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

Example 61 with Coverage

use of org.hl7.fhir.r4.model.Coverage in project CRD by HL7-DaVinci.

the class QueryBatchRequest method performQueryBatchRequest.

/**
 * Backfills the missing required values of the response that prefetch may have missed.
 * This implementation pulls the IDs of the required references from the request object's draft
 * orders, checks which of those values are missing from the current CRD response, builds the
 * Query Batch JSON request using
 * http://build.fhir.org/ig/HL7/davinci-crd/hooks.html#fhir-resource-access,
 * then populates the CRD response with the response from the Query Batch.
 */
public void performQueryBatchRequest(CdsRequest<?, ?> cdsRequest, CrdPrefetch crdPrefetch) {
    logger.info("***** ***** Performing Query Batch Request.");
    CrdPrefetch crdResponse = crdPrefetch;
    // The list of references that should be queried in the batch request.
    List<String> requiredReferences = new ArrayList<String>();
    // Get the IDs of references in the request's draft orders.
    Bundle draftOrdersBundle = cdsRequest.getContext().getDraftOrders();
    // This assumes that only the first draft order is relevant.
    Resource initialRequestResource = draftOrdersBundle.getEntry().get(0).getResource();
    ResourceType requestType = initialRequestResource.getResourceType();
    // Extract the references by iterating through the JSON.
    Gson gson = new Gson();
    final JsonObject jsonObject = gson.toJsonTree(initialRequestResource).getAsJsonObject();
    for (Map.Entry<String, JsonElement> entry : jsonObject.entrySet()) {
        FhirRequestProcessor.extractReferenceIds(requiredReferences, entry.getValue());
    }
    // Filter out references that already exist in the CRD Response.
    requiredReferences = requiredReferences.stream().filter(referenceId -> !crdResponse.containsRequestResourceId(referenceId)).collect(Collectors.toList());
    logger.info("References to query: " + requiredReferences);
    if (requiredReferences.isEmpty()) {
        logger.info("A Query Batch Request is not needed: all references have already already fetched.");
        return;
    }
    // Build the Query Batch Request JSON.
    Bundle queryBatchRequestBundle = buildQueryBatchRequestBundle(requiredReferences);
    String queryBatchRequestBody = FhirContext.forR4().newJsonParser().encodeResourceToString(queryBatchRequestBundle);
    // Make the query batch request to the EHR server.
    Bundle queryResponseBundle = null;
    try {
        logger.info("Executing Query Batch Request: " + queryBatchRequestBody);
        queryResponseBundle = (Bundle) FhirRequestProcessor.executeFhirQueryBody(queryBatchRequestBody, cdsRequest, this.fhirComponents, HttpMethod.POST);
        queryResponseBundle = extractNestedBundledResources(queryResponseBundle);
        logger.info("Extracted Query Batch Resources: " + (queryResponseBundle).getEntry().stream().map(entry -> entry.getResource()).collect(Collectors.toList()));
    } catch (Exception e) {
        logger.error("Failed to backfill prefetch with Query Batch Request " + queryBatchRequestBody, e);
    }
    if (queryResponseBundle == null) {
        logger.error("No response recieved from the Query Batch Request.");
        return;
    }
    // Add the request resource to the query batch response as it may be missing.
    // Coverage and Subject are not automatically being
    // linked to the request object. It seems to somehow automatically link during
    // standard prefetch, but not here so we're doing it manually.
    List<Coverage> coverages = FhirRequestProcessor.extractCoverageFromBundle(queryResponseBundle);
    List<Patient> patients = FhirRequestProcessor.extractPatientsFromBundle(queryResponseBundle);
    FhirRequestProcessor.addInsuranceAndSubject(initialRequestResource, patients, coverages);
    BundleEntryComponent newEntry = new BundleEntryComponent();
    newEntry.setResource(initialRequestResource);
    queryResponseBundle.addEntry(newEntry);
    // Add the query batch response resources to the CRD Prefetch request.
    logger.info("Query Batch Response Entries: " + queryResponseBundle.getEntry());
    FhirRequestProcessor.addToCrdPrefetchRequest(crdResponse, requestType, queryResponseBundle.getEntry());
    logger.info("Post-Query Batch CRDResponse: " + crdResponse);
}

Example 62 with Coverage

use of org.hl7.fhir.r4.model.Coverage in project CRD by HL7-DaVinci.

the class RuleFinder method findRules.

/**
 * Find and retern the relevant coverage rules in the database.
 * @param criteria The search criteria object
 * @return List of matching RuleMapping entries
 */
public List<RuleMapping> findRules(CoverageRequirementRuleCriteria criteria) {
    logger.info("RuleFinder::findRules(" + criteria.getQueryString() + ")");
    List<RuleMapping> ruleList = new ArrayList<>();
    if (ruleMappingRepository == null) {
        logger.warn("RuleFinder::findRules: the ruleMappingRepository is null");
        return ruleList;
    }
    for (RuleMapping rule : ruleMappingRepository.findRules(criteria)) {
        ruleList.add(rule);
    }
    if (ruleList.size() == 0) {
        logger.info("RuleFinder::findRules() returned no results for query: " + criteria.toString());
    }
    return ruleList;
}

Example 63 with Coverage

use of org.hl7.fhir.r4.model.Coverage 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));
    }
    String npi = "9999999999";
    if (encounter.clinician != null) {
        npi = encounter.clinician.npi;
    } else if (encounter.provider != null) {
        npi = encounter.provider.npi;
    }
    // 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()));
        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("referral"));
        eob.setReferral(new Reference("#referral"));
        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));
    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);
}

Example 64 with Coverage

use of org.hl7.fhir.r4.model.Coverage in project dpc-app by CMSgov.

the class BlueButtonClientTest method shouldGetCoverageFromPatientID.

@Test
void shouldGetCoverageFromPatientID() {
    final Bundle response = bbc.requestCoverageFromServer(TEST_PATIENT_ID, TEST_LAST_UPDATED, null);
    assertNotNull(response, "The demo patient should have a non-null Coverage bundle");
    assertEquals(3, response.getTotal(), "The demo patient should have exactly 3 Coverage");
}

Example 65 with Coverage

use of org.hl7.fhir.r4.model.Coverage in project dpc-app by CMSgov.

the class BlueButtonClientV2Test method shouldGetCoverageFromPatientID.

@Test
void shouldGetCoverageFromPatientID() {
    final Bundle response = bbc.requestCoverageFromServer(TEST_PATIENT_ID, TEST_LAST_UPDATED, null);
    assertNotNull(response, "The demo patient should have a non-null Coverage bundle");
    assertEquals(4, response.getTotal(), "The demo patient should have exactly 3 Coverage");
}