///<summary>Creates a procedure and computes estimates for a patient where the secondary insurance has a COB rule of Medicaid.</summary>
private void ComputeEstimatesMedicaidCOB(string suffix, double procFee, double priAllowed, double secAllowed, int priPercentCovered,
int secPercentCovered, Action <ClaimProc /*Primary*/, ClaimProc /*Secondary*/, Procedure> assertAct)
{
Patient pat = PatientT.CreatePatient(suffix);
long ppoFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "PPO " + suffix);
InsuranceT.AddInsurance(pat, suffix, "p", ppoFeeSchedNum);
long medicaidFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "PPO " + suffix);
InsuranceT.AddInsurance(pat, suffix, "p", medicaidFeeSchedNum, 2, cobRule: EnumCobRule.SecondaryMedicaid);
List <InsSub> listSubs = InsSubT.GetInsSubs(pat);
List <InsPlan> listPlans = InsPlans.RefreshForSubList(listSubs);
List <PatPlan> listPatPlans = PatPlans.Refresh(pat.PatNum);
InsPlan priPlan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Primary, listPatPlans, listPlans, listSubs);
BenefitT.CreateCategoryPercent(priPlan.PlanNum, EbenefitCategory.Diagnostic, priPercentCovered);
InsPlan secPlan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Secondary, listPatPlans, listPlans, listSubs);
BenefitT.CreateCategoryPercent(secPlan.PlanNum, EbenefitCategory.Diagnostic, secPercentCovered);
List <Benefit> listBens = Benefits.Refresh(listPatPlans, listSubs);
string procStr = "D0150";
Procedure proc = ProcedureT.CreateProcedure(pat, procStr, ProcStat.TP, "", procFee);
ProcedureCode procCode = ProcedureCodes.GetProcCode(procStr);
FeeT.CreateFee(ppoFeeSchedNum, procCode.CodeNum, priAllowed);
FeeT.CreateFee(medicaidFeeSchedNum, procCode.CodeNum, secAllowed);
Procedures.ComputeEstimates(proc, pat.PatNum, new List <ClaimProc>(), false, listPlans, listPatPlans, listBens, pat.Age, listSubs);
List <ClaimProc> listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
assertAct(listClaimProcs.FirstOrDefault(x => x.PlanNum == priPlan.PlanNum), listClaimProcs.FirstOrDefault(x => x.PlanNum == secPlan.PlanNum), proc);
}
///<summary>Creates a general deductible of $50, a deductible of $50 on D0220, sets a $30 D0220 complete and creates a claim,
///creates a $100 D2750, that is TP'ed, and then creates a $30 D0220 that is TP'ed.</summary>
///<param name="actAssert">The first claimproc is for the D2750 and the second claimproc is for the second D0220.</param>
public void GetDeductibleByCodeDeductLessThanGeneral(string suffix, Action <ClaimProc, ClaimProc> actAssert)
{
Patient pat = PatientT.CreatePatient(suffix);
InsuranceT.AddInsurance(pat, suffix);
List <InsSub> listSubs = InsSubT.GetInsSubs(pat);
List <InsPlan> listPlans = InsPlans.RefreshForSubList(listSubs);
List <PatPlan> listPatPlans = PatPlans.Refresh(pat.PatNum);
InsPlan plan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Primary, listPatPlans, listPlans, listSubs);
BenefitT.CreateDeductibleGeneral(plan.PlanNum, BenefitCoverageLevel.Individual, 50);
BenefitT.CreateCategoryPercent(plan.PlanNum, EbenefitCategory.Diagnostic, 100);
BenefitT.CreateCategoryPercent(plan.PlanNum, EbenefitCategory.Crowns, 50);
BenefitT.CreateDeductible(plan.PlanNum, EbenefitCategory.Diagnostic, 0);
BenefitT.CreateDeductible(plan.PlanNum, "D0220", 50);
List <Benefit> listBens = Benefits.Refresh(listPatPlans, listSubs);
Procedure proc1 = ProcedureT.CreateProcedure(pat, "D0220", ProcStat.C, "", 30);//proc1 - Intraoral - periapical first film
ClaimT.CreateClaim("P", listPatPlans, listPlans, new List <ClaimProc>(), new List <Procedure> {
proc1
}, pat, new List <Procedure> {
proc1
}, listBens,
listSubs);
Procedure proc2 = ProcedureT.CreateProcedure(pat, "D2750", ProcStat.TP, "", 100, priority: 0); //proc2 - Crown
Procedure proc3 = ProcedureT.CreateProcedure(pat, "D0220", ProcStat.TP, "", 30, priority: 1); //proc3 - Intraoral - periapical first film
List <ClaimProc> claimProcs = ProcedureT.ComputeEstimates(pat, listPatPlans, listPlans, listSubs, listBens);
ClaimProc claimProc2 = claimProcs.FirstOrDefault(x => x.ProcNum == proc2.ProcNum);
ClaimProc claimProc3 = claimProcs.FirstOrDefault(x => x.ProcNum == proc3.ProcNum);
actAssert(claimProc2, claimProc3);
}
private InsPlan GeneratePPOPlan(string suffix, bool codeSubstNone = true)
{
long baseFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "Normal_" + suffix, true);
Carrier carrier = CarrierT.CreateCarrier("Carrier_" + suffix);
return(InsPlanT.CreateInsPlanPPO(carrier.CarrierNum, baseFeeSchedNum, codeSubstNone));
}
private InsPlan GenerateMediFlatInsPlan(string suffix, bool codeSubstNone = true)
{
long baseFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "Normal_" + suffix, true);
long copayFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.CoPay, "Copay_" + suffix, true);
Carrier carrier = CarrierT.CreateCarrier("Carrier_" + suffix);
return(InsPlanT.CreateInsPlanMediFlatCopay(carrier.CarrierNum, baseFeeSchedNum, copayFeeSchedNum, codeSubstNone));
}
private InsPlan GenerateCapPlan(string suffix, bool createAllowed = true, bool codeSubstNone = true)
{
long baseFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "Normal_" + suffix, true);
long allowedFeeSchedNum = 0;
if (createAllowed)
{
allowedFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "Allowed_" + suffix, true);
}
Carrier carrier = CarrierT.CreateCarrier("Carrier_" + suffix);
return(InsPlanT.CreateInsPlanCapitation(carrier.CarrierNum, baseFeeSchedNum, allowedFeeSchedNum, codeSubstNone));
}
public void Procedures_ComputeEstimates_PrimaryInsuranceMedicaidCOB()
{
string suffix = MethodBase.GetCurrentMethod().Name;
Patient pat = PatientT.CreatePatient(suffix);
long ppoFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "PPO " + suffix);
InsuranceInfo insInfo = InsuranceT.AddInsurance(pat, suffix, "p", ppoFeeSchedNum, 1, cobRule: EnumCobRule.SecondaryMedicaid);
InsPlan priPlan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Primary, insInfo.ListPatPlans, insInfo.ListInsPlans, insInfo.ListInsSubs);
BenefitT.CreateCategoryPercent(priPlan.PlanNum, EbenefitCategory.Diagnostic, percent: 50);
List <Benefit> listBens = Benefits.Refresh(insInfo.ListPatPlans, insInfo.ListInsSubs);
string procStr = "D0150";
Procedure proc = ProcedureT.CreateProcedure(pat, procStr, ProcStat.TP, "", 125);
ProcedureCode procCode = ProcedureCodes.GetProcCode(procStr);
FeeT.CreateFee(ppoFeeSchedNum, procCode.CodeNum, amount: 80);
Procedures.ComputeEstimates(proc, pat.PatNum, new List <ClaimProc>(), false, insInfo.ListInsPlans, insInfo.ListPatPlans, listBens, pat.Age,
insInfo.ListInsSubs);
List <ClaimProc> listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
Assert.AreEqual(40, listClaimProcs[0].InsEstTotal, 0.001);
Assert.AreEqual(45, listClaimProcs[0].WriteOffEst, 0.001);
}
public void Claims_CalculateAndUpdate_PreauthOrderWriteoff()
{
string suffix = MethodBase.GetCurrentMethod().Name;
//create the patient and insurance information
Patient pat = PatientT.CreatePatient(suffix);
//proc - Crown
Procedure proc = ProcedureT.CreateProcedure(pat, "D2750", ProcStat.C, "8", 1000);
long feeSchedNum1 = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, suffix);
FeeT.CreateFee(feeSchedNum1, proc.CodeNum, 900);
Carrier carrier = CarrierT.CreateCarrier(suffix);
InsPlan insPlan = InsPlanT.CreateInsPlanPPO(carrier.CarrierNum, feeSchedNum1);
BenefitT.CreateAnnualMax(insPlan.PlanNum, 1000);
BenefitT.CreateCategoryPercent(insPlan.PlanNum, EbenefitCategory.Crowns, 100);
InsSub sub = InsSubT.CreateInsSub(pat.PatNum, insPlan.PlanNum);
PatPlan pp = PatPlanT.CreatePatPlan(1, pat.PatNum, sub.InsSubNum);
//create lists and variables required for ComputeEstimates()
List <InsSub> SubList = InsSubs.RefreshForFam(Patients.GetFamily(pat.PatNum));
List <InsPlan> listInsPlan = InsPlans.RefreshForSubList(SubList);
List <PatPlan> listPatPlan = PatPlans.Refresh(pat.PatNum);
List <Benefit> listBenefits = Benefits.Refresh(listPatPlan, SubList);
List <Procedure> listProcsForPat = Procedures.Refresh(pat.PatNum);
List <Procedure> procsForClaim = new List <Procedure>();
procsForClaim.Add(proc);
//Create the claim and associated claimprocs
//The order of these claimprocs is the whole point of the unit test.
//Create Preauth
ClaimProcs.CreateEst(new ClaimProc(), proc, insPlan, sub, 0, 500, true, true);
//Create Estimate
ClaimProcs.CreateEst(new ClaimProc(), proc, insPlan, sub, 1000, 1000, true, false);
List <ClaimProc> listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
Claim claimWaiting = ClaimT.CreateClaim("W", listPatPlan, listInsPlan, listClaimProcs, listProcsForPat, pat, procsForClaim, listBenefits, SubList, false);
Assert.AreEqual(100, claimWaiting.WriteOff, "WriteOff Amount");
}
///<summary>Creates a procedure and computes estimates for a patient where the secondary insurance has a COB rule of Medicaid.</summary>
private void ComputeEstimatesFixedBenefits(string suffix, double procFee, double ppoFee, double fixedBenefitFee
, int priPercentCoveredOverride, bool hasSecondary, double secFee, Action <FixedBenefitAssertItem> assertAct)
{
Patient pat = PatientT.CreatePatient(suffix);
string procStr = "D0150";
Procedure proc = ProcedureT.CreateProcedure(pat, procStr, ProcStat.TP, "", procFee);
ProcedureCode procCode = ProcedureCodes.GetProcCode(procStr);
long ppoFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "PPO " + suffix);
long catPercFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.Normal, "Category % " + suffix);
long fixedBenefitFeeSchedNum = FeeSchedT.CreateFeeSched(FeeScheduleType.FixedBenefit, "Fixed Benefit " + suffix);
if (ppoFee > -1)
{
FeeT.CreateFee(ppoFeeSchedNum, procCode.CodeNum, ppoFee);
}
FeeT.CreateFee(fixedBenefitFeeSchedNum, procCode.CodeNum, fixedBenefitFee);
InsuranceT.AddInsurance(pat, suffix, "p", ppoFeeSchedNum, copayFeeSchedNum: fixedBenefitFeeSchedNum);
if (hasSecondary)
{
FeeT.CreateFee(catPercFeeSchedNum, procCode.CodeNum, secFee);
InsuranceT.AddInsurance(pat, suffix, "", catPercFeeSchedNum, 2, false, EnumCobRule.Standard);
}
List <InsSub> listSubs = InsSubT.GetInsSubs(pat);
List <InsPlan> listPlans = InsPlans.RefreshForSubList(listSubs);
List <PatPlan> listPatPlans = PatPlans.Refresh(pat.PatNum);
InsPlan priPlan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Primary, listPatPlans, listPlans, listSubs);
InsPlan secPlan = null;
if (hasSecondary)
{
secPlan = InsPlanT.GetPlanForPriSecMed(PriSecMed.Secondary, listPatPlans, listPlans, listSubs);
//TODO: Add diagnostic code benefit for 100%
BenefitT.CreateCategoryPercent(secPlan.PlanNum, EbenefitCategory.Diagnostic, 100);
}
List <Benefit> listBens = Benefits.Refresh(listPatPlans, listSubs);
Procedures.ComputeEstimates(proc, pat.PatNum, new List <ClaimProc>(), false, listPlans, listPatPlans, listBens, pat.Age, listSubs);
List <ClaimProc> listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
if (priPercentCoveredOverride > 0)
{
foreach (ClaimProc cpCur in listClaimProcs)
{
cpCur.PercentOverride = priPercentCoveredOverride;
ClaimProcs.Update(cpCur);
}
Procedures.ComputeEstimates(proc, pat.PatNum, new List <ClaimProc>(), false, listPlans, listPatPlans, listBens, pat.Age, listSubs);
listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
}
foreach (ClaimProc cpCur in listClaimProcs)
{
cpCur.PercentOverride = priPercentCoveredOverride;
ClaimProcs.Update(cpCur);
}
Procedures.ComputeEstimates(proc, pat.PatNum, listClaimProcs, false, listPlans, listPatPlans, listBens, pat.Age, listSubs);
listClaimProcs = ClaimProcs.Refresh(pat.PatNum);
assertAct(new FixedBenefitAssertItem()
{
Procedure = proc,
PrimaryClaimProc = listClaimProcs.FirstOrDefault(x => x.PlanNum == priPlan.PlanNum),
SecondaryClaimProc = secPlan == null ? null : listClaimProcs.FirstOrDefault(x => x.PlanNum == secPlan.PlanNum),
});
}
