Nora
77 lines
2.9 KiB
Python
77 lines
2.9 KiB
Python
"""Visit-to-835 reconciliation on (member_id, procedure, DOS)."""
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from datetime import date
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from decimal import Decimal
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from cyclone.rebill.reconcile import (
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VisitRow,
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SvcRow,
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ReconcileOutcome,
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reconcile_visits_to_835,
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OutcomeCategory,
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)
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def _v(date, member, proc, amt):
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return VisitRow(date=date, member_id=member, procedure=proc, billed=Decimal(amt))
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def _s(date, member, proc, chg, paid, status="1"):
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return SvcRow(
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src_file="x.835", claim_id="c1", member_id=member, status=status,
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procedure=proc, modifiers="", charge=Decimal(chg), paid=Decimal(paid),
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units=Decimal("0"), svc_date=date, cas_reasons=(), pay_date=None,
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)
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def test_visit_paid_when_any_svc_paid_within_tolerance():
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
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svcs = [_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "2.30")]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.PAID
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assert out[0].unpaid == Decimal("0")
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def test_visit_paid_when_one_svc_paid_others_denied_duplicate():
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"""OA-18 on duplicates is noise; paid SVC wins."""
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
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svcs = [
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_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "2.30", "1"),
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_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
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_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
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]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.PAID
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def test_visit_denied_when_all_svc_denied():
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
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svcs = [
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_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
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_s(date(2026, 1, 18), "J813715", "T1019", "2.32", "0.00", "4"),
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]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.DENIED
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assert out[0].unpaid == Decimal("2.32")
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def test_visit_not_in_835_when_no_svc_match():
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
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svcs = [_s(date(2026, 1, 19), "J813715", "T1019", "2.32", "2.30")]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.NOT_IN_835
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assert out[0].unpaid == Decimal("2.32")
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def test_partial_when_total_paid_below_95pct_of_billed():
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "10.00")]
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svcs = [_s(date(2026, 1, 18), "J813715", "T1019", "10.00", "4.00")]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.PARTIAL
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assert out[0].unpaid == Decimal("6.00")
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def test_different_member_does_not_match():
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visits = [_v(date(2026, 1, 18), "J813715", "T1019", "2.32")]
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svcs = [_s(date(2026, 1, 18), "OTHERMEMBER", "T1019", "2.32", "2.30")]
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out = reconcile_visits_to_835(visits, svcs)
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assert out[0].category == OutcomeCategory.NOT_IN_835
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