Nora
61 lines
2.0 KiB
Python
61 lines
2.0 KiB
Python
"""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
|