Tyler
716bfb0a26
- R034 _r034_ref_g1_required: when payer opts in (require_ref_g1_for_adjustments),
emit error if frequency_code is 7/8 and no REF*G1 segment appears in raw_segments.
CO Medicaid stays lenient in v1 (gate is False by default).
- R035 _r035_bht06_allowed: BHT06 transaction type code must be in cfg.allowed_bht06.
Skipped silently when transaction_type_code is None.
- Add transaction_type_code (str|None) to Envelope and ClaimOutput.
- parse_837: read BHT06 (seg[6]) in _build_envelope; mirror onto each ClaimOutput
via the existing model_copy(update={...}) call site.
- 9 new tests in test_validator.py: 5 R034 (incl. lenient no-op) + 4 R035.
213 passed, 1 skipped (prodfile corpus present-conditional).
316 lines
10 KiB
Python
316 lines
10 KiB
Python
from datetime import date
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from decimal import Decimal
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import pytest
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from cyclone.parsers.models import (
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Address,
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BillingProvider,
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ClaimHeader,
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ClaimOutput,
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Diagnosis,
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Envelope,
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Payer,
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Procedure,
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ServiceLine,
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Subscriber,
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ValidationReport,
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)
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from cyclone.parsers.payer import PayerConfig
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from cyclone.parsers.validator import validate
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def _build_claim(**overrides) -> ClaimOutput:
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"""Build a passing claim for tests; override fields to break specific rules."""
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base = dict(
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claim_id="C1",
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control_number="991102977",
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transaction_date=date(2026, 6, 11),
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billing_provider=BillingProvider(
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name="Test Provider",
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npi="1234567890",
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tax_id="123456789",
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address=Address(line1="1 Main", city="X", state="CO", zip="80000"),
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),
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subscriber=Subscriber(
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first_name="John",
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last_name="Doe",
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member_id="M1",
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dob=date(1980, 1, 1),
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gender="M",
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address=Address(line1="1 Main", city="X", state="CO", zip="80000"),
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),
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payer=Payer(name="COHCPF", id="SKCO0"),
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claim=ClaimHeader(
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claim_id="C1",
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total_charge=Decimal("100.00"),
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place_of_service="12",
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frequency_code="1",
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provider_signature="Y",
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assignment="Y",
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release_of_info="Y",
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),
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diagnoses=[Diagnosis(code="Z00", qualifier="ABK")],
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service_lines=[
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ServiceLine(
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line_number=1,
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procedure=Procedure(qualifier="HC", code="99213", modifiers=[]),
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charge=Decimal("100.00"),
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unit_type="UN",
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units=Decimal("1.0"),
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service_date=date(2026, 6, 11),
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)
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],
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validation=ValidationReport(passed=True, errors=[], warnings=[]),
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raw_segments=[],
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)
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base.update(overrides)
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return ClaimOutput(**base)
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def test_validate_passing_claim():
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cfg = PayerConfig.co_medicaid()
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report = validate(_build_claim(), cfg)
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assert report.passed is True
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assert report.errors == []
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def test_r010_clm01_required():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.claim_id = ""
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report = validate(claim, cfg)
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assert not report.passed
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assert any(i.rule == "R010_clm01_present" for i in report.errors)
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def test_r011_total_charge_positive():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.total_charge = Decimal("0.00")
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report = validate(claim, cfg)
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assert any(i.rule == "R011_total_charge_positive" for i in report.errors)
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def test_r020_npi_must_be_ten_digits():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.billing_provider.npi = "12345"
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report = validate(claim, cfg)
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assert any(i.rule == "R020_npi_format" for i in report.errors)
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def test_r030_frequency_allowed():
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cfg = PayerConfig.co_medicaid() # only 1, 7, 8
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claim = _build_claim()
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claim.claim.frequency_code = "5"
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report = validate(claim, cfg)
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assert any(i.rule == "R030_frequency_allowed" for i in report.errors)
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def test_r031_ref_g1_optional_no_error():
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"""R031 is informational in v1 — no REF*G1 should not error."""
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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report = validate(claim, cfg)
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assert not any(i.rule == "R031_ref_g1_optional" and i.severity == "error" for i in report.errors)
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def test_r050_diagnosis_required():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim(diagnoses=[])
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report = validate(claim, cfg)
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assert any(i.rule == "R050_diagnosis_present" for i in report.errors)
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def test_r060_service_dates_required():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.service_lines[0].service_date = None
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report = validate(claim, cfg)
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assert any(i.rule == "R060_service_dates_present" for i in report.errors)
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# Now add the date:
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claim.service_lines[0].service_date = date(2026, 6, 11)
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report = validate(claim, cfg)
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assert not any(i.rule == "R060_service_dates_present" for i in report.errors + report.warnings)
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def test_r070_charges_sum_warning():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.total_charge = Decimal("999.00") # mismatch
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report = validate(claim, cfg)
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assert any(i.rule == "R070_charges_sum" and i.severity == "warning" for i in report.warnings)
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def test_r100_payer_id_warning_only():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.payer.id = "WRONG"
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report = validate(claim, cfg)
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assert any(i.rule == "R100_payer_id_matches" and i.severity == "warning" for i in report.warnings)
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assert report.passed is True
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def test_r032_passes_when_qualifier_b():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.facility_code_qualifier = "B"
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report = validate(claim, cfg)
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assert not any(i.rule == "R032_clm05_2_facility_qualifier" for i in report.errors + report.warnings)
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def test_r032_errors_when_qualifier_unknown():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.facility_code_qualifier = "X"
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report = validate(claim, cfg)
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assert any(i.rule == "R032_clm05_2_facility_qualifier" and i.severity == "error" for i in report.errors)
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assert report.passed is False
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def test_r032_skipped_when_qualifier_none():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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# Default _build_claim leaves facility_code_qualifier unset (None).
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assert claim.claim.facility_code_qualifier is None
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report = validate(claim, cfg)
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assert not any(i.rule == "R032_clm05_2_facility_qualifier" for i in report.errors + report.warnings)
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def test_r033_passes_with_valid_pos_code():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.place_of_service = "12" # Office — valid CMS POS
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report = validate(claim, cfg)
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assert not any(i.rule == "R033_clm05_1_place_of_service_code" for i in report.errors + report.warnings)
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def test_r033_errors_with_invalid_pos_code():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim()
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claim.claim.place_of_service = "999" # not a valid CMS POS code
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report = validate(claim, cfg)
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assert any(i.rule == "R033_clm05_1_place_of_service_code" and i.severity == "error" for i in report.errors)
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assert report.passed is False
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# --------------------------------------------------------------------------- #
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# R034 — REF*G1 enforcement (SP3 Phase 1)
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# --------------------------------------------------------------------------- #
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def _strict_cfg() -> PayerConfig:
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"""Strict cfg that mirrors the CO Medicaid defaults but turns on R034 enforcement.
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We don't modify :meth:`PayerConfig.co_medicaid` — the lenient default stays
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in v1. This local fixture lets us exercise the strict path without leaking
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config changes across the suite.
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"""
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return PayerConfig(
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name="StrictTest",
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require_ref_g1_for_adjustments=True,
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allowed_bht06={"CH"},
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payer_id="X",
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)
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def test_r034_ref_g1_required_freq_7_no_ref_g1_errors():
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cfg = _strict_cfg()
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claim = _build_claim()
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claim.claim.frequency_code = "7"
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claim.raw_segments = []
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report = validate(claim, cfg)
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assert any(
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i.rule == "R034_ref_g1_required" and i.severity == "error" for i in report.errors
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)
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assert report.passed is False
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def test_r034_ref_g1_required_freq_8_no_ref_g1_errors():
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cfg = _strict_cfg()
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claim = _build_claim()
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claim.claim.frequency_code = "8"
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claim.raw_segments = []
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report = validate(claim, cfg)
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assert any(
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i.rule == "R034_ref_g1_required" and i.severity == "error" for i in report.errors
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)
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assert report.passed is False
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def test_r034_ref_g1_required_freq_7_with_ref_g1_passes():
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cfg = _strict_cfg()
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claim = _build_claim()
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claim.claim.frequency_code = "7"
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claim.raw_segments = [["REF", "G1", "12345"]]
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R034_ref_g1_required" for i in report.errors + report.warnings
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)
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def test_r034_ref_g1_required_freq_1_no_ref_g1_passes():
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cfg = _strict_cfg()
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claim = _build_claim()
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claim.claim.frequency_code = "1"
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claim.raw_segments = []
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R034_ref_g1_required" for i in report.errors + report.warnings
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)
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def test_r034_ref_g1_lenient_cfg_never_errors():
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cfg = PayerConfig.co_medicaid() # require_ref_g1_for_adjustments=False (lenient v1)
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claim = _build_claim()
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claim.claim.frequency_code = "7"
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claim.raw_segments = []
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R034_ref_g1_required" for i in report.errors + report.warnings
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)
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# --------------------------------------------------------------------------- #
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# R035 — BHT06 transaction type code (SP3 Phase 1)
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# --------------------------------------------------------------------------- #
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def test_r035_bht06_allowed_ch_passes():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim(transaction_type_code="CH")
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R035_bht06_allowed" for i in report.errors + report.warnings
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)
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def test_r035_bht06_allowed_rp_errors_for_co_medicaid():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim(transaction_type_code="RP")
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report = validate(claim, cfg)
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assert any(
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i.rule == "R035_bht06_allowed" and i.severity == "error" for i in report.errors
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)
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assert report.passed is False
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def test_r035_bht06_missing_skips():
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cfg = PayerConfig.co_medicaid()
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claim = _build_claim(transaction_type_code=None)
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assert claim.transaction_type_code is None
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R035_bht06_allowed" for i in report.errors + report.warnings
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)
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def test_r035_bht06_rp_allowed_for_generic_837p():
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cfg = PayerConfig.generic_837p() # allows {"CH", "RP"}
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claim = _build_claim(transaction_type_code="RP")
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report = validate(claim, cfg)
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assert not any(
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i.rule == "R035_bht06_allowed" for i in report.errors + report.warnings
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)
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