use of org.hl7.fhir.r4.model.codesystems.ClaimCareteamrole 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.codesystems.ClaimCareteamrole in project beneficiary-fhir-data by CMSgov.
the class CarrierClaimTransformerV2Test method shouldHaveCareTeamMembers.
@Test
public void shouldHaveCareTeamMembers() {
// First member
CareTeamComponent member1 = TransformerTestUtilsV2.findCareTeamBySequence(1, eob.getCareTeam());
CareTeamComponent compare1 = TransformerTestUtilsV2.createNpiCareTeamMember(1, "8765676", "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "referring", "Referring");
assertTrue(compare1.equalsDeep(member1));
// Second member
CareTeamComponent member2 = TransformerTestUtilsV2.findCareTeamBySequence(2, eob.getCareTeam());
CareTeamComponent compare2 = TransformerTestUtilsV2.createNpiCareTeamMember(2, "K25852", "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "referring", "Referring");
assertTrue(compare2.equalsDeep(member2));
// // Third member
CareTeamComponent member3 = TransformerTestUtilsV2.findCareTeamBySequence(3, eob.getCareTeam());
CareTeamComponent compare3 = TransformerTestUtilsV2.createNpiCareTeamMember(3, "1923124", "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBClaimCareTeamRole", "performing", "Performing provider");
compare3.setResponsible(true);
compare3.setQualification(new CodeableConcept().setCoding(Arrays.asList(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/prvdr_spclty").setDisplay("Optometrist").setCode("41"))));
compare3.addExtension("https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd", new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/carr_line_prvdr_type_cd").setCode("0"));
compare3.addExtension("https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd", new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/prtcptng_ind_cd").setCode("1").setDisplay("Participating"));
assertTrue(compare3.equalsDeep(member3));
// Fourth member
CareTeamComponent member4 = TransformerTestUtilsV2.findCareTeamBySequence(4, eob.getCareTeam());
CareTeamComponent compare4 = TransformerTestUtilsV2.createNpiCareTeamMember(4, "1497758544", "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "primary", "Primary provider");
compare4.getProvider().setDisplay("CUMBERLAND COUNTY HOSPITAL SYSTEM, INC");
assertTrue(compare4.equalsDeep(member4));
}
use of org.hl7.fhir.r4.model.codesystems.ClaimCareteamrole in project beneficiary-fhir-data by CMSgov.
the class TransformerTestUtils method assertCareTeamEquals.
/**
* @param expectedPractitioner {@link CareTeamComponent#getProviderIdentifier)} to find and verify
* @param expectedCareTeamRole the {@link ClaimCareteamrole} for {@link
* CareTeamComponent#getRole)} to find and verify
* @param eob the actual {@link ExplanationOfBenefit}s to verify
*/
static void assertCareTeamEquals(String expectedPractitioner, ClaimCareteamrole expectedCareTeamRole, ExplanationOfBenefit eob) {
CareTeamComponent careTeamEntry = findCareTeamEntryForProviderIdentifier(TransformerConstants.CODING_NPI_US, expectedPractitioner, expectedCareTeamRole, eob.getCareTeam());
assertNotNull(careTeamEntry);
assertCodingEquals(expectedCareTeamRole.getSystem(), expectedCareTeamRole.toCode(), careTeamEntry.getRole().getCodingFirstRep());
}
use of org.hl7.fhir.r4.model.codesystems.ClaimCareteamrole 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);
}
use of org.hl7.fhir.r4.model.codesystems.ClaimCareteamrole 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);
}
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