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

Example 6 with ProcedureComponent

use of org.hl7.fhir.r4.model.ExplanationOfBenefit.ProcedureComponent in project synthea by synthetichealth.

the class FhirR4 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) {
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    eob.setStatus(org.hl7.fhir.r4.model.ExplanationOfBenefit.ExplanationOfBenefitStatus.ACTIVE);
    eob.setType(new CodeableConcept().addCoding(new Coding().setSystem("http://terminology.hl7.org/CodeSystem/claim-type").setCode("professional").setDisplay("Professional")));
    eob.setUse(Use.CLAIM);
    eob.setOutcome(RemittanceOutcome.COMPLETE);
    org.hl7.fhir.r4.model.Encounter encounterResource = (org.hl7.fhir.r4.model.Encounter) encounterEntry.getResource();
    // 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());
    eob.setBillablePeriod(billablePeriod);
    // cost is hardcoded to be USD in claim so this should be fine as well
    Money totalCost = new Money();
    totalCost.setCurrency("USD");
    totalCost.setValue(encounter.claim.getTotalClaimCost());
    TotalComponent total = eob.addTotal();
    total.setAmount(totalCost);
    Code submitted = new Code("http://terminology.hl7.org/CodeSystem/adjudication", "submitted", "Submitted Amount");
    total.setCategory(mapCodeToCodeableConcept(submitted, "http://terminology.hl7.org/CodeSystem/adjudication"));
    // Set References
    eob.setPatient(new Reference(personEntry.getFullUrl()));
    if (USE_US_CORE_IG) {
        eob.setFacility(encounterResource.getLocationFirstRep().getLocation());
    }
    ServiceRequest referral = (ServiceRequest) new ServiceRequest().setStatus(ServiceRequest.ServiceRequestStatus.COMPLETED).setIntent(ServiceRequest.ServiceRequestIntent.ORDER).setSubject(new Reference(personEntry.getFullUrl())).setId("referral");
    CodeableConcept primaryCareRole = new CodeableConcept().addCoding(new Coding().setCode("primary").setSystem("http://terminology.hl7.org/CodeSystem/claimcareteamrole").setDisplay("Primary Care Practitioner"));
    Reference providerReference = new Reference().setDisplay("Unknown");
    if (encounter.clinician != null) {
        String practitionerFullUrl = TRANSACTION_BUNDLE ? ExportHelper.buildFhirNpiSearchUrl(encounter.clinician) : findPractitioner(encounter.clinician, bundle);
        if (practitionerFullUrl != null) {
            providerReference = new Reference(practitionerFullUrl);
        }
    } else if (encounter.provider != null) {
        String providerUrl = TRANSACTION_BUNDLE ? ExportHelper.buildFhirSearchUrl("Location", encounter.provider.getResourceLocationID()) : findProviderUrl(encounter.provider, bundle);
        if (providerUrl != null) {
            providerReference = new Reference(providerUrl);
        }
    }
    eob.setProvider(providerReference);
    eob.addCareTeam(new ExplanationOfBenefit.CareTeamComponent().setSequence(1).setProvider(providerReference).setRole(primaryCareRole));
    referral.setRequester(providerReference);
    referral.addPerformer(providerReference);
    eob.addContained(referral);
    eob.setReferral(new Reference().setReference("#referral"));
    // Get the insurance info at the time that the encounter occurred.
    Payer payer = encounter.claim.payer;
    Coverage coverage = new Coverage();
    coverage.setId("coverage");
    coverage.setStatus(CoverageStatus.ACTIVE);
    coverage.setType(new CodeableConcept().setText(payer.getName()));
    coverage.setBeneficiary(new Reference(personEntry.getFullUrl()));
    coverage.addPayor(new Reference().setDisplay(payer.getName()));
    eob.addContained(coverage);
    ExplanationOfBenefit.InsuranceComponent insuranceComponent = new ExplanationOfBenefit.InsuranceComponent();
    insuranceComponent.setFocal(true);
    insuranceComponent.setCoverage(new Reference("#coverage").setDisplay(payer.getName()));
    eob.addInsurance(insuranceComponent);
    eob.setInsurer(new Reference().setDisplay(payer.getName()));
    org.hl7.fhir.r4.model.Claim claim = (org.hl7.fhir.r4.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.setClaim(new Reference().setReference(claimEntry.getFullUrl()));
    eob.setCreated(encounterResource.getPeriod().getEnd());
    eob.setType(claim.getType());
    List<ExplanationOfBenefit.DiagnosisComponent> eobDiag = new ArrayList<>();
    for (org.hl7.fhir.r4.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("http://terminology.hl7.org/CodeSystem/ex-diagnosistype")));
        diagnosisComponent.setSequence(claimDiagnosis.getSequence());
        diagnosisComponent.setPackageCode(claimDiagnosis.getPackageCode());
        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;
    // Get all the items info from the claim
    for (ItemComponent item : claim.getItem()) {
        ExplanationOfBenefit.ItemComponent itemComponent = new ExplanationOfBenefit.ItemComponent();
        itemComponent.setSequence(item.getSequence());
        itemComponent.setQuantity(item.getQuantity());
        itemComponent.setUnitPrice(item.getUnitPrice());
        itemComponent.setCareTeamSequence(item.getCareTeamSequence());
        itemComponent.setDiagnosisSequence(item.getDiagnosisSequence());
        itemComponent.setInformationSequence(item.getInformationSequence());
        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")));
        itemComponent.setProductOrService(item.getProductOrService());
        // 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 = "20";
                display = "Urgent Care Facility";
                break;
            case INPATIENT:
                code = "21";
                display = "Inpatient Hospital";
                break;
            case URGENTCARE:
                code = "20";
                display = "Urgent Care Facility";
                break;
            case WELLNESS:
                code = "19";
                display = "Off Campus-Outpatient Hospital";
                break;
            default:
                code = "21";
                display = "Inpatient Hospital";
        }
        location.addCoding().setCode(code).setSystem("http://terminology.hl7.org/CodeSystem/ex-serviceplace").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()).setCurrency("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()).setCurrency("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()).setCurrency("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()).setCurrency("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"));
            // 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).setCurrency("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).setCurrency("USD");
    eob.setPayment(new ExplanationOfBenefit.PaymentComponent().setAmount(payment));
    return newEntry(person, bundle, eob);
}

Example 7 with ProcedureComponent

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

the class TransformerUtilsV2 method addProcedureCode.

/**
 * @param eob the {@link ExplanationOfBenefit} to (possibly) modify
 * @param procedure the {@link CCWProcedure} 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).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 8 with ProcedureComponent

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

the class OutpatientClaimTransformerV2Test method shouldHaveProcedureMembers.

@Test
public void shouldHaveProcedureMembers() {
    ProcedureComponent proc1 = TransformerTestUtilsV2.findProcedureByCode("0AABBZZ", eob.getProcedure());
    ProcedureComponent cmp1 = TransformerTestUtilsV2.createProcedure(proc1.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "0AABBZZ", null), "2016-01-16T00:00:00-08:00");
    assertTrue(cmp1.equalsDeep(proc1), "Comparing Procedure code 0AABBZZ");
}

Example 9 with ProcedureComponent

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

the class InpatientClaimTransformerV2Test method shouldHaveProcedureMembers.

@Test
public void shouldHaveProcedureMembers() {
    ProcedureComponent proc1 = TransformerTestUtilsV2.findProcedureByCode("0TCDDEE", eob.getProcedure());
    ProcedureComponent cmp1 = TransformerTestUtilsV2.createProcedure(proc1.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "0TCDDEE", null), "2016-01-16T00:00:00-06:00");
    assertTrue(cmp1.equalsDeep(proc1), "Comparing Procedure code 0TCDDEE");
    ProcedureComponent proc2 = TransformerTestUtilsV2.findProcedureByCode("302DDAA", eob.getProcedure());
    ProcedureComponent cmp2 = TransformerTestUtilsV2.createProcedure(proc2.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "302DDAA", null), "2016-01-16T00:00:00-06:00");
    assertTrue(cmp2.equalsDeep(proc2), "Comparing Procedure code 302DDAA");
    ProcedureComponent proc3 = TransformerTestUtilsV2.findProcedureByCode("302ZZXX", eob.getProcedure());
    ProcedureComponent cmp3 = TransformerTestUtilsV2.createProcedure(proc3.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "302ZZXX", null), "2016-01-15T00:00:00-06:00");
    assertTrue(cmp3.equalsDeep(proc3), "Comparing Procedure code 302ZZXX");
    ProcedureComponent proc4 = TransformerTestUtilsV2.findProcedureByCode("5566AAA", eob.getProcedure());
    ProcedureComponent cmp4 = TransformerTestUtilsV2.createProcedure(proc4.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "5566AAA", null), "2016-01-17T00:00:00-06:00");
    assertTrue(cmp4.equalsDeep(proc4), "Comparing Procedure code 5566AAA");
    ProcedureComponent proc5 = TransformerTestUtilsV2.findProcedureByCode("6677BBB", eob.getProcedure());
    ProcedureComponent cmp5 = TransformerTestUtilsV2.createProcedure(proc5.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "6677BBB", null), "2016-01-24T00:00:00-06:00");
    assertTrue(cmp5.equalsDeep(proc5), "Comparing Procedure code 6677BBB");
    ProcedureComponent proc6 = TransformerTestUtilsV2.findProcedureByCode("8109", eob.getProcedure());
    ProcedureComponent cmp6 = TransformerTestUtilsV2.createProcedure(proc6.getSequence(), new Coding("http://hl7.org/fhir/sid/icd-10", "8109", "REFUSION OF SPINE"), "2016-01-24T00:00:00-06:00");
    assertTrue(cmp6.equalsDeep(proc6), "Comparing Procedure code 8109");
}