feat(backend): structural + CO Medicaid validation rules

2026-06-19 15:45:17 -06:00
parent 9db793c108
commit 1cab95ffc3
2 changed files with 267 additions and 0 deletions
@@ -0,0 +1,152 @@
+from datetime import date
+from decimal import Decimal
+
+import pytest
+
+from cyclone.parsers.models import (
+    Address,
+    BillingProvider,
+    ClaimHeader,
+    ClaimOutput,
+    Diagnosis,
+    Envelope,
+    Payer,
+    Procedure,
+    ServiceLine,
+    Subscriber,
+    ValidationReport,
+)
+from cyclone.parsers.payer import PayerConfig
+from cyclone.parsers.validator import validate
+
+
+def _build_claim(**overrides) -> ClaimOutput:
+    """Build a passing claim for tests; override fields to break specific rules."""
+    base = dict(
+        claim_id="C1",
+        control_number="991102977",
+        transaction_date=date(2026, 6, 11),
+        billing_provider=BillingProvider(
+            name="Test Provider",
+            npi="1234567890",
+            tax_id="123456789",
+            address=Address(line1="1 Main", city="X", state="CO", zip="80000"),
+        ),
+        subscriber=Subscriber(
+            first_name="John",
+            last_name="Doe",
+            member_id="M1",
+            dob=date(1980, 1, 1),
+            gender="M",
+            address=Address(line1="1 Main", city="X", state="CO", zip="80000"),
+        ),
+        payer=Payer(name="COHCPF", id="SKCO0"),
+        claim=ClaimHeader(
+            claim_id="C1",
+            total_charge=Decimal("100.00"),
+            place_of_service="12",
+            frequency_code="1",
+            provider_signature="Y",
+            assignment="Y",
+            release_of_info="Y",
+        ),
+        diagnoses=[Diagnosis(code="Z00", qualifier="ABK")],
+        service_lines=[
+            ServiceLine(
+                line_number=1,
+                procedure=Procedure(qualifier="HC", code="99213", modifiers=[]),
+                charge=Decimal("100.00"),
+                unit_type="UN",
+                units=Decimal("1.0"),
+                service_date=date(2026, 6, 11),
+            )
+        ],
+        validation=ValidationReport(passed=True, errors=[], warnings=[]),
+        raw_segments=[],
+    )
+    base.update(overrides)
+    return ClaimOutput(**base)
+
+
+def test_validate_passing_claim():
+    cfg = PayerConfig.co_medicaid()
+    report = validate(_build_claim(), cfg)
+    assert report.passed is True
+    assert report.errors == []
+
+
+def test_r010_clm01_required():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.claim.claim_id = ""
+    report = validate(claim, cfg)
+    assert not report.passed
+    assert any(i.rule == "R010_clm01_present" for i in report.errors)
+
+
+def test_r011_total_charge_positive():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.claim.total_charge = Decimal("0.00")
+    report = validate(claim, cfg)
+    assert any(i.rule == "R011_total_charge_positive" for i in report.errors)
+
+
+def test_r020_npi_must_be_ten_digits():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.billing_provider.npi = "12345"
+    report = validate(claim, cfg)
+    assert any(i.rule == "R020_npi_format" for i in report.errors)
+
+
+def test_r030_frequency_allowed():
+    cfg = PayerConfig.co_medicaid()  # only 1, 7, 8
+    claim = _build_claim()
+    claim.claim.frequency_code = "5"
+    report = validate(claim, cfg)
+    assert any(i.rule == "R030_frequency_allowed" for i in report.errors)
+
+
+def test_r031_ref_g1_optional_no_error():
+    """R031 is informational in v1 — no REF*G1 should not error."""
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    report = validate(claim, cfg)
+    assert not any(i.rule == "R031_ref_g1_optional" and i.severity == "error" for i in report.errors)
+
+
+def test_r050_diagnosis_required():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim(diagnoses=[])
+    report = validate(claim, cfg)
+    assert any(i.rule == "R050_diagnosis_present" for i in report.errors)
+
+
+def test_r060_service_dates_required():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.service_lines[0].service_date = None
+    report = validate(claim, cfg)
+    assert any(i.rule == "R060_service_dates_present" for i in report.errors)
+    # Now add the date:
+    claim.service_lines[0].service_date = date(2026, 6, 11)
+    report = validate(claim, cfg)
+    assert not any(i.rule == "R060_service_dates_present" for i in report.errors + report.warnings)
+
+
+def test_r070_charges_sum_warning():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.claim.total_charge = Decimal("999.00")  # mismatch
+    report = validate(claim, cfg)
+    assert any(i.rule == "R070_charges_sum" and i.severity == "warning" for i in report.warnings)
+
+
+def test_r100_payer_id_warning_only():
+    cfg = PayerConfig.co_medicaid()
+    claim = _build_claim()
+    claim.payer.id = "WRONG"
+    report = validate(claim, cfg)
+    assert any(i.rule == "R100_payer_id_matches" and i.severity == "warning" for i in report.warnings)
+    assert report.passed is True