem.addInformationSequence(informationSequence);
informationSequence++;
}
} else {
// assume it's a Condition, we don't have a Condition class specifically
// add diagnosisComponent to claim
Reference diagnosisReference = new Reference(item.fullUrl);
DiagnosisComponent diagnosisComponent = new DiagnosisComponent(new PositiveIntType(conditionSequence), diagnosisReference);
claimResource.addDiagnosis(diagnosisComponent);
// update claimItems with diagnosis
ItemComponent diagnosisItem = new ItemComponent(new PositiveIntType(itemSequence), mapCodeToCodeableConcept(item.codes.get(0), SNOMED_URI));
diagnosisItem.addDiagnosisSequence(conditionSequence);
claimResource.addItem(diagnosisItem);
conditionSequence++;
}
itemSequence++;
}
Money moneyResource = new Money();
moneyResource.setCurrency("USD");
moneyResource.setValue(claim.getTotalClaimCost());
claimResource.setTotal(moneyResource);
return newEntry(person, bundle, claimResource);
}
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