use of org.hl7.fhir.r4.model.Observation.ObservationStatus.FINAL in project beneficiary-fhir-data by CMSgov.
the class TransformerUtils method addCareTeamPractitioner.
/**
* Ensures that the specified {@link ExplanationOfBenefit} has the specified {@link
* CareTeamComponent}, and links the specified {@link ItemComponent} to that {@link
* CareTeamComponent} (via {@link ItemComponent#addCareTeamLinkId(int)}).
*
* @param eob the {@link ExplanationOfBenefit} that the {@link CareTeamComponent} should be part
* of
* @param eobItem the {@link ItemComponent} that should be linked to the {@link CareTeamComponent}
* @param practitionerIdSystem the {@link Identifier#getSystem()} of the practitioner to reference
* in {@link CareTeamComponent#getProvider()}
* @param practitionerIdValue the {@link Identifier#getValue()} of the practitioner to reference
* in {@link CareTeamComponent#getProvider()}
* @param careTeamRole the {@link ClaimCareteamrole} to use for the {@link
* CareTeamComponent#getRole()}
* @return the {@link CareTeamComponent} that was created/linked
*/
static CareTeamComponent addCareTeamPractitioner(ExplanationOfBenefit eob, ItemComponent eobItem, String practitionerIdSystem, String practitionerIdValue, ClaimCareteamrole careTeamRole) {
// Try to find a matching pre-existing entry.
CareTeamComponent careTeamEntry = eob.getCareTeam().stream().filter(ctc -> ctc.getProvider().hasIdentifier()).filter(ctc -> practitionerIdSystem.equals(ctc.getProvider().getIdentifier().getSystem()) && practitionerIdValue.equals(ctc.getProvider().getIdentifier().getValue())).filter(ctc -> ctc.hasRole()).filter(ctc -> careTeamRole.toCode().equals(ctc.getRole().getCodingFirstRep().getCode()) && careTeamRole.getSystem().equals(ctc.getRole().getCodingFirstRep().getSystem())).findAny().orElse(null);
// If no match was found, add one to the EOB.
if (careTeamEntry == null) {
careTeamEntry = eob.addCareTeam();
careTeamEntry.setSequence(eob.getCareTeam().size() + 1);
careTeamEntry.setProvider(createIdentifierReference(practitionerIdSystem, practitionerIdValue));
CodeableConcept careTeamRoleConcept = createCodeableConcept(ClaimCareteamrole.OTHER.getSystem(), careTeamRole.toCode());
careTeamRoleConcept.getCodingFirstRep().setDisplay(careTeamRole.getDisplay());
careTeamEntry.setRole(careTeamRoleConcept);
}
// care team entry is at eob level so no need to create item link id
if (eobItem == null) {
return careTeamEntry;
}
// Link the EOB.item to the care team entry (if it isn't already).
final int careTeamEntrySequence = careTeamEntry.getSequence();
if (eobItem.getCareTeamLinkId().stream().noneMatch(id -> id.getValue() == careTeamEntrySequence)) {
eobItem.addCareTeamLinkId(careTeamEntrySequence);
}
return careTeamEntry;
}
use of org.hl7.fhir.r4.model.Observation.ObservationStatus.FINAL in project beneficiary-fhir-data by CMSgov.
the class ExplanationOfBenefitResourceProvider method findClaimTypeByPatient.
/**
* @param claimType the {@link ClaimType} to find
* @param patientId the {@link Beneficiary#getBeneficiaryId()} to filter by
* @param lastUpdated the update time to filter by
* @return the matching claim/event entities
*/
@SuppressWarnings({ "rawtypes", "unchecked" })
@Trace
private <T> List<T> findClaimTypeByPatient(ClaimType claimType, String patientId, DateRangeParam lastUpdated, DateRangeParam serviceDate) {
CriteriaBuilder builder = entityManager.getCriteriaBuilder();
CriteriaQuery criteria = builder.createQuery((Class) claimType.getEntityClass());
Root root = criteria.from(claimType.getEntityClass());
claimType.getEntityLazyAttributes().stream().forEach(a -> root.fetch(a));
criteria.select(root).distinct(true);
// Search for a beneficiary's records. Use lastUpdated if present
Predicate wherePredicate = builder.equal(root.get(claimType.getEntityBeneficiaryIdAttribute()), patientId);
if (lastUpdated != null && !lastUpdated.isEmpty()) {
Predicate predicate = QueryUtils.createLastUpdatedPredicate(builder, root, lastUpdated);
wherePredicate = builder.and(wherePredicate, predicate);
}
criteria.where(wherePredicate);
List<T> claimEntities = null;
Long eobsByBeneIdQueryNanoSeconds = null;
Timer.Context timerEobQuery = metricRegistry.timer(MetricRegistry.name(metricRegistry.getClass().getSimpleName(), "query", "eobs_by_bene_id", claimType.name().toLowerCase())).time();
try {
claimEntities = entityManager.createQuery(criteria).getResultList();
} finally {
eobsByBeneIdQueryNanoSeconds = timerEobQuery.stop();
TransformerUtils.recordQueryInMdc(String.format("eobs_by_bene_id.%s", claimType.name().toLowerCase()), eobsByBeneIdQueryNanoSeconds, claimEntities == null ? 0 : claimEntities.size());
}
if (claimEntities != null && serviceDate != null && !serviceDate.isEmpty()) {
final Instant lowerBound = serviceDate.getLowerBoundAsInstant() != null ? serviceDate.getLowerBoundAsInstant().toInstant() : null;
final Instant upperBound = serviceDate.getUpperBoundAsInstant() != null ? serviceDate.getUpperBoundAsInstant().toInstant() : null;
final java.util.function.Predicate<LocalDate> lowerBoundCheck = lowerBound == null ? (date) -> true : (date) -> compareLocalDate(date, lowerBound.atZone(ZoneId.systemDefault()).toLocalDate(), serviceDate.getLowerBound().getPrefix());
final java.util.function.Predicate<LocalDate> upperBoundCheck = upperBound == null ? (date) -> true : (date) -> compareLocalDate(date, upperBound.atZone(ZoneId.systemDefault()).toLocalDate(), serviceDate.getUpperBound().getPrefix());
return claimEntities.stream().filter(entity -> lowerBoundCheck.test(claimType.getServiceEndAttributeFunction().apply(entity)) && upperBoundCheck.test(claimType.getServiceEndAttributeFunction().apply(entity))).collect(Collectors.toList());
}
return claimEntities;
}
use of org.hl7.fhir.r4.model.Observation.ObservationStatus.FINAL in project beneficiary-fhir-data by CMSgov.
the class InpatientClaimTransformerV2 method transformClaim.
/**
* @param claimGroup the CCW {@link InpatientClaim} to transform
* @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
* InpatientClaim}
*/
private static ExplanationOfBenefit transformClaim(InpatientClaim claimGroup) {
ExplanationOfBenefit eob = new ExplanationOfBenefit();
// Required values not directly mapped
eob.getMeta().addProfile(ProfileConstants.C4BB_EOB_INPATIENT_PROFILE_URL);
// Common group level fields between all claim types
// Claim Type + Claim ID => ExplanationOfBenefit.id
// CLM_ID => ExplanationOfBenefit.identifier
// CLM_GRP_ID => ExplanationOfBenefit.identifier
// BENE_ID + Coverage Type => ExplanationOfBenefit.insurance.coverage (reference)
// BENE_ID => ExplanationOfBenefit.patient (reference)
// FINAL_ACTION => ExplanationOfBenefit.status
// CLM_FROM_DT => ExplanationOfBenefit.billablePeriod.start
// CLM_THRU_DT => ExplanationOfBenefit.billablePeriod.end
// CLM_PMT_AMT => ExplanationOfBenefit.payment.amount
TransformerUtilsV2.mapEobCommonClaimHeaderData(eob, claimGroup.getClaimId(), claimGroup.getBeneficiaryId(), ClaimTypeV2.INPATIENT, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, Optional.of(claimGroup.getDateFrom()), Optional.of(claimGroup.getDateThrough()), Optional.of(claimGroup.getPaymentAmount()), claimGroup.getFinalAction());
// map eob type codes into FHIR
// NCH_CLM_TYPE_CD => ExplanationOfBenefit.type.coding
// EOB Type => ExplanationOfBenefit.type.coding
// Claim Type (institutional) => ExplanationOfBenefit.type.coding
// NCH_NEAR_LINE_REC_IDENT_CD => ExplanationOfBenefit.extension
TransformerUtilsV2.mapEobType(eob, ClaimTypeV2.INPATIENT, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
// set the provider number which is common among several claim types
// PRVDR_NUM => ExplanationOfBenefit.provider.identifier
TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
// NCH_PTNT_STUS_IND_CD => ExplanationOfBenefit.supportingInfo.code
claimGroup.getPatientStatusCd().ifPresent(c -> TransformerUtilsV2.addInformationWithCode(eob, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, c));
// CLM_ADMSN_DT => ExplanationOfBenefit.supportingInfo:admissionperiod
// NCH_BENE_DSCHRG_DT => ExplanationOfBenefit.supportingInfo:admissionperiod
TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationAdmPeriodSlice(eob, claimGroup.getClaimAdmissionDate(), claimGroup.getBeneficiaryDischargeDate()));
// add EOB information to fields that are common between the Inpatient and SNF claim types
// CLM_IP_ADMSN_TYPE_CD => ExplanationOfBenefit.supportingInfo.code
// CLM_SRC_IP_ADMSN_CD => ExplanationOfBenefit.supportingInfo.code
// NCH_VRFD_NCVRD_STAY_FROM_DT => ExplanationOfBenefit.supportingInfo.timingPeriod
// NCH_VRFD_NCVRD_STAY_THRU_DT => ExplanationOfBenefit.supportingInfo.timingPeriod
// NCH_ACTV_OR_CVRD_LVL_CARE_THRU => ExplanationOfBenefit.supportingInfo.timingDate
// NCH_BENE_MDCR_BNFTS_EXHTD_DT_I => ExplanationOfBenefit.supportingInfo.timingDate
// CLM_DRG_CD => ExplanationOfBenefit.supportingInfo.code
TransformerUtilsV2.addCommonEobInformationInpatientSNF(eob, claimGroup.getAdmissionTypeCd(), claimGroup.getSourceAdmissionCd(), claimGroup.getNoncoveredStayFromDate(), claimGroup.getNoncoveredStayThroughDate(), claimGroup.getCoveredCareThoughDate(), claimGroup.getMedicareBenefitsExhaustedDate(), claimGroup.getDiagnosisRelatedGroupCd());
// IME_OP_CLM_VAL_AMT => ExplanationOfBenefit.extension
TransformerUtilsV2.addAdjudicationTotal(eob, CcwCodebookVariable.IME_OP_CLM_VAL_AMT, claimGroup.getIndirectMedicalEducationAmount());
// DSH_OP_CLM_VAL_AMT => ExplanationOfBenefit.extension
TransformerUtilsV2.addAdjudicationTotal(eob, CcwCodebookVariable.DSH_OP_CLM_VAL_AMT, claimGroup.getDisproportionateShareAmount());
// CLM_PASS_THRU_PER_DIEM_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_PASS_THRU_PER_DIEM_AMT, Optional.ofNullable(claimGroup.getPassThruPerDiemAmount()));
// NCH_PROFNL_CMPNT_CHRG_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_PROFNL_CMPNT_CHRG_AMT, Optional.ofNullable(claimGroup.getProfessionalComponentCharge()));
// CLM_TOT_PPS_CPTL_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_TOT_PPS_CPTL_AMT, claimGroup.getClaimTotalPPSCapitalAmount());
/*
* add field values to the benefit balances that are common between the
* Inpatient and SNF claim types
*/
// BENE_TOT_COINSRNC_DAYS_CNT => ExplanationOfBenefit.benefitBalance.financial
// CLM_NON_UTLZTN_DAYS_CNT => ExplanationOfBenefit.benefitBalance.financial
// NCH_BENE_IP_DDCTBL_AMT => ExplanationOfBenefit.benefitBalance.financial
// NCH_BENE_PTA_COINSRNC_LBLTY_AMT => ExplanationOfBenefit.benefitBalance.financial
// NCH_BLOOD_PNTS_FRNSHD_QTY => ExplanationOfBenefit.supportingInfo.valueQuantity
// NCH_IP_NCVRD_CHRG_AMT => ExplanationOfBenefit.benefitBalance.financial
// NCH_IP_TOT_DDCTN_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_CPTL_EXCPTN_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_CPTL_FSP_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_CPTL_IME_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_CPTL_OUTLIER_AMT => ExplanationOfBenefit.benefitBalance.financial
// CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addCommonGroupInpatientSNF(eob, claimGroup.getCoinsuranceDayCount(), claimGroup.getNonUtilizationDayCount(), claimGroup.getDeductibleAmount(), claimGroup.getPartACoinsuranceLiabilityAmount(), claimGroup.getBloodPintsFurnishedQty(), claimGroup.getNoncoveredCharge(), claimGroup.getTotalDeductionAmount(), claimGroup.getClaimPPSCapitalDisproportionateShareAmt(), claimGroup.getClaimPPSCapitalExceptionAmount(), claimGroup.getClaimPPSCapitalFSPAmount(), claimGroup.getClaimPPSCapitalIMEAmount(), claimGroup.getClaimPPSCapitalOutlierAmount(), claimGroup.getClaimPPSOldCapitalHoldHarmlessAmount());
// NCH_DRG_OUTLIER_APRVD_PMT_AMT => ExplanationOfBenefit.extension
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_DRG_OUTLIER_APRVD_PMT_AMT, claimGroup.getDrgOutlierApprovedPaymentAmount());
// Map care team
// AT_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Primary)
// AT_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
// OP_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Assisting)
// OP_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
// OT_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Other)
// OT_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.mapCareTeam(eob, claimGroup.getAttendingPhysicianNpi(), claimGroup.getOperatingPhysicianNpi(), claimGroup.getOtherPhysicianNpi(), claimGroup.getAttendingPhysicianUpin(), claimGroup.getOperatingPhysicianUpin(), claimGroup.getOtherPhysicianUpin());
// Common group level fields between Inpatient, Outpatient and SNF
// NCH_BENE_BLOOD_DDCTBL_LBLTY_AM => ExplanationOfBenefit.benefitBalance.financial
// CLAIM_QUERY_CODE => ExplanationOfBenefit.billablePeriod.extension
// CLM_MCO_PD_SW => ExplanationOfBenefit.supportingInfo.code
TransformerUtilsV2.mapEobCommonGroupInpOutSNF(eob, claimGroup.getBloodDeductibleLiabilityAmount(), claimGroup.getClaimQueryCode(), claimGroup.getMcoPaidSw());
// Common group level fields between Inpatient, Outpatient Hospice, HHA and SNF
// ORG_NPI_NUM => ExplanationOfBenefit.provider
// CLM_FAC_TYPE_CD => ExplanationOfBenefit.facility.extension
// CLM_FREQ_CD => ExplanationOfBenefit.supportingInfo
// CLM_MDCR_NON_PMT_RSN_CD => ExplanationOfBenefit.extension
// PTNT_DSCHRG_STUS_CD => ExplanationOfBenefit.supportingInfo
// CLM_SRVC_CLSFCTN_TYPE_CD => ExplanationOfBenefit.extension
// NCH_PRMRY_PYR_CD => ExplanationOfBenefit.supportingInfo
// CLM_TOT_CHRG_AMT => ExplanationOfBenefit.total.amount
// NCH_PRMRY_PYR_CLM_PD_AMT => ExplanationOfBenefit.benefitBalance.financial (PRPAYAMT)
TransformerUtilsV2.mapEobCommonGroupInpOutHHAHospiceSNF(eob, claimGroup.getOrganizationNpi(), claimGroup.getClaimFacilityTypeCode(), claimGroup.getClaimFrequencyCode(), claimGroup.getClaimNonPaymentReasonCode(), claimGroup.getPatientDischargeStatusCode(), claimGroup.getClaimServiceClassificationTypeCode(), claimGroup.getClaimPrimaryPayerCode(), claimGroup.getTotalChargeAmount(), claimGroup.getPrimaryPayerPaidAmount(), claimGroup.getFiscalIntermediaryNumber(), claimGroup.getLastUpdated());
// CLM_UTLZTN_DAY_CNT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_UTLZTN_DAY_CNT, Optional.of(claimGroup.getUtilizationDayCount()));
// CLM_E_POA_IND_SW(1-12) => diagnosis.type
for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.INPATIENT);
}
// Handle Procedures
// ICD_PRCDR_CD(1-25) => ExplanationOfBenefit.procedure.procedureCodableConcept
// ICD_PRCDR_VRSN_CD(1-25) => ExplanationOfBenefit.procedure.procedureCodableConcept
// PRCDR_DT(1-25) => ExplanationOfBenefit.procedure.date
final int FIRST_PROCEDURE = 1;
final int LAST_PROCEDURE = 25;
IntStream.range(FIRST_PROCEDURE, LAST_PROCEDURE + 1).mapToObj(i -> TransformerUtilsV2.extractCCWProcedure(i, claimGroup)).filter(p -> p.isPresent()).forEach(p -> TransformerUtilsV2.addProcedureCode(eob, p.get()));
// NCH_WKLY_PROC_DT => ExplanationOfBenefit.supportinginfo.timingDate
TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationRecievedDateSlice(eob, CcwCodebookVariable.NCH_WKLY_PROC_DT, Optional.of(claimGroup.getWeeklyProcessDate())));
// CLM_PPS_CPTL_DRG_WT_NUM => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.CLM_PPS_CPTL_DRG_WT_NUM, claimGroup.getClaimPPSCapitalDrgWeightNumber());
// BENE_LRD_USED_CNT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalInt(eob, CcwCodebookVariable.BENE_LRD_USED_CNT, claimGroup.getLifetimeReservedDaysUsedCount());
// ClaimLine => ExplanationOfBenefit.item
for (InpatientClaimLine line : claimGroup.getLines()) {
ItemComponent item = TransformerUtilsV2.addItem(eob);
// Override the default sequence
// CLM_LINE_NUM => item.sequence
item.setSequence(line.getLineNumber().intValue());
// PRVDR_STATE_CD => item.location
TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
// REV_CNTR => ExplanationOfBenefit.item.revenue
// REV_CNTR_RATE_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_TOT_CHRG_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_NCVRD_CHRG_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_NDC_QTY => ExplanationOfBenefit.item.quantity
// REV_CNTR_NDC_QTY_QLFR_CD => ExplanationOfBenefit.modifier
TransformerUtilsV2.mapEobCommonItemRevenue(item, eob, line.getRevenueCenter(), line.getRateAmount(), line.getTotalChargeAmount(), Optional.of(line.getNonCoveredChargeAmount()), line.getNationalDrugCodeQuantity(), line.getNationalDrugCodeQualifierCode());
// REV_CNTR_DDCTBL_COINSRNC_CD => item.revenue
TransformerUtilsV2.addItemRevenue(item, eob, CcwCodebookVariable.REV_CNTR_DDCTBL_COINSRNC_CD, line.getDeductibleCoinsuranceCd());
// HCPCS_CD => item.productOrService
line.getHcpcsCode().ifPresent(c -> item.setProductOrService(new CodeableConcept().setCoding(Arrays.asList(new Coding().setSystem(CCWUtils.calculateVariableReferenceUrl(CcwCodebookVariable.HCPCS_CD)).setCode(c), new Coding().setSystem(TransformerConstants.CODING_SYSTEM_HCPCS).setCode(c)))));
// RNDRNG_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.UPIN, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianUPIN());
// RNDRNG_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.NPI, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianNPI());
}
// Last Updated => ExplanationOfBenefit.meta.lastUpdated
TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
return eob;
}
use of org.hl7.fhir.r4.model.Observation.ObservationStatus.FINAL in project beneficiary-fhir-data by CMSgov.
the class OutpatientClaimTransformerV2 method transformClaim.
/**
* @param claimGroup the CCW {@link InpatientClaim} to transform
* @return a FHIR {@link ExplanationOfBenefit} resource that represents the specified {@link
* InpatientClaim}
*/
private static ExplanationOfBenefit transformClaim(OutpatientClaim claimGroup) {
ExplanationOfBenefit eob = new ExplanationOfBenefit();
// Required values not directly mapped
eob.getMeta().addProfile(ProfileConstants.C4BB_EOB_OUTPATIENT_PROFILE_URL);
// Common group level fields between all claim types
// Claim Type + Claim ID => ExplanationOfBenefit.id
// CLM_ID => ExplanationOfBenefit.identifier
// CLM_GRP_ID => ExplanationOfBenefit.identifier
// FINAL_ACTION => ExplanationOfBenefit.status
// CLM_FROM_DT => ExplanationOfBenefit.billablePeriod.start
// CLM_THRU_DT => ExplanationOfBenefit.billablePeriod.end
// CLM_PMT_AMT => ExplanationOfBenefit.payment.amount
TransformerUtilsV2.mapEobCommonClaimHeaderData(eob, claimGroup.getClaimId(), claimGroup.getBeneficiaryId(), ClaimTypeV2.OUTPATIENT, claimGroup.getClaimGroupId().toPlainString(), MedicareSegment.PART_B, Optional.of(claimGroup.getDateFrom()), Optional.of(claimGroup.getDateThrough()), Optional.of(claimGroup.getPaymentAmount()), claimGroup.getFinalAction());
// NCH_WKLY_PROC_DT => ExplanationOfBenefit.supportinginfo.timingDate
TransformerUtilsV2.addInformation(eob, TransformerUtilsV2.createInformationRecievedDateSlice(eob, CcwCodebookVariable.NCH_WKLY_PROC_DT, Optional.of(claimGroup.getWeeklyProcessDate())));
// Map care team
// AT_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Primary)
// AT_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
// OP_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Assisting)
// OP_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
// OT_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider (Other)
// OT_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.mapCareTeam(eob, claimGroup.getAttendingPhysicianNpi(), claimGroup.getOperatingPhysicianNpi(), claimGroup.getOtherPhysicianNpi(), claimGroup.getAttendingPhysicianUpin(), claimGroup.getOperatingPhysicianUpin(), claimGroup.getOtherPhysicianUpin());
// map eob type codes into FHIR
// NCH_CLM_TYPE_CD => ExplanationOfBenefit.type.coding
// EOB Type => ExplanationOfBenefit.type.coding
// Claim Type (institutional) => ExplanationOfBenefit.type.coding
// NCH_NEAR_LINE_REC_IDENT_CD => ExplanationOfBenefit.extension
TransformerUtilsV2.mapEobType(eob, ClaimTypeV2.OUTPATIENT, Optional.of(claimGroup.getNearLineRecordIdCode()), Optional.of(claimGroup.getClaimTypeCode()));
// set the provider number which is common among several claim types
// PRVDR_NUM => ExplanationOfBenefit.provider.identifier
TransformerUtilsV2.addProviderSlice(eob, C4BBOrganizationIdentifierType.PRN, claimGroup.getProviderNumber(), claimGroup.getLastUpdated());
// NCH_PROFNL_CMPNT_CHRG_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_PROFNL_CMPNT_CHRG_AMT, Optional.ofNullable(claimGroup.getProfessionalComponentCharge()));
// NCH_BENE_PTB_DDCTBL_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_BENE_PTB_DDCTBL_AMT, Optional.ofNullable(claimGroup.getDeductibleAmount()));
// NCH_BENE_PTB_COINSRNC_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.NCH_BENE_PTB_COINSRNC_AMT, Optional.ofNullable(claimGroup.getCoinsuranceAmount()));
// CLM_OP_PRVDR_PMT_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_OP_PRVDR_PMT_AMT, Optional.ofNullable(claimGroup.getProviderPaymentAmount()));
// CLM_OP_PRVDR_PMT_AMT => ExplanationOfBenefit.benefitBalance.financial
TransformerUtilsV2.addBenefitBalanceFinancialMedicalAmt(eob, CcwCodebookVariable.CLM_OP_BENE_PMT_AMT, Optional.ofNullable(claimGroup.getBeneficiaryPaymentAmount()));
// Common group level fields between Inpatient, Outpatient and SNF
// NCH_BENE_BLOOD_DDCTBL_LBLTY_AM =>
// ExplanationOfBenefit.benefitBalance.financial
// CLAIM_QUERY_CODE => ExplanationOfBenefit.billablePeriod.extension
// CLM_MCO_PD_SW => ExplanationOfBenefit.supportingInfo.code
TransformerUtilsV2.mapEobCommonGroupInpOutSNF(eob, claimGroup.getBloodDeductibleLiabilityAmount(), claimGroup.getClaimQueryCode(), claimGroup.getMcoPaidSw());
// Common group level fields between Inpatient, Outpatient Hospice, HHA and SNF
// ORG_NPI_NUM => ExplanationOfBenefit.provider
// CLM_FAC_TYPE_CD => ExplanationOfBenefit.facility.extension
// CLM_FREQ_CD => ExplanationOfBenefit.supportingInfo
// CLM_MDCR_NON_PMT_RSN_CD => ExplanationOfBenefit.extension
// PTNT_DSCHRG_STUS_CD => ExplanationOfBenefit.supportingInfo
// CLM_SRVC_CLSFCTN_TYPE_CD => ExplanationOfBenefit.extension
// NCH_PRMRY_PYR_CD => ExplanationOfBenefit.supportingInfo
// CLM_TOT_CHRG_AMT => ExplanationOfBenefit.total.amount
// NCH_PRMRY_PYR_CLM_PD_AMT => ExplanationOfBenefit.benefitBalance.financial (PRPAYAMT)
TransformerUtilsV2.mapEobCommonGroupInpOutHHAHospiceSNF(eob, claimGroup.getOrganizationNpi(), claimGroup.getClaimFacilityTypeCode(), claimGroup.getClaimFrequencyCode(), claimGroup.getClaimNonPaymentReasonCode(), claimGroup.getPatientDischargeStatusCode().get(), claimGroup.getClaimServiceClassificationTypeCode(), claimGroup.getClaimPrimaryPayerCode(), claimGroup.getTotalChargeAmount(), claimGroup.getPrimaryPayerPaidAmount(), claimGroup.getFiscalIntermediaryNumber(), claimGroup.getLastUpdated());
// ICD_DGNS_E_VRSN_CD(1-12) => diagnosis.diagnosisCodeableConcept
for (Diagnosis diagnosis : DiagnosisUtilV2.extractDiagnoses(claimGroup)) {
DiagnosisUtilV2.addDiagnosisCode(eob, diagnosis, ClaimTypeV2.OUTPATIENT);
}
// Handle Inpatient Diagnosis. Only three, so just brute force it
// RSN_VISIT_CD1 => diagnosis.diagnosisCodeableConcept
// RSN_VISIT_VRSN_CD1 => diagnosis.diagnosisCodeableConcept
DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission1", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
// RSN_VISIT_CD2 => diagnosis.diagnosisCodeableConcept
// RSN_VISIT_VRSN_CD2 => diagnosis.diagnosisCodeableConcept
DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission2", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
// RSN_VISIT_CD3 => diagnosis.diagnosisCodeableConcept
// RSN_VISIT_VRSN_CD3 => diagnosis.diagnosisCodeableConcept
DiagnosisUtilV2.addDiagnosisCode(eob, DiagnosisUtilV2.extractDiagnosis("Admission3", claimGroup, Optional.empty(), DiagnosisLabel.REASONFORVISIT), ClaimTypeV2.OUTPATIENT);
// Handle Procedures
// ICD_PRCDR_CD(1-25) => ExplanationOfBenefit.procedure.procedureCodableConcept
// ICD_PRCDR_VRSN_CD(1-25) => ExplanationOfBenefit.procedure.procedureCodableConcept
// PRCDR_DT(1-25) => ExplanationOfBenefit.procedure.date
final int FIRST_PROCEDURE = 1;
final int LAST_PROCEDURE = 25;
IntStream.range(FIRST_PROCEDURE, LAST_PROCEDURE + 1).mapToObj(i -> TransformerUtilsV2.extractCCWProcedure(i, claimGroup)).filter(p -> p.isPresent()).forEach(p -> TransformerUtilsV2.addProcedureCode(eob, p.get()));
// ClaimLine => ExplanationOfBenefit.item
for (OutpatientClaimLine line : claimGroup.getLines()) {
ItemComponent item = TransformerUtilsV2.addItem(eob);
// CLM_LINE_NUM => item.sequence
item.setSequence(line.getLineNumber().intValue());
// PRVDR_STATE_CD => item.location
TransformerUtilsV2.addLocationState(item, claimGroup.getProviderStateCode());
// REV_CNTR => item.revenue
item.setRevenue(TransformerUtilsV2.createCodeableConcept(eob, CcwCodebookVariable.REV_CNTR, line.getRevenueCenterCode()));
// REV_CNTR_1ST_ANSI_CD => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_1ST_ANSI_CD, line.getRevCntr1stAnsiCd()));
// REV_CNTR_2ND_ANSI_CD => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_2ND_ANSI_CD, line.getRevCntr2ndAnsiCd()));
// REV_CNTR_3RD_ANSI_CD => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_3RD_ANSI_CD, line.getRevCntr3rdAnsiCd()));
// REV_CNTR_4RD_ANSI_CD => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationDenialReasonSlice(eob, CcwCodebookVariable.REV_CNTR_4TH_ANSI_CD, line.getRevCntr4thAnsiCd()));
// HCPCS_CD => ExplanationOfBenefit.item.productOrService
// HCPCS_1ST_MDFR_CD => ExplanationOfBenefit.item.modifier
// HCPCS_2ND_MDFR_CD => ExplanationOfBenefit.item.modifier
TransformerUtilsV2.mapHcpcs(eob, item, line.getHcpcsCode(), Optional.empty(), Arrays.asList(line.getHcpcsInitialModifierCode(), line.getHcpcsSecondModifierCode()));
// REV_CNTR => ExplanationOfBenefit.item.revenue
// REV_CNTR_RATE_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_TOT_CHRG_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_NCVRD_CHRG_AMT => ExplanationOfBenefit.item.adjudication
// REV_CNTR_NDC_QTY => ExplanationOfBenefit.item.quantity
// REV_CNTR_NDC_QTY_QLFR_CD => ExplanationOfBenefit.modifier
TransformerUtilsV2.mapEobCommonItemRevenue(item, eob, line.getRevenueCenterCode(), line.getRateAmount(), line.getTotalChargeAmount(), Optional.of(line.getNonCoveredChargeAmount()), line.getNationalDrugCodeQuantity(), line.getNationalDrugCodeQualifierCode());
// REV_CNTR_BLOOD_DDCTBL_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_BLOOD_DDCTBL_AMT, C4BBAdjudication.DEDUCTIBLE, line.getBloodDeductibleAmount()));
// REV_CNTR_CASH_DDCTBL_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_CASH_DDCTBL_AMT, C4BBAdjudication.DEDUCTIBLE, line.getCashDeductibleAmount()));
// REV_CNTR_COINSRNC_WGE_ADJSTD_C => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_COINSRNC_WGE_ADJSTD_C, C4BBAdjudication.COINSURANCE, line.getWageAdjustedCoinsuranceAmount()));
// REV_CNTR_RDCD_COINSRNC_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_RDCD_COINSRNC_AMT, C4BBAdjudication.COINSURANCE, line.getReducedCoinsuranceAmount()));
// REV_CNTR_1ST_MSP_PD_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_1ST_MSP_PD_AMT, C4BBAdjudication.PRIOR_PAYER_PAID, line.getFirstMspPaidAmount()));
// REV_CNTR_2ND_MSP_PD_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_2ND_MSP_PD_AMT, C4BBAdjudication.PRIOR_PAYER_PAID, line.getSecondMspPaidAmount()));
// REV_CNTR_PRVDR_PMT_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_PRVDR_PMT_AMT, C4BBAdjudication.PAID_TO_PROVIDER, line.getProviderPaymentAmount()));
// REV_CNTR_BENE_PMT_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_BENE_PMT_AMT, C4BBAdjudication.PAID_TO_PATIENT, line.getBenficiaryPaymentAmount()));
// REV_CNTR_PTNT_RSPNSBLTY_PMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.addAdjudication(item, TransformerUtilsV2.createAdjudicationAmtSlice(CcwCodebookVariable.REV_CNTR_PTNT_RSPNSBLTY_PMT, C4BBAdjudication.PAID_BY_PATIENT, line.getPatientResponsibilityAmount()));
// Common item level fields between Outpatient, HHA and Hospice
// REV_CNTR_DT => ExplanationOfBenefit.item.servicedDate
// REV_CNTR_PMT_AMT_AMT => ExplanationOfBenefit.item.adjudication
TransformerUtilsV2.mapEobCommonItemRevenueOutHHAHospice(item, line.getRevenueCenterDate(), line.getPaymentAmount());
// REV_CNTR_IDE_NDC_UPC_NUM => ExplanationOfBenefit.item.productOrService.extension
TransformerUtilsV2.addNationalDrugCode(item, line.getNationalDrugCode());
// RNDRNG_PHYSN_UPIN => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.UPIN, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianUPIN());
// RNDRNG_PHYSN_NPI => ExplanationOfBenefit.careTeam.provider
TransformerUtilsV2.addCareTeamMember(eob, item, C4BBPractitionerIdentifierType.NPI, C4BBClaimInstitutionalCareTeamRole.PERFORMING, line.getRevenueCenterRenderingPhysicianNPI());
// REV_CNTR_STUS_IND_CD => ExplanationOfBenefit.item.revenue.extension
TransformerUtilsV2.mapEobCommonItemRevenueStatusCode(item, eob, line.getStatusCode());
}
TransformerUtilsV2.setLastUpdated(eob, claimGroup.getLastUpdated());
return eob;
}
use of org.hl7.fhir.r4.model.Observation.ObservationStatus.FINAL in project beneficiary-fhir-data by CMSgov.
the class TransformerTestUtilsV2 method findAdjudicationByCategoryAndAmount.
/**
* Finds an {@link AdjudicationComponent} using a code in the category and value in amount
*
* @param code
* @param amount
* @param components
* @return
*/
static AdjudicationComponent findAdjudicationByCategoryAndAmount(String code, BigDecimal amount, List<AdjudicationComponent> components) {
final BigDecimal amt = amount.setScale(2, RoundingMode.HALF_DOWN);
Optional<AdjudicationComponent> adjudication = components.stream().filter(cmp -> (amt.equals(cmp.getAmount().getValue()))).filter(cmp -> cmp.getCategory().getCoding().stream().filter(c -> code.equals(c.getCode())).count() > 0).findFirst();
assertTrue(adjudication.isPresent());
return adjudication.get();
}
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