Examples with Claim org.hl7.fhir.r4.model.Claim used on opensource projects

Example 56 with Claim

use of org.hl7.fhir.r4.model.Claim in project beneficiary-fhir-data by CMSgov.

the class CarrierClaimTransformerV2Test method shouldHaveClmPassThruClaimSubmittedChargeFinancial.

@Test
public void shouldHaveClmPassThruClaimSubmittedChargeFinancial() {
    BenefitComponent benefit = TransformerTestUtilsV2.findFinancial("https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt", eob.getBenefitBalanceFirstRep().getFinancial());
    BenefitComponent compare = new BenefitComponent().setType(new CodeableConcept().setCoding(Arrays.asList(new Coding("https://bluebutton.cms.gov/resources/codesystem/benefit-balance", "https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt", "NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)")))).setUsed(new Money().setValueElement(new DecimalType("245.04")).setCurrency(TransformerConstants.CODED_MONEY_USD));
    assertTrue(compare.equalsDeep(benefit));
}

Example 57 with Claim

use of org.hl7.fhir.r4.model.Claim in project beneficiary-fhir-data by CMSgov.

the class CarrierClaimTransformerV2Test method shouldHaveClmPassThruClaimAllowedChargeFinancial.

@Test
public void shouldHaveClmPassThruClaimAllowedChargeFinancial() {
    BenefitComponent benefit = TransformerTestUtilsV2.findFinancial("https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt", eob.getBenefitBalanceFirstRep().getFinancial());
    BenefitComponent compare = new BenefitComponent().setType(new CodeableConcept().setCoding(Arrays.asList(new Coding("https://bluebutton.cms.gov/resources/codesystem/benefit-balance", "https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt", "NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)")))).setUsed(new Money().setValueElement(new DecimalType("166.23")).setCurrency(TransformerConstants.CODED_MONEY_USD));
    assertTrue(compare.equalsDeep(benefit));
}

Example 58 with Claim

use of org.hl7.fhir.r4.model.Claim in project beneficiary-fhir-data by CMSgov.

the class HospiceClaimTransformerV2 method transformClaim.

/**
 * @param claimGroup the CCW {@link HospiceClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     HospiceClaim}
 */
private static ExplanationOfBenefit transformClaim(HospiceClaim 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.HOSPICE, 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.HOSPICE, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // PRVDR_NUM => ExplanationOfBenefit.provider.identifier
    TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
    // NCH_PTNT_STUS_IND_CD => ExplanationOfBenefit.supportingInfo.code
    if (claimGroup.getPatientStatusCd().isPresent()) {
        TransformerUtilsV2.addInformationWithCode(eob, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, claimGroup.getPatientStatusCd());
    }
    // CLM_ADMSN_DT       => ExplanationOfBenefit.supportingInfo:admissionperiod
    // NCH_BENE_DSCHRG_DT => ExplanationOfBenefit.supportingInfo:admissionperiod
    TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationAdmPeriodSlice(eob, claimGroup.getClaimHospiceStartDate(), claimGroup.getBeneficiaryDischargeDate()));
    // CLM_UTLZTN_DAY_CNT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_UTLZTN_DAY_CNT, claimGroup.getUtilizationDayCount());
    // 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 (PRPAYAMT)
    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());
    // CLM_E_POA_IND_SW(1-12)   => diagnosis.type
    for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
        DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.HOSPICE);
    }
    // Map care team
    // AT_PHYSN_NPI     => ExplanationOfBenefit.careTeam.provider
    // AT_PHYSN_UPIN    => ExplanationOfBenefit.careTeam.provider
    TransformerUtilsV2.mapCareTeam(eob, claimGroup.getAttendingPhysicianNpi(), Optional.empty(), Optional.empty(), claimGroup.getAttendingPhysicianUpin(), Optional.empty(), Optional.empty());
    for (HospiceClaimLine line : claimGroup.getLines()) {
        ItemComponent item = TransformerUtilsV2.addItem(eob);
        // Override the default sequence
        // CLM_LINE_NUM => item.sequence
        item.setSequence(line.getLineNumber().intValue());
        // PRVDR_STATE_CD => item.location
        TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
        // 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.getRevenueCenterCode(), line.getRateAmount(), line.getTotalChargeAmount(), 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());
        // HCPCS_CD           => ExplanationOfBenefit.item.productOrService
        // HCPCS_1ST_MDFR_CD  => ExplanationOfBenefit.item.modifier
        // HCPCS_2ND_MDFR_CD  => ExplanationOfBenefit.item.modifier
        TransformerUtilsV2.mapHcpcs(eob, item, line.getHcpcsCode(), Optional.empty(), Arrays.asList(line.getHcpcsInitialModifierCode(), line.getHcpcsSecondModifierCode()));
        // REV_CNTR_PRVDR_PMT_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_PRVDR_PMT_AMT, C4BBAdjudication.PAID_TO_PROVIDER, line.getProviderPaymentAmount()));
        // REV_CNTR_BENE_PMT_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_BENE_PMT_AMT, C4BBAdjudication.PAID_TO_PATIENT, line.getBenficiaryPaymentAmount()));
        // Common item level fields between Outpatient, HHA and Hospice
        // REV_CNTR_DT              => ExplanationOfBenefit.item.servicedDate
        // REV_CNTR_PMT_AMT_AMT     => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.mapEobCommonItemRevenueOutHHAHospice(item, line.getRevenueCenterDate(), line.getPaymentAmount());
    }
    TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}

Example 59 with Claim

use of org.hl7.fhir.r4.model.Claim in project beneficiary-fhir-data by CMSgov.

the class InpatientClaimTransformerV2 method transformClaim.

/**
 * @param claimGroup the CCW {@link InpatientClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     InpatientClaim}
 */
private static ExplanationOfBenefit transformClaim(InpatientClaim 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 (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.INPATIENT, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, Optional.of(claimGroup.getDateFrom()), Optional.of(claimGroup.getDateThrough()), Optional.of(claimGroup.getPaymentAmount()), claimGroup.getFinalAction());
    // map eob type codes into FHIR
    // NCH_CLM_TYPE_CD              => ExplanationOfBenefit.type.coding
    // EOB Type                     => ExplanationOfBenefit.type.coding
    // Claim Type  (institutional)  => ExplanationOfBenefit.type.coding
    // NCH_NEAR_LINE_REC_IDENT_CD   => ExplanationOfBenefit.extension
    TransformerUtilsV2.mapEobType(eob, ClaimTypeV2.INPATIENT, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // set the provider number which is common among several claim types
    // PRVDR_NUM => ExplanationOfBenefit.provider.identifier
    TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
    // 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()));
    // 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.getCoveredCareThoughDate(), claimGroup.getMedicareBenefitsExhaustedDate(), claimGroup.getDiagnosisRelatedGroupCd());
    // IME_OP_CLM_VAL_AMT => ExplanationOfBenefit.extension
    TransformerUtilsV2.addAdjudicationTotal(eob, CcwCodebookVariable.IME_OP_CLM_VAL_AMT, claimGroup.getIndirectMedicalEducationAmount());
    // DSH_OP_CLM_VAL_AMT => ExplanationOfBenefit.extension
    TransformerUtilsV2.addAdjudicationTotal(eob, CcwCodebookVariable.DSH_OP_CLM_VAL_AMT, claimGroup.getDisproportionateShareAmount());
    // CLM_PASS_THRU_PER_DIEM_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_PASS_THRU_PER_DIEM_AMT, Optional.ofNullable(claimGroup.getPassThruPerDiemAmount()));
    // NCH_PROFNL_CMPNT_CHRG_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_PROFNL_CMPNT_CHRG_AMT, Optional.ofNullable(claimGroup.getProfessionalComponentCharge()));
    // CLM_TOT_PPS_CPTL_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_TOT_PPS_CPTL_AMT, claimGroup.getClaimTotalPPSCapitalAmount());
    /*
     * 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());
    // NCH_DRG_OUTLIER_APRVD_PMT_AMT => ExplanationOfBenefit.extension
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_DRG_OUTLIER_APRVD_PMT_AMT, claimGroup.getDrgOutlierApprovedPaymentAmount());
    // 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 (PRPAYAMT)
    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());
    // CLM_UTLZTN_DAY_CNT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_UTLZTN_DAY_CNT, Optional.of(claimGroup.getUtilizationDayCount()));
    // CLM_E_POA_IND_SW(1-12)   => diagnosis.type
    for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
        DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.INPATIENT);
    }
    // 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()));
    // NCH_WKLY_PROC_DT => ExplanationOfBenefit.supportinginfo.timingDate
    TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationRecievedDateSlice(eob, CcwCodebookVariable.NCH_WKLY_PROC_DT, Optional.of(claimGroup.getWeeklyProcessDate())));
    // CLM_PPS_CPTL_DRG_WT_NUM => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_PPS_CPTL_DRG_WT_NUM, claimGroup.getClaimPPSCapitalDrgWeightNumber());
    // BENE_LRD_USED_CNT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.BENE_LRD_USED_CNT, claimGroup.getLifetimeReservedDaysUsedCount());
    // ClaimLine => ExplanationOfBenefit.item
    for (InpatientClaimLine line : claimGroup.getLines()) {
        ItemComponent item = TransformerUtilsV2.addItem(eob);
        // Override the default sequence
        // CLM_LINE_NUM => item.sequence
        item.setSequence(line.getLineNumber().intValue());
        // PRVDR_STATE_CD => item.location
        TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
        // 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());
        // HCPCS_CD => item.productOrService
        line.getHcpcsCode().ifPresent(c -> item.setProductOrService(new CodeableConcept().setCoding(Arrays.asList(new Coding().setSystem(CCWUtils.calculateVariableReferenceUrl(CcwCodebookVariable.HCPCS_CD)).setCode(c), new Coding().setSystem(TransformerConstants.CODING_SYSTEM_HCPCS).setCode(c)))));
        // 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 60 with Claim

use of org.hl7.fhir.r4.model.Claim in project beneficiary-fhir-data by CMSgov.

the class OutpatientClaimTransformerV2 method transformClaim.

/**
 * @param claimGroup the CCW {@link InpatientClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     InpatientClaim}
 */
private static ExplanationOfBenefit transformClaim(OutpatientClaim claimGroup) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    // Required values not directly mapped
    eob.getMeta().addProfile(ProfileConstants.C4BB_EOB_OUTPATIENT_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
    // 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.OUTPATIENT, 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 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());
    // map eob type codes into FHIR
    // NCH_CLM_TYPE_CD => ExplanationOfBenefit.type.coding
    // EOB Type => ExplanationOfBenefit.type.coding
    // Claim Type (institutional) => ExplanationOfBenefit.type.coding
    // NCH_NEAR_LINE_REC_IDENT_CD => ExplanationOfBenefit.extension
    TransformerUtilsV2.mapEobType(eob, ClaimTypeV2.OUTPATIENT, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
    // set the provider number which is common among several claim types
    // PRVDR_NUM => ExplanationOfBenefit.provider.identifier
    TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
    // NCH_PROFNL_CMPNT_CHRG_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_PROFNL_CMPNT_CHRG_AMT, Optional.ofNullable(claimGroup.getProfessionalComponentCharge()));
    // NCH_BENE_PTB_DDCTBL_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_BENE_PTB_DDCTBL_AMT, Optional.ofNullable(claimGroup.getDeductibleAmount()));
    // NCH_BENE_PTB_COINSRNC_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_BENE_PTB_COINSRNC_AMT, Optional.ofNullable(claimGroup.getCoinsuranceAmount()));
    // CLM_OP_PRVDR_PMT_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_OP_PRVDR_PMT_AMT, Optional.ofNullable(claimGroup.getProviderPaymentAmount()));
    // CLM_OP_PRVDR_PMT_AMT => ExplanationOfBenefit.benefitBalance.financial
    TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_OP_BENE_PMT_AMT, Optional.ofNullable(claimGroup.getBeneficiaryPaymentAmount()));
    // 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 (PRPAYAMT)
    TransformerUtilsV2.mapEobCommonGroupInpOutHHAHospiceSNF(eob, claimGroup.getOrganizationNpi(), claimGroup.getClaimFacilityTypeCode(), claimGroup.getClaimFrequencyCode(), claimGroup.getClaimNonPaymentReasonCode(), claimGroup.getPatientDischargeStatusCode().get(), 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.OUTPATIENT);
    }
    // Handle Inpatient Diagnosis.  Only three, so just brute force it
    // RSN_VISIT_CD1        => diagnosis.diagnosisCodeableConcept
    // RSN_VISIT_VRSN_CD1   => diagnosis.diagnosisCodeableConcept
    DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission1", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
    // RSN_VISIT_CD2        => diagnosis.diagnosisCodeableConcept
    // RSN_VISIT_VRSN_CD2   => diagnosis.diagnosisCodeableConcept
    DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission2", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
    // RSN_VISIT_CD3        => diagnosis.diagnosisCodeableConcept
    // RSN_VISIT_VRSN_CD3   => diagnosis.diagnosisCodeableConcept
    DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission3", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
    // 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()));
    // ClaimLine => ExplanationOfBenefit.item
    for (OutpatientClaimLine line : claimGroup.getLines()) {
        ItemComponent item = TransformerUtilsV2.addItem(eob);
        // CLM_LINE_NUM => item.sequence
        item.setSequence(line.getLineNumber().intValue());
        // PRVDR_STATE_CD => item.location
        TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
        // REV_CNTR => item.revenue
        item.setRevenue(TransformerUtilsV2.createCodeableConcept(eob, CcwCodebookVariable.REV_CNTR, line.getRevenueCenterCode()));
        // REV_CNTR_1ST_ANSI_CD => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_1ST_ANSI_CD, line.getRevCntr1stAnsiCd()));
        // REV_CNTR_2ND_ANSI_CD => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_2ND_ANSI_CD, line.getRevCntr2ndAnsiCd()));
        // REV_CNTR_3RD_ANSI_CD => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_3RD_ANSI_CD, line.getRevCntr3rdAnsiCd()));
        // REV_CNTR_4RD_ANSI_CD => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_4TH_ANSI_CD, line.getRevCntr4thAnsiCd()));
        // HCPCS_CD               => ExplanationOfBenefit.item.productOrService
        // HCPCS_1ST_MDFR_CD      => ExplanationOfBenefit.item.modifier
        // HCPCS_2ND_MDFR_CD      => ExplanationOfBenefit.item.modifier
        TransformerUtilsV2.mapHcpcs(eob, item, line.getHcpcsCode(), Optional.empty(), Arrays.asList(line.getHcpcsInitialModifierCode(), line.getHcpcsSecondModifierCode()));
        // 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.getRevenueCenterCode(), line.getRateAmount(), line.getTotalChargeAmount(), Optional.of(line.getNonCoveredChargeAmount()), line.getNationalDrugCodeQuantity(), line.getNationalDrugCodeQualifierCode());
        // REV_CNTR_BLOOD_DDCTBL_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_BLOOD_DDCTBL_AMT, C4BBAdjudication.DEDUCTIBLE, line.getBloodDeductibleAmount()));
        // REV_CNTR_CASH_DDCTBL_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_CASH_DDCTBL_AMT, C4BBAdjudication.DEDUCTIBLE, line.getCashDeductibleAmount()));
        // REV_CNTR_COINSRNC_WGE_ADJSTD_C => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_COINSRNC_WGE_ADJSTD_C, C4BBAdjudication.COINSURANCE, line.getWageAdjustedCoinsuranceAmount()));
        // REV_CNTR_RDCD_COINSRNC_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_RDCD_COINSRNC_AMT, C4BBAdjudication.COINSURANCE, line.getReducedCoinsuranceAmount()));
        // REV_CNTR_1ST_MSP_PD_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_1ST_MSP_PD_AMT, C4BBAdjudication.PRIOR_PAYER_PAID, line.getFirstMspPaidAmount()));
        // REV_CNTR_2ND_MSP_PD_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_2ND_MSP_PD_AMT, C4BBAdjudication.PRIOR_PAYER_PAID, line.getSecondMspPaidAmount()));
        // REV_CNTR_PRVDR_PMT_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_PRVDR_PMT_AMT, C4BBAdjudication.PAID_TO_PROVIDER, line.getProviderPaymentAmount()));
        // REV_CNTR_BENE_PMT_AMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_BENE_PMT_AMT, C4BBAdjudication.PAID_TO_PATIENT, line.getBenficiaryPaymentAmount()));
        // REV_CNTR_PTNT_RSPNSBLTY_PMT => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_PTNT_RSPNSBLTY_PMT, C4BBAdjudication.PAID_BY_PATIENT, line.getPatientResponsibilityAmount()));
        // Common item level fields between Outpatient, HHA and Hospice
        // REV_CNTR_DT              => ExplanationOfBenefit.item.servicedDate
        // REV_CNTR_PMT_AMT_AMT     => ExplanationOfBenefit.item.adjudication
        TransformerUtilsV2.mapEobCommonItemRevenueOutHHAHospice(item, line.getRevenueCenterDate(), line.getPaymentAmount());
        // REV_CNTR_IDE_NDC_UPC_NUM => ExplanationOfBenefit.item.productOrService.extension
        TransformerUtilsV2.addNationalDrugCode(item, line.getNationalDrugCode());
        // 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());
        // REV_CNTR_STUS_IND_CD => ExplanationOfBenefit.item.revenue.extension
        TransformerUtilsV2.mapEobCommonItemRevenueStatusCode(item, eob, line.getStatusCode());
    }
    TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
    return eob;
}