Examples with Payer org.mitre.synthea.world.agents.Payer used on opensource projects

Example 1 with Payer

use of org.mitre.synthea.world.agents.Payer in project synthea by synthetichealth.

the class PayerFinderTest method noPayersRandom.

@Test
public void noPayersRandom() {
    Config.set("generate.payers.selection_behavior", "random");
    Payer.clear();
    Payer.loadPayers(new Location((String) person.attributes.get(Person.STATE), null));
    PayerFinderRandom finder = new PayerFinderRandom();
    List<Payer> options = new ArrayList<Payer>();
    Payer payer = finder.find(options, person, null, 0L);
    assertNotNull(payer);
    assertEquals("NO_INSURANCE", payer.getName());
}

Example 2 with Payer

use of org.mitre.synthea.world.agents.Payer in project synthea by synthetichealth.

the class CoverageRecord method getPayerAtTime.

/**
 * Returns the person's Payer at the given time.
 */
public Payer getPayerAtTime(long time) {
    Payer payer = null;
    Plan plan = getPlanAtTime(time);
    if (plan != null) {
        payer = plan.payer;
    }
    return payer;
}

Example 3 with Payer

use of org.mitre.synthea.world.agents.Payer in project synthea by synthetichealth.

the class CoverageRecord method getLastPayer.

/**
 * Get the payer associated with the last plan.
 * @return the payer associated with the last plan.
 */
public Payer getLastPayer() {
    Payer payer = null;
    Plan plan = getLastPlan();
    if (plan != null) {
        payer = plan.payer;
    }
    return payer;
}

Example 4 with Payer

use of org.mitre.synthea.world.agents.Payer in project synthea by synthetichealth.

the class FhirStu3 method explanationOfBenefit.

/**
 * Create an explanation of benefit resource for each claim, detailing insurance
 * information.
 *
 * @param personEntry Entry for the person
 * @param bundle The Bundle to add to
 * @param encounterEntry The current Encounter
 * @param claimEntry the Claim object
 * @param person the person the health record belongs to
 * @param encounter the current Encounter as an object
 * @return the added entry
 */
private static BundleEntryComponent explanationOfBenefit(BundleEntryComponent personEntry, Bundle bundle, BundleEntryComponent encounterEntry, Person person, BundleEntryComponent claimEntry, Encounter encounter) {
    boolean inpatient = false;
    boolean outpatient = false;
    EncounterType type = EncounterType.fromString(encounter.type);
    if (type == EncounterType.INPATIENT) {
        inpatient = true;
    // Provider enum doesn't include outpatient, but it can still be
    // an encounter type.
    } else if (type == EncounterType.AMBULATORY || type == EncounterType.WELLNESS) {
        outpatient = true;
    }
    ExplanationOfBenefit eob = new ExplanationOfBenefit();
    org.hl7.fhir.dstu3.model.Encounter encounterResource = (org.hl7.fhir.dstu3.model.Encounter) encounterEntry.getResource();
    // will have to deal with different claim types (e.g. inpatient vs outpatient)
    if (inpatient) {
        // https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Indirect-Medical-Education-IME
        // Extra cost for educational hospitals
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-ime-op-clm-val-amt-extension", 400));
        // DSH payment-- Massachusetts does not make DSH payments at all, so set to 0 for now
        // https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dsh
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-dsh-op-clm-val-amt-extension", 0));
        // The pass through per diem rate
        // not really defined by CMS
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pass-thru-per-diem-amt-extension", 0));
        // Professional charge
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-profnl-cmpnt-chrg-amt-extension", 0));
        // total claim PPS charge
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-tot-pps-cptl-amt-extension", 0));
        // Deductible Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-ip-ddctbl-amt-extension", 0));
        // Coinsurance Liability
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-pta-coinsrnc-lblty-amt-extension", 0));
        // Non-covered Charge Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-ncvrd-chrg-amt-extension", 0));
        // Total Deductible/Coinsurance Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-ip-tot-ddctn-amt-extension", 0));
        // PPS Capital DSH Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-dsprprtnt-shr-amt-extension", 0));
        // PPS Capital Exception Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-excptn-amt-extension", 0));
        // PPS FSP
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-fsp-amt-extension", 0));
        // PPS IME
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-ime-amt-extension", 400));
        // PPS Capital Outlier Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-cptl-outlier-amt-extension", 0));
        // Old capital hold harmless amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-pps-old-cptl-hld-hrmls-amt-extension", 0));
        // NCH DRG Outlier Approved Payment Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-drg-outlier-aprvd-pmt-amt-extension", 0));
        // NCH Beneficiary Blood Deductible Liability Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-nch-bene-blood-ddctbl-lblty-am-extension", 0));
        // Non-payment reason
        eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-mdcr-non-pmt-rsn-cd-extension").setValue(new Coding().setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd").setDisplay("All other reasons for non-payment").setCode("N"));
        // Prepayment
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-prpayamt-extension", 0));
        // FI or MAC number
        eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-fi-num-extension").setValue(new Identifier().setValue("002000").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"));
    } else if (outpatient) {
        // Professional component charge amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-profnl-cmpnt-chrg-amt-extension", 0));
        // Deductible amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-ddctbl-amt-extension", 0));
        // Coinsurance amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-ptb-coinsrnc-amt-extension", 0));
        // Provider Payment
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-prvdr-pmt-amt-extension", 0));
        // Beneficiary payment
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-op-bene-pmt-amt-extension", 0));
        // Beneficiary Blood Deductible Liability Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-nch-bene-blood-ddctbl-lblty-am-extension", 0));
        // Claim Medicare Non Payment Reason Code
        eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-clm-mdcr-non-pmt-rsn-cd-extension").setValue(new Coding().setDisplay("All other reasons for non-payment").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-mdcr-non-pmt-rsn-cd").setCode("N"));
        // NCH Primary Payer Claim Paid Amount
        eob.addExtension(createMoneyExtension("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-prpayamt-extension", 0));
        // FI or MAC number
        eob.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-fi-num-extension").setValue(new Identifier().setValue("002000").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-fi-num"));
    }
    // according to CMS guidelines claims have 12 months to be
    // billed, so we set the billable period to 1 year after
    // services have ended (the encounter ends).
    Calendar cal = Calendar.getInstance();
    cal.setTime(encounterResource.getPeriod().getEnd());
    cal.add(Calendar.YEAR, 1);
    Period billablePeriod = new Period().setStart(encounterResource.getPeriod().getEnd()).setEnd(cal.getTime());
    if (inpatient) {
        billablePeriod.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-claim-query-cd-extension").setValue(new Coding().setCode("3").setSystem("https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd").setDisplay("Final Bill")));
    } else if (outpatient) {
        billablePeriod.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-claim-query-cd-extension").setValue(new Coding().setCode("3").setSystem("https://bluebutton.cms.gov/assets/ig/ValueSet-claim-query-cd").setDisplay("Final Bill")));
    }
    eob.setBillablePeriod(billablePeriod);
    // cost is hardcoded to be USD in claim so this should be fine as well
    Money totalCost = new Money();
    totalCost.setSystem("urn:iso:std:iso:4217");
    totalCost.setCode("USD");
    totalCost.setValue(encounter.claim.getTotalClaimCost());
    eob.setTotalCost(totalCost);
    // Set References
    eob.setPatient(new Reference(personEntry.getFullUrl()));
    if (encounter.provider != null) {
        // This is what should happen if BlueButton 2.0 wasn't needlessly restrictive
        // String providerUrl = findProviderUrl(encounter.provider, bundle);
        // eob.setOrganization(new Reference().setReference(providerUrl));
        // Instead, we'll create the BlueButton 2.0 reference via identifier...
        Identifier identifier = new Identifier();
        identifier.setValue(encounter.provider.getResourceID());
        eob.setOrganization(new Reference().setIdentifier(identifier));
    }
    // Get the insurance info at the time that the encounter happened.
    Payer payer = encounter.claim.payer;
    Coverage coverage = new Coverage();
    coverage.setId("coverage");
    coverage.setType(new CodeableConcept().setText(payer.getName()));
    eob.addContained(coverage);
    ExplanationOfBenefit.InsuranceComponent insuranceComponent = new ExplanationOfBenefit.InsuranceComponent();
    insuranceComponent.setCoverage(new Reference("#coverage"));
    eob.setInsurance(insuranceComponent);
    org.hl7.fhir.dstu3.model.Claim claim = (org.hl7.fhir.dstu3.model.Claim) claimEntry.getResource();
    eob.addIdentifier().setSystem("https://bluebutton.cms.gov/resources/variables/clm_id").setValue(claim.getId());
    // Hardcoded group id
    eob.addIdentifier().setSystem("https://bluebutton.cms.gov/resources/identifier/claim-group").setValue("99999999999");
    eob.setStatus(org.hl7.fhir.dstu3.model.ExplanationOfBenefit.ExplanationOfBenefitStatus.ACTIVE);
    if (!inpatient && !outpatient) {
        eob.setClaim(new Reference().setReference(claimEntry.getFullUrl()));
        eob.setReferral(new Reference("#1"));
        eob.setCreated(encounterResource.getPeriod().getEnd());
    }
    eob.setType(claim.getType());
    List<ExplanationOfBenefit.DiagnosisComponent> eobDiag = new ArrayList<>();
    for (org.hl7.fhir.dstu3.model.Claim.DiagnosisComponent claimDiagnosis : claim.getDiagnosis()) {
        ExplanationOfBenefit.DiagnosisComponent diagnosisComponent = new ExplanationOfBenefit.DiagnosisComponent();
        diagnosisComponent.setDiagnosis(claimDiagnosis.getDiagnosis());
        diagnosisComponent.getType().add(new CodeableConcept().addCoding(new Coding().setCode("principal").setSystem("https://bluebutton.cms.gov/resources/codesystem/diagnosis-type")));
        diagnosisComponent.setSequence(claimDiagnosis.getSequence());
        diagnosisComponent.setPackageCode(claimDiagnosis.getPackageCode());
        diagnosisComponent.addExtension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-clm-poa-ind-sw1-extension").setValue(new Coding().setCode("Y").setSystem("https://bluebutton.cms.gov/assets/ig/CodeSystem-clm-poa-ind-sw1").setDisplay("Diagnosis present at time of admission"));
        eobDiag.add(diagnosisComponent);
    }
    eob.setDiagnosis(eobDiag);
    List<ExplanationOfBenefit.ProcedureComponent> eobProc = new ArrayList<>();
    for (ProcedureComponent proc : claim.getProcedure()) {
        ExplanationOfBenefit.ProcedureComponent p = new ExplanationOfBenefit.ProcedureComponent();
        p.setDate(proc.getDate());
        p.setSequence(proc.getSequence());
        p.setProcedure(proc.getProcedure());
    }
    eob.setProcedure(eobProc);
    List<ExplanationOfBenefit.ItemComponent> eobItem = new ArrayList<>();
    double totalPayment = 0;
    for (ItemComponent item : claim.getItem()) {
        ExplanationOfBenefit.ItemComponent itemComponent = new ExplanationOfBenefit.ItemComponent();
        itemComponent.setSequence(item.getSequence());
        itemComponent.setQuantity(item.getQuantity());
        itemComponent.setUnitPrice(item.getUnitPrice());
        itemComponent.setCareTeamLinkId(item.getCareTeamLinkId());
        if (item.hasService()) {
            itemComponent.setService(item.getService());
        }
        if (!inpatient && !outpatient) {
            itemComponent.setDiagnosisLinkId(item.getDiagnosisLinkId());
            itemComponent.setInformationLinkId(item.getInformationLinkId());
            itemComponent.setNet(item.getNet());
            itemComponent.setEncounter(item.getEncounter());
            itemComponent.setServiced(encounterResource.getPeriod());
            itemComponent.setCategory(new CodeableConcept().addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd").setCode("1").setDisplay("Medical care")));
        }
        if (inpatient) {
            itemComponent.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-inpatient-rev-cntr-ndc-qty-extension").setValue(new Quantity().setValue(0)));
        } else if (outpatient) {
            itemComponent.addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ndc-qty-extension").setValue(new Quantity().setValue(0)));
            if (itemComponent.hasService()) {
                itemComponent.getService().addExtension(new Extension().setUrl("https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-outpatient-rev-cntr-ide-ndc-upc-num-extension").setValue(new Coding().setSystem("https://www.accessdata.fda.gov/scripts/cder/ndc").setDisplay("Dummy").setCode("0624")));
            }
        }
        // Location of service, can use switch statement based on
        // encounter type
        String code;
        String display;
        CodeableConcept location = new CodeableConcept();
        EncounterType encounterType = EncounterType.fromString(encounter.type);
        switch(encounterType) {
            case AMBULATORY:
                code = "21";
                display = "Inpatient Hospital";
                break;
            case EMERGENCY:
                code = "23";
                display = "Emergency Room";
                break;
            case INPATIENT:
                code = "21";
                display = "Inpatient Hospital";
                break;
            case URGENTCARE:
                code = "20";
                display = "Urgent Care Facility";
                break;
            case WELLNESS:
                code = "22";
                display = "Outpatient Hospital";
                break;
            default:
                code = "21";
                display = "Inpatient Hospital";
        }
        location.addCoding().setCode(code).setSystem("https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd").setDisplay(display);
        itemComponent.setLocation(location);
        // Adjudication
        if (item.hasNet()) {
            // Assume that the patient has already paid deductible and
            // has 20/80 coinsurance
            ExplanationOfBenefit.AdjudicationComponent coinsuranceAmount = new ExplanationOfBenefit.AdjudicationComponent();
            coinsuranceAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Beneficiary Coinsurance Amount"));
            coinsuranceAmount.getAmount().setValue(// 20% coinsurance
            0.2 * item.getNet().getValue().doubleValue()).setSystem(// USD
            "urn:iso:std:iso:4217").setCode("USD");
            ExplanationOfBenefit.AdjudicationComponent lineProviderAmount = new ExplanationOfBenefit.AdjudicationComponent();
            lineProviderAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Provider Payment Amount"));
            lineProviderAmount.getAmount().setValue(0.8 * item.getNet().getValue().doubleValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
            // assume the allowed and submitted amounts are the same for now
            ExplanationOfBenefit.AdjudicationComponent submittedAmount = new ExplanationOfBenefit.AdjudicationComponent();
            submittedAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Submitted Charge Amount"));
            submittedAmount.getAmount().setValue(item.getNet().getValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
            ExplanationOfBenefit.AdjudicationComponent allowedAmount = new ExplanationOfBenefit.AdjudicationComponent();
            allowedAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Allowed Charge Amount"));
            allowedAmount.getAmount().setValue(item.getNet().getValue()).setSystem("urn:iso:std:iso:4217").setCode("USD");
            ExplanationOfBenefit.AdjudicationComponent indicatorCode = new ExplanationOfBenefit.AdjudicationComponent();
            indicatorCode.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Processing Indicator Code"));
            if (!inpatient && !outpatient) {
                indicatorCode.getReason().addCoding().setCode("A").setSystem("https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd");
                indicatorCode.getReason().getCodingFirstRep().setDisplay("Allowed");
            }
            // assume deductible is 0
            ExplanationOfBenefit.AdjudicationComponent deductibleAmount = new ExplanationOfBenefit.AdjudicationComponent();
            deductibleAmount.getCategory().getCoding().add(new Coding().setCode("https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt").setSystem("https://bluebutton.cms.gov/resources/codesystem/adjudication").setDisplay("Line Beneficiary Part B Deductible Amount"));
            deductibleAmount.getAmount().setValue(0).setSystem("urn:iso:std:iso:4217").setCode("USD");
            List<ExplanationOfBenefit.AdjudicationComponent> adjudicationComponents = new ArrayList<>();
            adjudicationComponents.add(coinsuranceAmount);
            adjudicationComponents.add(lineProviderAmount);
            adjudicationComponents.add(submittedAmount);
            adjudicationComponents.add(allowedAmount);
            adjudicationComponents.add(deductibleAmount);
            adjudicationComponents.add(indicatorCode);
            itemComponent.setAdjudication(adjudicationComponents);
            // the total payment is what the insurance ends up paying
            totalPayment += 0.8 * item.getNet().getValue().doubleValue();
        }
        eobItem.add(itemComponent);
    }
    eob.setItem(eobItem);
    // This will throw a validation error no matter what.  The
    // payment section is required, and it requires a value.
    // The validator will complain that if there is a value, the payment
    // needs a code, but it will also complain if there is a code.
    // There is no way to resolve this error.
    Money payment = new Money();
    payment.setValue(totalPayment).setSystem("urn:iso:std:iso:4217").setCode("USD");
    eob.setPayment(new ExplanationOfBenefit.PaymentComponent().setAmount(payment));
    // Hardcoded
    String npi = "9999999999";
    if (encounter.clinician != null) {
        npi = encounter.clinician.npi;
    } else if (encounter.provider != null) {
        npi = encounter.provider.npi;
    }
    List<Reference> recipientList = new ArrayList<>();
    recipientList.add(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi)));
    eob.addContained(new ReferralRequest().setStatus(ReferralRequest.ReferralRequestStatus.COMPLETED).setIntent(ReferralRequest.ReferralCategory.ORDER).setSubject(new Reference(personEntry.getFullUrl())).setRequester(new ReferralRequest.ReferralRequestRequesterComponent().setAgent(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi)))).setRecipient(recipientList).setId("1"));
    if (encounter.clinician != null) {
        // This is what should happen if BlueButton 2.0 wasn't needlessly restrictive
        // String practitionerFullUrl = findPractitioner(encounter.clinician, bundle);
        // eob.setProvider(new Reference().setReference(practitionerFullUrl));
        // Instead, we'll create the BlueButton 2.0 reference via identifier...
        Identifier identifier = new Identifier();
        identifier.setValue(encounter.clinician.getResourceID());
        eob.setProvider(new Reference().setIdentifier(identifier));
    } else {
        Identifier identifier = new Identifier();
        identifier.setValue("Unknown");
        eob.setProvider(new Reference().setIdentifier(identifier));
    }
    eob.addCareTeam(new ExplanationOfBenefit.CareTeamComponent().setSequence(1).setProvider(new Reference().setIdentifier(new Identifier().setSystem("http://hl7.org/fhir/sid/us-npi").setValue(npi))).setRole(new CodeableConcept().addCoding(new Coding().setCode("primary").setSystem("http://hl7.org/fhir/claimcareteamrole").setDisplay("Primary Care Practitioner"))));
    eob.setType(new CodeableConcept().addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd").setCode("71").setDisplay("Local carrier non-durable medical equipment, prosthetics, orthotics, " + "and supplies (DMEPOS) claim")).addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/codesystem/eob-type").setCode("CARRIER").setDisplay("EOB Type")).addCoding(new Coding().setSystem("http://hl7.org/fhir/ex-claimtype").setCode("professional").setDisplay("Claim Type")).addCoding(new Coding().setSystem("https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd").setCode("O").setDisplay("Part B physician/supplier claim record (processed by local " + "carriers; can include DMEPOS services)")));
    return newEntry(person, bundle, eob);
}

Example 5 with Payer

use of org.mitre.synthea.world.agents.Payer in project synthea by synthetichealth.

the class PayerFinderBestRates method find.

/**
 * Find a provider with a specific service for the person.
 *
 * @param payers  The list of eligible payers.
 * @param person  The patient who requires the service.
 * @param service The service required.
 * @param time    The date/time within the simulated world, in milliseconds.
 * @return Service provider or null if none is available.
 */
@Override
public Payer find(List<Payer> payers, Person person, EncounterType service, long time) {
    int numberOfExpectedEncounters = 0;
    if (person.hasMultipleRecords) {
        for (HealthRecord record : person.records.values()) {
            numberOfExpectedEncounters += numberOfEncounterDuringLastTwelveMonths(record, time);
        }
    } else {
        numberOfExpectedEncounters = numberOfEncounterDuringLastTwelveMonths(person.defaultRecord, time);
    }
    HealthRecord.Encounter dummy = person.record.new Encounter(time, EncounterType.AMBULATORY.toString());
    Payer bestRatePayer = Payer.noInsurance;
    double bestExpectedRate = Double.MAX_VALUE;
    for (Payer payer : payers) {
        if (IPayerFinder.meetsBasicRequirements(payer, person, service, time)) {
            // First, calculate the annual premium.
            double expectedRate = (payer.getMonthlyPremium() * 12.0);
            // Second, calculate expected copays based on last years visits.
            expectedRate += (payer.determineCopay(dummy) * numberOfExpectedEncounters);
            // TODO consider deductibles, coinsurance, covered services, etc.
            if (expectedRate < bestExpectedRate) {
                bestExpectedRate = expectedRate;
                bestRatePayer = payer;
            }
        }
    }
    return bestRatePayer;
}