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

Example 66 with Claim

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

the class CarrierClaimTransformerV2 method transform.

/**
 * @param metricRegistry the {@link MetricRegistry} to use
 * @param claim the CCW {@link CarrierClaim} to transform
 * @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
 *     CarrierClaim}
 */
@Trace
static ExplanationOfBenefit transform(MetricRegistry metricRegistry, Object claim, Optional<Boolean> includeTaxNumbers) {
    Timer.Context timer = metricRegistry.timer(MetricRegistry.name(CarrierClaimTransformerV2.class.getSimpleName(), "transform")).time();
    if (!(claim instanceof CarrierClaim)) {
        throw new BadCodeMonkeyException();
    }
    ExplanationOfBenefit eob = transformClaim((CarrierClaim) claim, includeTaxNumbers);
    timer.stop();
    return eob;
}

Example 67 with Claim

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

the class CarrierClaimTransformerV2 method transformClaim.

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

Example 68 with Claim

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

the class R4ExplanationOfBenefitResourceProviderIT method readEobForExistingInpatientClaim.

/**
 * Verifies that {@link
 * gov.cms.bfd.server.war.r4.providers.ExplanationOfBenefitResourceProvider#read(org.hl7.fhir.r4.model.IdType)}
 * works as expected for an {@link InpatientClaim}-derived {@link ExplanationOfBenefit} that does
 * exist in the DB.
 *
 * @throws FHIRException (indicates test failure)
 */
@Test
public void readEobForExistingInpatientClaim() throws FHIRException {
    List<Object> loadedRecords = ServerTestUtils.get().loadData(Arrays.asList(StaticRifResourceGroup.SAMPLE_A.getResources()));
    IGenericClient fhirClient = ServerTestUtils.get().createFhirClientV2();
    InpatientClaim claim = loadedRecords.stream().filter(r -> r instanceof InpatientClaim).map(r -> (InpatientClaim) r).findFirst().get();
    ExplanationOfBenefit eob = fhirClient.read().resource(ExplanationOfBenefit.class).withId(TransformerUtilsV2.buildEobId(ClaimTypeV2.INPATIENT, claim.getClaimId())).execute();
    assertNotNull(eob);
    // Compare result to transformed EOB
    compareEob(ClaimTypeV2.INPATIENT, eob, loadedRecords);
}

Example 69 with Claim

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

the class R4ExplanationOfBenefitResourceProviderIT method searchForSamhsaEobsWithExcludeSamhsaTrue.

/**
 * Verifies that {@link
 * gov.cms.bfd.server.war.r4.providers.R4ExplanationOfBenefitResourceProvider#findByPatient} with
 * <code>excludeSAMHSA=true</code> properly filters out SAMHSA-related claims.
 *
 * @throws FHIRException (indicates test failure)
 */
@Test
public void searchForSamhsaEobsWithExcludeSamhsaTrue() throws FHIRException {
    Beneficiary beneficiary = loadSampleAWithSamhsa();
    IGenericClient fhirClient = ServerTestUtils.get().createFhirClientV2();
    Bundle searchResults = fhirClient.search().forResource(ExplanationOfBenefit.class).where(ExplanationOfBenefit.PATIENT.hasId(TransformerUtilsV2.buildPatientId(beneficiary.getBeneficiaryId()))).and(new StringClientParam(EXCLUDE_SAMHSA_PARAM).matches().value("true")).returnBundle(Bundle.class).execute();
    assertNotNull(searchResults);
    for (ClaimTypeV2 claimType : ClaimTypeV2.values()) {
        /*
       * SAMHSA fields are present on all claim types except for PDE so we should not
       * get any claims back in the results except for PDE.
       */
        if (claimType == ClaimTypeV2.PDE) {
            assertEquals(1, filterToClaimType(searchResults, claimType).size());
        } else {
            assertEquals(0, filterToClaimType(searchResults, claimType).size());
        }
    }
}

Example 70 with Claim

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

the class R4ExplanationOfBenefitResourceProviderIT method adjustCarrierClaimForSamhsaDiagnosis.

/**
 * Adjusts the carrier claim to support samhsa.
 *
 * @param loadedRecords the loaded records
 * @param entityManager the entity manager
 */
private void adjustCarrierClaimForSamhsaDiagnosis(List<Object> loadedRecords, EntityManager entityManager) {
    CarrierClaim carrierRifRecord = loadedRecords.stream().filter(r -> r instanceof CarrierClaim).map(r -> (CarrierClaim) r).findFirst().get();
    entityManager.getTransaction().begin();
    carrierRifRecord = entityManager.find(CarrierClaim.class, carrierRifRecord.getClaimId());
    carrierRifRecord.setDiagnosis2Code(Optional.of(Stu3EobSamhsaMatcherTest.SAMPLE_SAMHSA_ICD_9_DIAGNOSIS_CODE));
    carrierRifRecord.setDiagnosis2CodeVersion(Optional.of('9'));
    entityManager.merge(carrierRifRecord);
    entityManager.getTransaction().commit();
}