/// <summary>Search predicate returns true if code matches.</summary>
private bool EB03MatchesCode(EB03 eb03val)
{
if (Segment.Get(3) == eb03val.Code)
{
return(true);
}
return(false);
}
/// <summary>Search predicate returns true if code matches.</summary>
private bool EB03MatchesCode(EB03 eb03val) {
if(Segment.Get(3)==eb03val.Code) {
return true;
}
return false;
}
public EB271(X12Segment segment, bool isInNetwork, bool isCoinsuranceInverted, X12Segment segHsd = null)
{
if (eb01 == null)
{
FillDictionaries();
}
Segment = segment;
SupplementalSegments = new List <X12Segment>();
//start pattern matching to generate closest Benefit
EB01 eb01val = eb01.Find(EB01MatchesCode);
EB02 eb02val = eb02.Find(EB02MatchesCode);
EB03 eb03val = eb03.Find(EB03MatchesCode);
EB06 eb06val = eb06.Find(EB06MatchesCode);
EB09 eb09val = eb09.Find(EB09MatchesCode);
ProcedureCode proccode = null;
if (ProcedureCodes.IsValidCode(Segment.Get(13, 2)))
{
proccode = ProcedureCodes.GetProcCode(Segment.Get(13, 2));
}
if (!eb01val.IsSupported ||
(eb02val != null && !eb02val.IsSupported) ||
(eb03val != null && !eb03val.IsSupported) ||
(eb06val != null && !eb06val.IsSupported) ||
(eb09val != null && !eb09val.IsSupported))
{
Benefitt = null;
return;
}
if (eb01val.BenefitType == InsBenefitType.ActiveCoverage && Segment.Get(3) == "30")
{
Benefitt = null;
return;
}
if (eb01val.BenefitType == InsBenefitType.ActiveCoverage && proccode != null)
{
//A code is covered. Informational only.
Benefitt = null;
return;
}
if (Segment.Get(8) != "") //if percentage
//must have either a category or a proc code
{
if (proccode == null) //if no proc code is specified
{
if (eb03val == null || eb03val.ServiceType == EbenefitCategory.None || eb03val.ServiceType == EbenefitCategory.General) //and no category specified
{
Benefitt = null;
return;
}
}
}
//coinsurance amounts are handled with fee schedules rather than benefits
if (eb01val.BenefitType == InsBenefitType.CoPayment || eb01val.BenefitType == InsBenefitType.CoInsurance)
{
if (Segment.Get(7) != "") //and a monetary amount specified
{
Benefitt = null;
return;
}
}
//a limitation without an amount is meaningless
if (eb01val.BenefitType == InsBenefitType.Limitations &&
segHsd == null) //Some benefits do not have monetary value but limit service in a time period. Originally done for customer 27936.
{
if (Segment.Get(7) == "") //no monetary amount specified
{
Benefitt = null;
return;
}
}
if (isInNetwork && (Segment.Get(12) == "N" || Segment.Get(12) == "U"))
{
Benefitt = null;
return;
}
if (!isInNetwork && Segment.Get(12) == "Y")
{
Benefitt = null;
return;
}
//if only a quantity is specified with no qualifier, it's meaningless
if (Segment.Get(10) != "" && eb09val == null)
{
Benefitt = null;
return;
}
//if only a qualifier is specified with no quantity, it's meaningless
if (eb09val != null && Segment.Get(10) == "")
{
Benefitt = null;
return;
}
Benefitt = new Benefit();
//1
Benefitt.BenefitType = eb01val.BenefitType;
//2
if (eb02val != null)
{
Benefitt.CoverageLevel = eb02val.CoverageLevel;
}
//3
if (eb03val != null)
{
Benefitt.CovCatNum = CovCats.GetForEbenCat(eb03val.ServiceType).CovCatNum;
}
//4-Insurance type - we ignore.
//5-Plan description - we ignore.
//6
if (eb06val != null)
{
Benefitt.TimePeriod = eb06val.TimePeriod;
}
//7
if (Segment.Get(7) != "")
{
Benefitt.MonetaryAmt = PIn.Double(Segment.Get(7)); //Monetary amount. Situational
}
//8
if (Segment.Get(8) != "")
{
if (isCoinsuranceInverted && Benefitt.BenefitType == InsBenefitType.CoInsurance) //Some carriers incorrectly send insurance percentage.
{
Benefitt.Percent = (int)(PIn.Double(Segment.Get(8)) * 100); //Percent. Came to us inverted, do Not Invert.
}
else
{
//OD shows the percentage paid by Insurance by default.
//Some carriers submit 271s to us showing percentage paid by Patient, so we need to invert this case to match OD expectations.
Benefitt.Percent = 100 - (int)(PIn.Double(Segment.Get(8)) * 100); //Percent. Invert.
}
Benefitt.CoverageLevel = BenefitCoverageLevel.None;
}
//9-Quantity qualifier
if (eb09val != null)
{
Benefitt.QuantityQualifier = eb09val.QuantityQualifier;
}
//10-Quantity
if (Segment.Get(10) != "")
{
Benefitt.Quantity = (byte)PIn.Double(Segment.Get(10)); //Example: "19.0" with Quantity qualifier "S7" (age).
}
//11-Authorization. Ignored.
//12-In network. Ignored.
//13-proc
if (proccode != null)
{
Benefitt.CodeNum = proccode.CodeNum; //element 13,2
}
if (Benefitt.BenefitType == InsBenefitType.Limitations &&
proccode != null && //Valid ADA code.
segHsd != null)
{
if (segHsd.Elements.Length < 6 || segHsd.Elements[2] == "" || segHsd.Elements[5] == "")
{
Benefitt = null;
return;
}
Benefitt.Quantity = PIn.Byte(segHsd.Elements[2]); //HSD02: Quantity.
Benefitt.TimePeriod = eb06.FirstOrDefault(x => x.Code == segHsd.Elements[5]).TimePeriod; //HSD05: Frequency.
}
}
///<summary>The most human-readable description possible for a single element.</summary>
public string GetDescript(int elementPos, bool isMessageMode, bool isCoinsurancePatPays = true)
{
string elementCode = Segment.Get(elementPos);
if (elementCode == "")
{
return("");
}
switch (elementPos)
{
case 1:
//This is a required element, but we still won't assume it's found
EB01 eb01val = eb01.Find(EB01MatchesCode);
if (eb01val == null)
{
return("");
}
if (eb01val.Code == "D" && isMessageMode) //D is for benefit description, which is already obvious
{
return("");
}
return(eb01val.Descript);
case 2:
EB02 eb02val = eb02.Find(EB02MatchesCode);
if (eb02val == null)
{
return("");
}
return(eb02val.Descript);
case 3:
EB03 eb03val = eb03.Find(EB03MatchesCode);
if (eb03val == null)
{
return("");
}
return(eb03val.Descript);
case 4:
if (!EB04.ContainsKey(elementCode))
{
return("");
}
return(EB04[elementCode]);
case 5:
return(Segment.Get(5));
case 6:
EB06 eb06val = eb06.Find(EB06MatchesCode);
if (eb06val == null)
{
return("");
}
return(eb06val.Descript);
case 7:
return(PIn.Double(elementCode).ToString("c")); //Monetary amount. Situational
case 8:
if (isMessageMode) //delta sends 80% instead of 20% like they should
{
return((PIn.Double(elementCode) * 100).ToString() + "%"); //Percent.
}
else
{
string leadingStr = "Patient pays ";
if (!isCoinsurancePatPays)
{
leadingStr = "Insurance pays ";
}
return(leadingStr + (PIn.Double(elementCode) * 100).ToString() + "%"); //Percent. Situational
}
case 9: //Quantity qualifier. Situational
EB09 eb09val = eb09.Find(EB09MatchesCode);
if (eb09val == null)
{
return("");
}
return(eb09val.Descript);
case 10:
return(elementCode); //Quantity. Situational
case 11:
return("Authorization Required-" + elementCode); //Situational.
case 12: //Situational.
if (elementCode == "Y")
{
return("In network");
}
else if (elementCode == "N")
{
return("Out of network");
}
else //elementCode=="U"
{
return("Unknown if in network");
}
case 13:
string procStr = Segment.Get(13, 2);
if (procStr == "")
{
return("");
}
ProcedureCode procCode = ProcedureCodes.GetProcCode(procStr);
return(procStr + " - " + procCode.AbbrDesc); //ProcedureCodes.GetLaymanTerm(procCode.CodeNum);
//Even though we don't make requests about specific procedure codes, some ins co's will send back codes.
default:
return("");
}
}
public EB271(X12Segment segment, bool isInNetwork)
{
if (eb01 == null)
{
FillDictionaries();
}
Segment = segment;
SupplementalSegments = new List <X12Segment>();
//start pattern matching to generate closest Benefit
EB01 eb01val = eb01.Find(EB01MatchesCode);
EB02 eb02val = eb02.Find(EB02MatchesCode);
EB03 eb03val = eb03.Find(EB03MatchesCode);
EB06 eb06val = eb06.Find(EB06MatchesCode);
EB09 eb09val = eb09.Find(EB09MatchesCode);
ProcedureCode proccode = null;
if (ProcedureCodes.IsValidCode(Segment.Get(13, 2)))
{
proccode = ProcedureCodes.GetProcCode(Segment.Get(13, 2));
}
if (!eb01val.IsSupported ||
(eb02val != null && !eb02val.IsSupported) ||
(eb03val != null && !eb03val.IsSupported) ||
(eb06val != null && !eb06val.IsSupported) ||
(eb09val != null && !eb09val.IsSupported))
{
Benefitt = null;
return;
}
if (eb01val.BenefitType == InsBenefitType.ActiveCoverage && Segment.Get(3) == "30")
{
Benefitt = null;
return;
}
if (eb01val.BenefitType == InsBenefitType.ActiveCoverage && proccode != null)
{
//A code is covered. Informational only.
Benefitt = null;
return;
}
if (Segment.Get(8) != "") //if percentage
//must have either a category or a proc code
{
if (proccode == null) //if no proc code is specified
{
if (eb03val == null || eb03val.ServiceType == EbenefitCategory.None || eb03val.ServiceType == EbenefitCategory.General) //and no category specified
{
Benefitt = null;
return;
}
}
}
//coinsurance amounts are handled with fee schedules rather than benefits
if (eb01val.BenefitType == InsBenefitType.CoPayment || eb01val.BenefitType == InsBenefitType.CoInsurance)
{
if (Segment.Get(7) != "") //and a monetary amount specified
{
Benefitt = null;
return;
}
}
//a limitation without an amount is meaningless
if (eb01val.BenefitType == InsBenefitType.Limitations)
{
if (Segment.Get(7) == "") //no monetary amount specified
{
Benefitt = null;
return;
}
}
if (isInNetwork && Segment.Get(12) == "N")
{
Benefitt = null;
return;
}
if (!isInNetwork && Segment.Get(12) == "Y")
{
Benefitt = null;
return;
}
//if only a quantity is specified with no qualifier, it's meaningless
if (Segment.Get(10) != "" && eb09val == null)
{
Benefitt = null;
return;
}
//if only a qualifier is specified with no quantity, it's meaningless
if (eb09val != null && Segment.Get(10) == "")
{
Benefitt = null;
return;
}
Benefitt = new Benefit();
//1
Benefitt.BenefitType = eb01val.BenefitType;
//2
if (eb02val != null)
{
Benefitt.CoverageLevel = eb02val.CoverageLevel;
}
//3
if (eb03val != null)
{
Benefitt.CovCatNum = CovCats.GetForEbenCat(eb03val.ServiceType).CovCatNum;
}
//4-Insurance type - we ignore.
//5-Plan description - we ignore.
//6
if (eb06val != null)
{
Benefitt.TimePeriod = eb06val.TimePeriod;
}
//7
if (Segment.Get(7) != "")
{
Benefitt.MonetaryAmt = PIn.Double(Segment.Get(7)); //Monetary amount. Situational
}
//8
if (Segment.Get(8) != "")
{
Benefitt.Percent = 100 - (int)(PIn.Double(Segment.Get(8)) * 100); //Percent. Situational
Benefitt.CoverageLevel = BenefitCoverageLevel.None;
}
//9-Quantity qualifier
if (eb09val != null)
{
Benefitt.QuantityQualifier = eb09val.QuantityQualifier;
}
//10-Quantity
if (Segment.Get(10) != "")
{
Benefitt.Quantity = (byte)PIn.Double(Segment.Get(10)); //Example: "19.0" with Quantity qualifier "S7" (age).
}
//11-Authorization. Ignored.
//12-In network. Ignored.
//13-proc
if (proccode != null)
{
Benefitt.CodeNum = proccode.CodeNum; //element 13,2
}
}