feat(sp41): visit-to-835 reconcile on (member_id, procedure, DOS) with best-of-N

2026-07-07 19:59:18 -06:00
parent f8e2f0933e
commit 69b760e890
2 changed files with 145 additions and 0 deletions
@@ -0,0 +1,76 @@
+"""Visit-to-835 reconciliation on (member_id, procedure, DOS)."""
+from datetime import date
+from decimal import Decimal
+from cyclone.rebill.reconcile import (
+    VisitRow,
+    SvcRow,
+    ReconcileOutcome,
+    reconcile_visits_to_835,
+    OutcomeCategory,
+)
+
+
+def _v(date, member, proc, amt):
+    return VisitRow(date=date, member_id=member, procedure=proc, billed=Decimal(amt))
+
+
+def _s(date, member, proc, chg, paid, status="1"):
+    return SvcRow(
+        src_file="x.835", claim_id="c1", member_id=member, status=status,
+        procedure=proc, modifiers="", charge=Decimal(chg), paid=Decimal(paid),
+        units=Decimal("0"), svc_date=date, cas_reasons=(), pay_date=None,
+    )
+
+
+def test_visit_paid_when_any_svc_paid_within_tolerance():
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
+    svcs = [_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "2.30")]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.PAID
+    assert out[0].unpaid == Decimal("0")
+
+
+def test_visit_paid_when_one_svc_paid_others_denied_duplicate():
+    """OA-18 on duplicates is noise; paid SVC wins."""
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
+    svcs = [
+        _s(date(2026, 1, 18), "J813715", "T1019", "2.32", "2.30", "1"),
+        _s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
+        _s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
+    ]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.PAID
+
+
+def test_visit_denied_when_all_svc_denied():
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
+    svcs = [
+        _s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
+        _s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
+    ]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.DENIED
+    assert out[0].unpaid == Decimal("2.32")
+
+
+def test_visit_not_in_835_when_no_svc_match():
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
+    svcs = [_s(date(2026, 1, 19), "J813715", "T1019", "2.32", "2.30")]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.NOT_IN_835
+    assert out[0].unpaid == Decimal("2.32")
+
+
+def test_partial_when_total_paid_below_95pct_of_billed():
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "10.00")]
+    svcs = [_s(date(2026, 1, 18), "J813715", "T1019", "10.00", "4.00")]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.PARTIAL
+    assert out[0].unpaid == Decimal("6.00")
+
+
+def test_different_member_does_not_match():
+    visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
+    svcs = [_s(date(2026, 1, 18), "OTHERMEMBER", "T1019", "2.32", "2.30")]
+    out = reconcile_visits_to_835(visits, svcs)
+    assert out[0].category == OutcomeCategory.NOT_IN_835