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

Example 1 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.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();
}

Example 2 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.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");
}

Example 3 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.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);
}

Example 4 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.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);
}

Example 5 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.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);
}