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

Example 16 with ClaimType

use of org.hl7.fhir.r4.model.codesystems.ClaimType in project beneficiary-fhir-data by CMSgov.

the class InpatientClaimTransformerTest method assertMatches.

/**
 * Verifies that the {@link ExplanationOfBenefit} "looks like" it should, if it were produced from
 * the specified {@link InpatientClaim}.
 *
 * @param claim the {@link InpatientClaim} that the {@link ExplanationOfBenefit} was generated
 *     from
 * @param eob the {@link ExplanationOfBenefit} that was generated from the specified {@link
 *     InpatientClaim}
 * @throws FHIRException (indicates test failure)
 */
static void assertMatches(InpatientClaim claim, ExplanationOfBenefit eob) throws FHIRException {
    // Test to ensure group level fields between all claim types match
    TransformerTestUtils.assertEobCommonClaimHeaderData(eob, claim.getClaimId(), claim.getBeneficiaryId(), ClaimType.INPATIENT, claim.getClaimGroupId().toPlainString(), MedicareSegment.PART_A, Optional.of(claim.getDateFrom()), Optional.of(claim.getDateThrough()), Optional.of(claim.getPaymentAmount()), claim.getFinalAction());
    // test the common field provider number is set as expected in the EOB
    TransformerTestUtils.assertProviderNumber(eob, claim.getProviderNumber());
    if (claim.getPatientStatusCd().isPresent())
        TransformerTestUtils.assertInfoWithCodeEquals(CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, CcwCodebookVariable.NCH_PTNT_STUS_IND_CD, claim.getPatientStatusCd(), eob);
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.CLM_PASS_THRU_PER_DIEM_AMT, claim.getPassThruPerDiemAmount(), eob);
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.NCH_PROFNL_CMPNT_CHRG_AMT, claim.getProfessionalComponentCharge(), eob);
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.CLM_TOT_PPS_CPTL_AMT, claim.getClaimTotalPPSCapitalAmount(), eob);
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.IME_OP_CLM_VAL_AMT, claim.getIndirectMedicalEducationAmount(), eob);
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.DSH_OP_CLM_VAL_AMT, claim.getDisproportionateShareAmount(), eob);
    // test common eob information between Inpatient, HHA, Hospice and SNF claims are set as
    // expected
    TransformerTestUtils.assertEobCommonGroupInpHHAHospiceSNFEquals(eob, claim.getClaimAdmissionDate(), claim.getBeneficiaryDischargeDate(), Optional.of(claim.getUtilizationDayCount()));
    // test common benefit components between SNF and Inpatient claims are set as expected
    TransformerTestUtils.assertCommonGroupInpatientSNF(eob, claim.getCoinsuranceDayCount(), claim.getNonUtilizationDayCount(), claim.getDeductibleAmount(), claim.getPartACoinsuranceLiabilityAmount(), claim.getBloodPintsFurnishedQty(), claim.getNoncoveredCharge(), claim.getTotalDeductionAmount(), claim.getClaimPPSCapitalDisproportionateShareAmt(), claim.getClaimPPSCapitalExceptionAmount(), claim.getClaimPPSCapitalFSPAmount(), claim.getClaimPPSCapitalIMEAmount(), claim.getClaimPPSCapitalOutlierAmount(), claim.getClaimPPSOldCapitalHoldHarmlessAmount());
    // test common eob information between SNF and Inpatient claims are set as expected
    TransformerTestUtils.assertCommonEobInformationInpatientSNF(eob, claim.getNoncoveredStayFromDate(), claim.getNoncoveredStayThroughDate(), claim.getCoveredCareThoughDate(), claim.getMedicareBenefitsExhaustedDate(), claim.getDiagnosisRelatedGroupCd());
    TransformerTestUtils.assertAdjudicationTotalAmountEquals(CcwCodebookVariable.NCH_DRG_OUTLIER_APRVD_PMT_AMT, claim.getDrgOutlierApprovedPaymentAmount(), eob);
    // Test to ensure common group fields between Inpatient, Outpatient and SNF
    // match
    TransformerTestUtils.assertEobCommonGroupInpOutSNFEquals(eob, claim.getBloodDeductibleLiabilityAmount(), claim.getOperatingPhysicianNpi(), claim.getOtherPhysicianNpi(), claim.getClaimQueryCode(), claim.getMcoPaidSw());
    // Test to ensure common group fields between Inpatient, Outpatient HHA, Hospice
    // and SNF match
    TransformerTestUtils.assertEobCommonGroupInpOutHHAHospiceSNFEquals(eob, claim.getOrganizationNpi(), claim.getClaimFacilityTypeCode(), claim.getClaimFrequencyCode(), claim.getClaimNonPaymentReasonCode(), claim.getPatientDischargeStatusCode(), claim.getClaimServiceClassificationTypeCode(), claim.getClaimPrimaryPayerCode(), claim.getAttendingPhysicianNpi(), claim.getTotalChargeAmount(), claim.getPrimaryPayerPaidAmount(), claim.getFiscalIntermediaryNumber(), claim.getFiDocumentClaimControlNumber(), claim.getFiOriginalClaimControlNumber());
    assertEquals(9, eob.getDiagnosis().size());
    // test to ensure the diagnosis code display lookup table process works
    Optional<Diagnosis> diagnosis = Diagnosis.from(claim.getDiagnosis5Code(), claim.getDiagnosis5CodeVersion());
    TransformerTestUtils.assertHasCoding(diagnosis.get().getFhirSystem(), null, TransformerUtils.retrieveIcdCodeDisplay(diagnosis.get().getCode()), diagnosis.get().getCode(), eob.getDiagnosis().get(6).getDiagnosisCodeableConcept().getCoding());
    CCWProcedure ccwProcedure = new CCWProcedure(claim.getProcedure1Code(), claim.getProcedure1CodeVersion(), claim.getProcedure1Date());
    TransformerTestUtils.assertHasCoding(ccwProcedure.getFhirSystem().toString(), claim.getProcedure1Code().get(), eob.getProcedure().get(0).getProcedureCodeableConcept().getCoding());
    assertEquals(TransformerUtils.convertToDate(claim.getProcedure1Date().get()), eob.getProcedure().get(0).getDate());
    // test to ensure the procedure code display lookup table process works
    CCWProcedure ccwProcedureDisplay = new CCWProcedure(claim.getProcedure6Code(), claim.getProcedure6CodeVersion(), claim.getProcedure6Date());
    TransformerTestUtils.assertHasCoding(ccwProcedureDisplay.getFhirSystem().toString(), null, TransformerUtils.retrieveProcedureCodeDisplay(claim.getProcedure6Code().get()), claim.getProcedure6Code().get(), eob.getProcedure().get(5).getProcedureCodeableConcept().getCoding());
    assertEquals(1, eob.getItem().size());
    ItemComponent eobItem0 = eob.getItem().get(0);
    InpatientClaimLine claimLine1 = claim.getLines().get(0);
    assertEquals(claimLine1.getLineNumber(), new BigDecimal(eobItem0.getSequence()));
    assertEquals(claim.getProviderStateCode(), eobItem0.getLocationAddress().getState());
    TransformerTestUtils.assertHcpcsCodes(eobItem0, claimLine1.getHcpcsCode(), Optional.empty(), Optional.empty(), Optional.empty(), 0);
    // Test to ensure common group field coinsurance between Inpatient, HHA, Hospice and SNF match
    TransformerTestUtils.assertEobCommonGroupInpHHAHospiceSNFCoinsuranceEquals(eobItem0, claimLine1.getDeductibleCoinsuranceCd());
    String claimControlNumber = "0000000000";
    // Test to ensure item level fields between Inpatient, Outpatient, HHA, Hopsice
    // and SNF match
    TransformerTestUtils.assertEobCommonItemRevenueEquals(eobItem0, eob, claimLine1.getRevenueCenter(), claimLine1.getRateAmount(), claimLine1.getTotalChargeAmount(), claimLine1.getNonCoveredChargeAmount(), claimLine1.getUnitCount(), claimControlNumber, claimLine1.getNationalDrugCodeQuantity(), claimLine1.getNationalDrugCodeQualifierCode(), claimLine1.getRevenueCenterRenderingPhysicianNPI(), 0);
    // verify {@link
    // TransformerUtils#mapEobType(CodeableConcept,ClaimType,Optional,Optional)}
    // method worked as expected for this claim type
    TransformerTestUtils.assertMapEobType(eob.getType(), ClaimType.INPATIENT, Optional.of(org.hl7.fhir.dstu3.model.codesystems.ClaimType.INSTITUTIONAL), Optional.of(claim.getNearLineRecordIdCode()), Optional.of(claim.getClaimTypeCode()));
    // Test lastUpdated
    TransformerTestUtils.assertLastUpdatedEquals(claim.getLastUpdated(), eob);
}

Example 17 with ClaimType

use of org.hl7.fhir.r4.model.codesystems.ClaimType in project beneficiary-fhir-data by CMSgov.

the class TransformerUtilsV2 method mapEobCommonClaimHeaderData.

/**
 * Transforms the common group level header fields between all claim types
 *
 * @param eob the {@link ExplanationOfBenefit} to modify
 * @param claimId CLM_ID
 * @param beneficiaryId BENE_ID
 * @param claimType {@link ClaimTypeV2} to process
 * @param claimGroupId CLM_GRP_ID
 * @param coverageType {@link MedicareSegment}
 * @param dateFrom CLM_FROM_DT || SRVC_DT (For Part D Events)
 * @param dateThrough CLM_THRU_DT || SRVC_DT (For Part D Events)
 * @param paymentAmount CLM_PMT_AMT
 * @param finalAction FINAL_ACTION
 */
static void mapEobCommonClaimHeaderData(ExplanationOfBenefit eob, String claimId, String beneficiaryId, ClaimTypeV2 claimType, String claimGroupId, MedicareSegment coverageType, Optional<LocalDate> dateFrom, Optional<LocalDate> dateThrough, Optional<BigDecimal> paymentAmount, char finalAction) {
    // Claim Type + Claim ID => ExplanationOfBenefit.id
    eob.setId(buildEobId(claimType, claimId));
    // Current timestamp => Created
    eob.setCreated(new Date());
    // "claim" => ExplanationOfBenefit.use
    eob.setUse(Use.CLAIM);
    if (claimType.equals(ClaimTypeV2.PDE)) {
        // PDE_ID => ExplanationOfBenefit.identifier
        eob.addIdentifier(createClaimIdentifier(CcwCodebookVariable.PDE_ID, claimId));
    } else {
        // CLM_ID => ExplanationOfBenefit.identifier
        eob.addIdentifier(createClaimIdentifier(CcwCodebookVariable.CLM_ID, claimId));
    }
    // CLM_GRP_ID => ExplanationOfBenefit.identifier
    eob.addIdentifier().setSystem(TransformerConstants.IDENTIFIER_SYSTEM_BBAPI_CLAIM_GROUP_ID).setValue(claimGroupId).setType(createC4BBClaimCodeableConcept());
    // BENE_ID + Coverage Type => ExplanationOfBenefit.insurance.coverage (ref)
    eob.addInsurance().setCoverage(referenceCoverage(beneficiaryId, coverageType));
    // BENE_ID => ExplanationOfBenefit.patient (reference)
    eob.setPatient(referencePatient(beneficiaryId));
    // "insurer" => ExplanationOfBenefit.insurer
    eob.setInsurer(new Reference().setIdentifier(new Identifier().setValue("CMS")));
    // "outcome" => ExplanationOfBenefit.outcome
    eob.setOutcome(RemittanceOutcome.COMPLETE);
    // FINAL_ACTION => ExplanationOfBenefit.status
    switch(finalAction) {
        case 'F':
            eob.setStatus(ExplanationOfBenefitStatus.ACTIVE);
            break;
        case 'N':
            eob.setStatus(ExplanationOfBenefitStatus.CANCELLED);
            break;
        default:
            // unknown final action value
            throw new BadCodeMonkeyException();
    }
    // CLM_THRU_DT || SRVC_DT (For Part D Events) => ExplanationOfBenefit.billablePeriod.end
    if (dateFrom.isPresent()) {
        validatePeriodDates(dateFrom, dateThrough);
        setPeriodStart(eob.getBillablePeriod(), dateFrom.get());
        setPeriodEnd(eob.getBillablePeriod(), dateThrough.get());
    }
    // CLM_PMT_AMT => ExplanationOfBenefit.payment.amount
    if (paymentAmount.isPresent()) {
        eob.getPayment().setAmount(createMoney(paymentAmount));
    }
}

Example 18 with ClaimType

use of org.hl7.fhir.r4.model.codesystems.ClaimType in project beneficiary-fhir-data by CMSgov.

the class R4ExplanationOfBenefitResourceProvider method findClaimTypeByPatient.

/**
 * @param claimType the {@link ClaimTypeV2} 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(ClaimTypeV2 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();
        TransformerUtilsV2.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;
}

Example 19 with ClaimType

use of org.hl7.fhir.r4.model.codesystems.ClaimType in project beneficiary-fhir-data by CMSgov.

the class ExplanationOfBenefitResourceProvider method read.

/**
 * Adds support for the FHIR "read" operation, for {@link ExplanationOfBenefit}s. The {@link Read}
 * annotation indicates that this method supports the read operation.
 *
 * <p>Read operations take a single parameter annotated with {@link IdParam}, and should return a
 * single resource instance.
 *
 * @param eobId The read operation takes one parameter, which must be of type {@link IdType} and
 *     must be annotated with the {@link IdParam} annotation.
 * @param requestDetails a {@link RequestDetails} containing the details of the request URL, used
 *     to parse out header values
 * @return Returns a resource matching the specified {@link IdDt}, or <code>null</code> if none
 *     exists.
 */
@SuppressWarnings({ "rawtypes", "unchecked" })
@Read(version = false)
@Trace
public ExplanationOfBenefit read(@IdParam IdType eobId, RequestDetails requestDetails) {
    if (eobId == null)
        throw new IllegalArgumentException();
    if (eobId.getVersionIdPartAsLong() != null)
        throw new IllegalArgumentException();
    String eobIdText = eobId.getIdPart();
    if (eobIdText == null || eobIdText.trim().isEmpty())
        throw new IllegalArgumentException();
    Matcher eobIdMatcher = EOB_ID_PATTERN.matcher(eobIdText);
    if (!eobIdMatcher.matches())
        throw new IllegalArgumentException("Unsupported ID pattern: " + eobIdText);
    String eobIdTypeText = eobIdMatcher.group(1);
    Optional<ClaimType> eobIdType = ClaimType.parse(eobIdTypeText);
    Boolean includeTaxNumbers = returnIncludeTaxNumbers(requestDetails);
    if (!eobIdType.isPresent())
        throw new ResourceNotFoundException(eobId);
    String eobIdClaimIdText = eobIdMatcher.group(2);
    Operation operation = new Operation(Operation.Endpoint.V1_EOB);
    operation.setOption("IncludeTaxNumbers", "" + includeTaxNumbers);
    operation.setOption("by", "id");
    operation.publishOperationName();
    Class<?> entityClass = eobIdType.get().getEntityClass();
    CriteriaBuilder builder = entityManager.getCriteriaBuilder();
    CriteriaQuery criteria = builder.createQuery(entityClass);
    Root root = criteria.from(entityClass);
    eobIdType.get().getEntityLazyAttributes().stream().forEach(a -> root.fetch(a));
    criteria.select(root);
    criteria.where(builder.equal(root.get(eobIdType.get().getEntityIdAttribute()), eobIdClaimIdText));
    Object claimEntity = null;
    Long eobByIdQueryNanoSeconds = null;
    Timer.Context timerEobQuery = metricRegistry.timer(MetricRegistry.name(getClass().getSimpleName(), "query", "eob_by_id")).time();
    try {
        claimEntity = entityManager.createQuery(criteria).getSingleResult();
    } catch (NoResultException e) {
        throw new ResourceNotFoundException(eobId);
    } finally {
        eobByIdQueryNanoSeconds = timerEobQuery.stop();
        TransformerUtils.recordQueryInMdc("eob_by_id", eobByIdQueryNanoSeconds, claimEntity == null ? 0 : 1);
    }
    ExplanationOfBenefit eob = eobIdType.get().getTransformer().transform(metricRegistry, claimEntity, Optional.of(includeTaxNumbers));
    return eob;
}

Example 20 with ClaimType

use of org.hl7.fhir.r4.model.codesystems.ClaimType in project beneficiary-fhir-data by CMSgov.

the class DiagnosisUtilV2 method translateLabels.

/**
 * Translates a list of {@link DiagnosisLabel} to an EOB type specific Coding based on the (@link
 * ClaimTypeV2}.
 *
 * <p>In practice, the list will only ever be one {@link DiagnosisLabel}. The {@link Diagnosis}
 * class allows multiple labels to be present, so we cover that case here. In V2, only a single
 * label will ever be assigned.
 */
static CodeableConcept translateLabels(Set<DiagnosisLabel> labels, ClaimTypeV2 claimType) {
    CodeableConcept diagType = new CodeableConcept();
    List<Coding> codings = labels.stream().map(l -> translateLabelCode(l, claimType)).collect(Collectors.toList());
    return diagType.setCoding(codings);
}