BFD-4764: Prior Auth Server Implementation

apps/bfd-db-migrator-ng/migrations/V1_35_0__add_prvdr_prior_auth_item.sql

@@ -0,0 +1,63 @@
+ALTER TABLE idr.prior_auth
+ADD COLUMN bfd_order_refer_careteam_name character varying(135),
+ADD COLUMN bfd_order_refer_npi_type      integer,
+ADD COLUMN bfd_render_careteam_name      character varying(135),
+ADD COLUMN bfd_render_npi_type           integer,
+ADD COLUMN bfd_att_phy_careteam_name     character varying(135),
+ADD COLUMN bfd_att_phy_npi_type          integer;
+
+ALTER TABLE idr.prior_auth
+ADD COLUMN resource_id UUID DEFAULT gen_random_uuid();
+
+CREATE TABLE idr.prior_auth_item (
+    mbi_num VARCHAR(11) NOT NULL,
+    utn VARCHAR(14) NOT NULL,
+    current_segment INT NOT NULL,
+    hcpcs_or_cpt_or_hipps VARCHAR(5) NOT NULL,
+    price_mod1 VARCHAR(2) NOT NULL,
+    price_mod2 VARCHAR(2) NOT NULL,
+    place_of_serv VARCHAR(2) NOT NULL,
+    rev_code_1 VARCHAR(4) NOT NULL,
+    pa_dt_added DATE NOT NULL,
+    pa_dt_updated DATE,
+    pa_decision VARCHAR(1) NOT NULL,
+    pa_req_sub_dt DATE NOT NULL,
+    pa_req_rec_dt DATE NOT NULL,
+    pa_decision_dt DATE,
+    pa_decision_exp_dt DATE,
+    service_cnts INT NOT NULL,
+    svc_render_st VARCHAR(2) NOT NULL,
+    mr_count_ind INT NOT NULL,
+    mr_count_st_dt DATE,
+    mr_count_end_dt DATE,
+    rrb_excl_ind VARCHAR(1) NOT NULL,
+    bfd_created_ts TIMESTAMPTZ NOT NULL,
+    bfd_updated_ts TIMESTAMPTZ,
+    PRIMARY KEY(mbi_num, utn, current_segment)
+);
+
+ALTER TABLE idr.prior_auth
+DROP CONSTRAINT prior_auth_pkey,
+DROP COLUMN current_segment,
+ADD CONSTRAINT prior_auth_pkey PRIMARY KEY (mbi_num, utn);
+
+ALTER TABLE idr.prior_auth
+DROP COLUMN hcpcs_or_cpt_or_hipps,
+DROP COLUMN price_mod1,
+DROP COLUMN price_mod2,
+DROP COLUMN place_of_serv,
+DROP COLUMN rev_code_1,
+DROP COLUMN pa_dt_added,
+DROP COLUMN pa_dt_updated,
+DROP COLUMN pa_decision,
+DROP COLUMN pa_req_sub_dt,
+DROP COLUMN pa_req_rec_dt,
+DROP COLUMN pa_decision_dt,
+DROP COLUMN pa_decision_exp_dt,
+DROP COLUMN service_cnts,
+DROP COLUMN svc_render_st,
+DROP COLUMN mr_count_ind,
+DROP COLUMN mr_count_st_dt,
+DROP COLUMN mr_count_end_dt,
+DROP COLUMN rrb_excl_ind;
+

apps/bfd-model-idr/docker-compose.yml

@@ -32,7 +32,7 @@ services:
     container_name: matchbox-db
     restart: always
     ports:
-      - "5432:5432"
+      - "15432:5432"
     environment:
       POSTGRES_DB: 'matchbox'
       POSTGRES_USER: 'matchbox'

apps/bfd-model-idr/maps/ExplanationOfBenefit-Helper.map

@@ -358,58 +358,6 @@ conceptmap "CLM_PD_STUS_CD" {
   s:"T" == t:"partial"
 }
 
-conceptmap "CLM_AUDT_TRL_STUS_CD_MCS" {
-  prefix s = "https://hl7.org/fhir/string"
-  prefix t = "https://hl7.org/fhir/string"
-
-  s:"A" = t:"queued"
-  s:"B" = t:"queued"
-  s:"C" = t:"partial"
-  s:"D" = t:"complete"
-  s:"E" = t:"complete"
-  s:"F" = t:"complete"
-  s:"G" = t:"complete"
-  s:"J" = t:"queued"
-  s:"K" = t:"queued"
-  s:"L" = t:"partial"
-  s:"M" = t:"complete"
-  s:"N" = t:"complete"
-  s:"P" = t:"complete"
-  s:"Q" = t:"complete"
-  s:"R" = t:"complete"
-  s:"U" = t:"complete"
-  s:"V" = t:"complete"
-  s:"W" = t:"complete"
-  s:"X" = t:"complete"
-  s:"Y" = t:"complete"
-  s:"Z" = t:"complete"
-  s:"1" = t:"queued"
-  s:"2" = t:"queued"
-  s:"3" = t:"partial"
-  s:"4" = t:"complete"
-  s:"5" = t:"complete"
-  s:"6" = t:"error"
-  s:"8" = t:"complete"
-  s:"9" = t:"complete"
-}
-
-// Separate concept map for FISS since outcome differs for codes F & M
-conceptmap "CLM_AUDT_TRL_STUS_CD_FISS" {
-  prefix s = "https://hl7.org/fhir/string"
-  prefix t = "https://hl7.org/fhir/string"
-
-  s:"A" == t:"queued"
-  s:"F" == t:"partial"
-  s:"I" == t:"partial"
-  s:"S" == t:"partial"
-  s:"M" == t:"partial"
-  s:"P" == t:"complete"
-  s:"R" == t:"complete"
-  s:"D" == t:"complete"
-  s:"T" == t:"partial"
-  s:"U" == t:"complete"
-}
-
 conceptmap "CLM_DGNS_PRCDR_ICD_IND_PROCEDURE" {
   prefix s = "https://hl7.org/fhir/string"
   prefix t = "https://hl7.org/fhir/string"

apps/bfd-model-idr/maps/ExplanationOfBenefit-PriorAuth.map

@@ -34,7 +34,7 @@ group createEOBPriorAuth(source src: ExplanationOfBenefitPA, target tgt: BFDEOB)
     } "Create metadata";
 
     src -> tgt.type = create('CodeableConcept') as tgtCC then {
-      //CodeSystem -> CLM_TYPE_CD
+      //CodeSystem -> CLM_TYPE
       //Two types -  1: PDEX, 2: CMS-specific. use concept map
       src.CLM_TYPE as typeCd -> tgtCC.coding = translate(typeCd,'https://bfd.cms.gov/MappingLanguage/Maps/ExplanationOfBenefit-Helper#PriorAuthType','coding') "translate code";
       //No blanks here since 2023. 
@@ -98,10 +98,9 @@ group createEOBPriorAuth(source src: ExplanationOfBenefitPA, target tgt: BFDEOB)
       //Current_segment (line item)
       paItem.CURRENT_SEGMENT as sequenceNumber -> tgtItem.sequence = sequenceNumber "Add sequence number";
 
-      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.length()=5 and itemCode.substring(0,1).convertsToInteger()) -> tgtItem.productOrService = cc("http://www.ama-assn.org/go/cpt", itemCode) "Add item code";
-      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.length()=5 and itemCode.substring(0,1).convertsToInteger().not()) -> tgtItem.productOrService = cc("https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", itemCode) "Add item code";
-      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.length()=5 and itemCode.substring(1,2).convertsToInteger().not()) -> tgtItem.productOrService = cc("https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes", itemCode) "Add item code";
-      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.length()!=5) -> tgtItem.productOrService = cc("http://terminology.hl7.org/CodeSystem/data-absent-reason","not-applicable") "add DAR";
+      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.substring(0,1).convertsToInteger() and src.CLM_TYPE != 'I') -> tgtItem.productOrService = cc("http://www.ama-assn.org/go/cpt", itemCode) "Add item code";
+      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(itemCode.substring(0,1).convertsToInteger().not() and src.CLM_TYPE != 'I') -> tgtItem.productOrService = cc("https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", itemCode) "Add item code";
+      paItem.HCPCS_OR_CPT_OR_HIPPS as itemCode where(src.CLM_TYPE = 'I') -> tgtItem.productOrService = cc("https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes", itemCode) "Add item code";
 
       paItem.PRICE_MOD1 as modifierCode where(modifierCode.length()=2) -> tgtItem.modifier = cc("https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", modifierCode) "Add modifier";
       paItem.PRICE_MOD2 as modifierCode where(modifierCode.length()=2) -> tgtItem.modifier = cc("https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets", modifierCode) "Add modifier";
@@ -236,7 +235,7 @@ group addSvcRenderSt(source src: String, target tgt: Extension){
 
 group addMRCountInd(source src: String, target tgt: Extension){
     src -> tgt.url = "https://bluebutton.cms.gov/fhir/StructureDefinition/MR-COUNT-IND" "Add extension url";
-    src as val -> tgt.value = cast(val, "decimal") "set value";
+    src as val -> tgt.value = cast(val, 'unsignedInt') "set value";
 }
 
 group addMRCountStDt(source src: String, target tgt: Extension){

apps/bfd-pipeline-idr/load_events.py

@@ -43,6 +43,7 @@
 from model.idr_contract_pbp_contact import IdrContractPbpContact
 from model.idr_contract_pbp_number import IdrContractPbpNumber
 from model.idr_prior_auth import IdrPriorAuth
+from model.idr_prior_auth_item import IdrPriorAuthItem
 from pydantic_utils import fields
 
 LOAD_EVENTS_TABLE = "source_load_events"
@@ -90,6 +91,7 @@
         IdrBeneficiaryMaPartDEnrollment,
         IdrBeneficiaryMaPartDEnrollmentRx,
         IdrPriorAuth,
+        IdrPriorAuthItem,
     }
 }
 _HPMS_TABLES = {

apps/bfd-pipeline-idr/model/base_model.py

@@ -154,6 +154,16 @@ def provider_careteam_name_expr(alias: str, type: str | None) -> str:
     """
 
 
+def provider_npi_type_expr(alias: str) -> str:
+    return f"""
+        CASE 
+            WHEN {alias}.prvdr_lgl_name IS NOT NULL THEN 2
+            WHEN {alias}.prvdr_lgl_name IS NULL AND {alias}.prvdr_1st_name IS NOT NULL THEN 1
+            ELSE NULL 
+        END
+    """
+
+
 MEDICARE_EXHAUSTED_CD = "A3"
 ACTIVE_CARE_CD = "22"
 QUALIFYING_STAY_CD = "70"
@@ -374,6 +384,10 @@ def base_claim_filter(partition: LoadPartition) -> str:
 ALIAS_PRVDR_ATNDG = "prvdr_atndg"
 ALIAS_PRVDR_OPRTG = "prvdr_oprtg"
 ALIAS_PRVDR_OTHR = "prvdr_othr"
+ALIAS_PRVDR_ATT_PHY = "prvdr_att"
+ALIAS_PRVDR_RENDER = "prvdr_render"
+ALIAS_PRVDR_ORDER_REFER = "prvdr_order_refer"
+ALIAS_PRIOR_AUTH = "prior_auth"
 ALIAS_XREF = "xref"
 ALIAS_LCTN_HSTRY = "lctn_hstry"
 ALIAS_CLM_GRP = "clm_grp"

apps/bfd-pipeline-idr/model/idr_claim_item_institutional_nch.py

@@ -179,7 +179,9 @@ class IdrClaimItemInstitutionalNch(IdrBaseModel):
     clm_line_instnl_rdcd_amt: Annotated[float | None, {ALIAS: ALIAS_LINE_INSTNL}]
     clm_line_instnl_msp1_pd_amt: Annotated[float | None, {ALIAS: ALIAS_LINE_INSTNL}]
     clm_line_instnl_msp2_pd_amt: Annotated[float | None, {ALIAS: ALIAS_LINE_INSTNL}]
-    clm_line_instnl_rev_ctr_dt: Annotated[date | None, {ALIAS: ALIAS_LINE_INSTNL}]
+    clm_line_instnl_rev_ctr_dt: Annotated[
+        date | None, {ALIAS: ALIAS_LINE_INSTNL}, BeforeValidator(transform_default_date_to_null)
+    ]
     clm_rev_cntr_tdapa_amt: Annotated[float | None, {ALIAS: ALIAS_LINE_INSTNL}]
     clm_line_add_on_pymt_amt: Annotated[float | None, {ALIAS: ALIAS_LINE_INSTNL}]
     idr_insrt_ts_line_instnl: Annotated[

apps/bfd-pipeline-idr/model/idr_prior_auth.py

@@ -3,16 +3,23 @@
 
 from pydantic import BeforeValidator
 
-from constants import IDR_PRIOR_AUTH_TABLE
+from constants import DEFAULT_MAX_DATE, IDR_PRIOR_AUTH_TABLE, IDR_PROVIDER_HISTORY_TABLE
 from load_partition import LoadPartition
 from model.base_model import (
+    ALIAS_PRIOR_AUTH,
+    ALIAS_PRVDR_ATT_PHY,
+    ALIAS_PRVDR_ORDER_REFER,
+    ALIAS_PRVDR_RENDER,
     BATCH_TIMESTAMP,
+    EXPR,
     INSERT_EXCLUDE,
     PRIMARY_KEY_ORDER,
     UPDATE_TIMESTAMP,
     IdrBaseModel,
     ModelType,
     Source,
+    provider_careteam_name_expr,
+    provider_npi_type_expr,
     transform_default_string,
     transform_null_date_to_max,
     transform_null_date_to_min,
@@ -23,37 +30,38 @@
 class IdrPriorAuth(IdrBaseModel):
     mbi_num: Annotated[str, {PRIMARY_KEY_ORDER: 0}]
     utn: Annotated[str, {PRIMARY_KEY_ORDER: 1}]
-    current_segment: Annotated[int, {PRIMARY_KEY_ORDER: 2}]
     utn_valid_st_dt: Annotated[date, BeforeValidator(transform_null_date_to_min)]
     utn_valid_en_dt: Annotated[date, BeforeValidator(transform_null_date_to_max)]
     clm_type: Annotated[str, BeforeValidator(transform_default_string)]
-    hcpcs_or_cpt_or_hipps: str
     mac_id: str
-    pa_dt_added: date
-    pa_dt_updated: Annotated[date, BeforeValidator(transform_null_date_to_max)]
-    service_cnts: int
-    pa_decision: str
-    pa_req_sub_dt: date
-    pa_req_rec_dt: date
-    pa_decision_dt: Annotated[date, BeforeValidator(transform_null_date_to_min)]
-    pa_decision_exp_dt: Annotated[date, BeforeValidator(transform_null_date_to_max)]
     order_refer_npi: Annotated[str, BeforeValidator(transform_default_string)]
+    bfd_order_refer_careteam_name: Annotated[
+        str,
+        {EXPR: provider_careteam_name_expr(ALIAS_PRVDR_ORDER_REFER, None)},
+        BeforeValidator(transform_default_string),
+    ]
+    bfd_order_refer_npi_type: Annotated[
+        int | None, {EXPR: provider_npi_type_expr(ALIAS_PRVDR_ORDER_REFER)}
+    ]
     render_npi: Annotated[str, BeforeValidator(transform_default_string)]
-    svc_render_st: str
-    place_of_serv: Annotated[str, BeforeValidator(transform_default_string)]
-    price_mod1: Annotated[str, BeforeValidator(transform_default_string)]
-    price_mod2: Annotated[str, BeforeValidator(transform_default_string)]
+    bfd_render_careteam_name: Annotated[
+        str,
+        {EXPR: provider_careteam_name_expr(ALIAS_PRVDR_RENDER, None)},
+        BeforeValidator(transform_default_string),
+    ]
+    bfd_render_npi_type: Annotated[int | None, {EXPR: provider_npi_type_expr(ALIAS_PRVDR_RENDER)}]
     icn_dcn: Annotated[str, BeforeValidator(transform_default_string)]
     cms_cert: Annotated[str, BeforeValidator(transform_default_string)]
     npi: Annotated[str, BeforeValidator(transform_default_string)]
     name: str
-    rev_code_1: Annotated[str, BeforeValidator(transform_default_string)]
     tob: Annotated[str, BeforeValidator(transform_default_string)]
-    mr_count_ind: int
-    mr_count_st_dt: Annotated[date, BeforeValidator(transform_null_date_to_min)]
-    mr_count_end_dt: Annotated[date, BeforeValidator(transform_null_date_to_max)]
     att_phy_npi: Annotated[str, BeforeValidator(transform_default_string)]
-    rrb_excl_ind: Annotated[str, BeforeValidator(transform_default_string)]
+    bfd_att_phy_careteam_name: Annotated[
+        str,
+        {EXPR: provider_careteam_name_expr(ALIAS_PRVDR_ATT_PHY, None)},
+        BeforeValidator(transform_default_string),
+    ]
+    bfd_att_phy_npi_type: Annotated[int | None, {EXPR: provider_npi_type_expr(ALIAS_PRVDR_ATT_PHY)}]
     # TBD: might have to change the insert & update ts once IDR adds those
     idr_insrt_ts: Annotated[datetime, {BATCH_TIMESTAMP: True, INSERT_EXCLUDE: True}]
     idr_updt_ts: Annotated[
@@ -81,13 +89,26 @@ def model_type() -> ModelType:
     @classmethod
     def fetch_query(cls, partition: LoadPartition, start_time: datetime, source: Source) -> str:
         # Prior auth data older than the lookback period should be filtered
+        prior_auth = ALIAS_PRIOR_AUTH
+        prvdr_att_phy = ALIAS_PRVDR_ATT_PHY
+        prvdr_order_refer = ALIAS_PRVDR_ORDER_REFER
+        prvdr_render = ALIAS_PRVDR_RENDER
         return f"""
             WITH distinct_prior_auths AS (
                 SELECT *, ROW_NUMBER() 
-                    OVER (PARTITION BY mbi_num, utn, current_segment ORDER BY mbi_num) as row_order
+                    OVER (PARTITION BY mbi_num, utn ORDER BY current_segment) as row_order
                 FROM {IDR_PRIOR_AUTH_TABLE}
                 WHERE pa_req_rec_dt > '{MIN_PRIOR_AUTH_LOAD_DATE}'
             ) 
-            SELECT {{COLUMNS}} FROM distinct_prior_auths 
+            SELECT {{COLUMNS}} FROM distinct_prior_auths {prior_auth}
+            LEFT JOIN {IDR_PROVIDER_HISTORY_TABLE} {prvdr_att_phy}
+                ON {prvdr_att_phy}.prvdr_npi_num = {prior_auth}.att_phy_npi
+                AND {prvdr_att_phy}.prvdr_hstry_obslt_dt >= '{DEFAULT_MAX_DATE}'
+            LEFT JOIN {IDR_PROVIDER_HISTORY_TABLE} {prvdr_order_refer}
+                ON {prvdr_order_refer}.prvdr_npi_num = {prior_auth}.order_refer_npi
+                AND {prvdr_order_refer}.prvdr_hstry_obslt_dt >= '{DEFAULT_MAX_DATE}'
+            LEFT JOIN {IDR_PROVIDER_HISTORY_TABLE} {prvdr_render}
+                ON {prvdr_render}.prvdr_npi_num = {prior_auth}.render_npi
+                AND {prvdr_render}.prvdr_hstry_obslt_dt >= '{DEFAULT_MAX_DATE}'
             {{WHERE_CLAUSE}} AND row_order = 1;
             """