Merged in bugfix/reimb_primary (pull request #890)

Update reimbursement prompts for consistent PMPM handling, time-unit dedup, and validation improvements

* Update reimbursement prompts for consistent PMPM handling, time-unit dedup, and validation improvements

- REIMBURSEMENT_PRIMARY: append unit of measure (PMPM, per visit, etc.) from table headers into REIMB_TERM
- METHODOLOGY_BREAKOUT: collapse mathematically equivalent time-unit rates into single entry
- VALIDATE_REIMBURSEMENTS: add umbrella terms as valid service terms, accept CPT/HCPCS percentage as concrete rate, narrow COB disqualifier to primary subject only

Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>


Approved-by: Siddhant Medar

src/prompts/prompt_templates.py

@@ -584,6 +584,7 @@ REIMB_TERM: Describes the method by which the price of the Service is calculated
 - NEVER return a partial sentence - include the entire sentence even if only part of the sentence is necessary.
 - It's ok if the SERVICE_TERM shows up in the REIMB_TERM. Prioritize maintaining complete sentences.
 - Do not leave out any relevant information from either the SERVICE_TERM or REIMB_TERM even if it is not present in the vicinity. e.g. answer "$100 per visit" rather than just "$100". If table headers OR table rows provide ANY relevant information (like code type, provider type, hospital name, provider name, Tax ID, legal name, etc), include that in the SERVICE_TERM or REIMB_TERM as appropriate.
+- When a unit of measure (e.g., "PMPM", "per member per month", "per visit", "per diem", "per case") appears in a table header, column label, or surrounding context, always append it to the REIMB_TERM for each rate in that table. For example, if the header says "Payment PMPM" and a row shows "$31.51", the REIMB_TERM should be "$31.51 PMPM", not just "$31.51".
 - Include all SERVICE_TERM and REIMB_TERM pairs mentioned, even if they are redundant or overlapping. There should be at least one entry for each SERVICE_TERM and REIMB_TERM pair mentioned.
 - If different reimbursement percentages or dollar values are mentioned for different effective dates, create separate entries for each effective date.
 - For the tables: Extract EVERY ROW as a separate entry, including all line items, subtotals, totals, adjustments, charges, and calculated ratios. When rows involve different providers/entities, create separate entries for EACH provider/entity and include the provider/entity name in the SERVICE_TERM (e.g., "Provider Name – Service Category").
@@ -963,7 +964,7 @@ Analyze a given term from a Payer-Provider contract and extract key fields.
 - For each dictionary, only one of the following fields should be present: REIMB_FEE_RATE, REIMB_PCT_RATE, or REIMB_CONVERSION_FACTOR. The others should be "N/A".
 - Do not repeat the same reimbursement information in different output entries. For example, if 'cost of vaccines plus a $5 administration fee' is present and $5 is already captured as an addition, do not create a separate dictionary with $5 as a flat fee. Include it only once as an addition.
 - For direct calculations like a flat fee of "$150.00 + $8.00", calculate the total ($158.00) and include only this flat fee rate in one dictionary.
-
+- When multiple rates are expressed in different time units and are mathematically equivalent via a standard time conversion (e.g., "$50 per 30 min" and "$100 per hour" where $50 × 2 = $100), treat them as a single reimbursement methodology. Extract only the most granular (smallest) time unit. If the values are not mathematically equivalent, extract each as a separate dictionary.
 If AARETE_DERIVED_REIMB_METHOD is Grouper, the dollar amount refers to REIMB_CONVERSION_FACTOR. If AARETE_DERIVED_REIMB_METHOD is Flat Rate or similar, the dollar amount refers to a REIMB_FEE_RATE.
 
 [FIELDS]
@@ -1959,7 +1960,7 @@ Default is NO. Return YES only if ALL three conditions pass:
 
 Must identify a billable service, procedure, or care category.
 
-Valid examples: service names, procedure types, CPT/HCPCS codes, care categories
+Valid examples: service names, procedure types, CPT/HCPCS codes, care categories, umbrella terms like "Covered Services" or "All Services"
 
 Invalid - return NO if SERVICE TERM is:
 - Clinical definitions or level-of-care descriptions (acuity, intervention frequency, co-morbidities)
@@ -1986,7 +1987,7 @@ Valid payment methods:
 - Special types: OUTLIER, STOP_LOSS, SEQUESTRATION, DISCOUNT, PREMIUM, RATE_ESCALATOR, FACILITY_ADJUSTMENT
 
 Invalid - return NO if REIMBURSEMENT TERM is:
-- Empty reimbursements: structure of a payment method but actual rate/percentage is not stated or references another location (e.g., "paid at rates in the next section", "the percentage listed below", "per the attached schedule", "as set forth in Exhibit A"). Note: formulas that define calculation methodology (e.g., "base rate multiplied by DRG weight") ARE valid even if specific dollar amounts aren't stated.
+- Empty reimbursements: structure of a payment method but actual rate/percentage is not stated or references another location (e.g., "paid at rates in the next section", "the percentage listed below", "per the attached schedule", "as set forth in Exhibit A"). Note: formulas that define calculation methodology (e.g., "base rate multiplied by DRG weight") ARE valid even if specific dollar amounts aren't stated. Also valid: a percentage tied to a specific CPT/HCPCS code (e.g., "100% of S5125-U3") — the percentage IS the concrete rate.
 - Vague or undefined amounts: uses non-specific language like "appropriate amount", "applicable rate", "as determined", "reasonable charges", "customary charges" without a concrete percentage or dollar figure. A fee schedule reference is only valid if paired with a specific percentage (e.g., "100% of fee schedule" is valid; "appropriate amount under fee schedule" is NOT valid).
 - Service definitions without payment terms
 - Authorization or coverage requirements only
@@ -2000,7 +2001,7 @@ Invalid - return NO if REIMBURSEMENT TERM is:
 ## CONDITION 3: No Disqualifiers
 
 Return NO if EITHER term contains (even if valid payment method exists):
-- Coordination of Benefits (COB)
+- Coordination of Benefits (COB) as the primary subject. Note: standard payment reductions (e.g., "less co-payments, deductibles, or amounts paid by third parties") within a reimbursement formula are NOT COB disqualifiers.
 - Risk-sharing, surplus/deficit distributions, settlement payments
 - Performance bonuses, incentives, administrative compensation
 - Audit/timeliness metrics (e.g., "pay 85% of claims within 30 days")