feat(sp41): pipeline A — denied/partial rebill with frequency-7 + CARC gate

2026-07-07 20:34:04 -06:00
parent 30d13876cd
commit e946a4f7aa
2 changed files with 139 additions and 0 deletions
@@ -0,0 +1,60 @@
+"""Pipeline A: denied/partial visits become frequency-7 replacement claims."""
+from datetime import date
+from decimal import Decimal
+from pathlib import Path
+from cyclone.rebill.pipeline_a import (
+    RebillClaim,
+    build_pipeline_a_claims,
+    write_pipeline_a_files,
+)
+from cyclone.rebill.reconcile import VisitRow, ReconcileOutcome, OutcomeCategory
+from cyclone.rebill.carc_filter import CarcDecision
+
+
+def _outcome(date_, member, proc, billed, cat, unpaid=Decimal("0")):
+    visit = VisitRow(date=date_, member_id=member, procedure=proc, billed=Decimal(billed))
+    return ReconcileOutcome(visit, cat, unpaid, 0)
+
+
+def test_pipeline_a_emits_frequency_7():
+    """CLM05-3 must be 7 (replacement), preserving the original claim_submit_id."""
+    out = build_pipeline_a_claims(
+        original_claim_id="ORIG-001",
+        visit_outcomes=[
+            _outcome(date(2026, 6, 27), "J813715", "T1019", "2.32",
+                     OutcomeCategory.DENIED, unpaid=Decimal("2.32")),
+        ],
+        carc_decisions=[CarcDecision.REBILL],
+        cas_reasons_per_visit=[()],
+    )
+    assert len(out) == 1
+    assert out[0].claim_id == "ORIG-001"
+    assert out[0].frequency_code == "7"
+    assert out[0].svc_date == date(2026, 6, 27)
+
+
+def test_pipeline_a_excludes_carc_excluded_visits():
+    out = build_pipeline_a_claims(
+        original_claim_id="ORIG-002",
+        visit_outcomes=[
+            _outcome(date(2026, 6, 27), "J813715", "T1019", "2.32",
+                     OutcomeCategory.DENIED),
+        ],
+        carc_decisions=[CarcDecision.EXCLUDED],
+        cas_reasons_per_visit=[("CO-45",)],
+    )
+    assert out == []  # not emitted
+
+
+def test_pipeline_a_surfaces_review_visits_with_flag():
+    out = build_pipeline_a_claims(
+        original_claim_id="ORIG-003",
+        visit_outcomes=[
+            _outcome(date(2026, 6, 27), "J813715", "T1019", "2.32",
+                     OutcomeCategory.DENIED),
+        ],
+        carc_decisions=[CarcDecision.REVIEW],
+        cas_reasons_per_visit=[("PI-16",)],
+    )
+    assert len(out) == 1
+    assert out[0].needs_review is True