From 457249e768cef9699bff25a04229f6ecb856eae0 Mon Sep 17 00:00:00 2001 From: Mayank Aamseek Date: Fri, 5 Sep 2025 14:46:12 +0000 Subject: [PATCH] Merged in bugfix/carveout_cd_fixes (pull request #694) Bugfix/carveout cd fixes * comment added * prompt change * prompt change * Merged main into bugfix/carveout_cd_fixes * updated payment carveout definition * prompt refinement * updated carveout prompt Approved-by: Alex Galarce --- fieldExtraction/constants/mappings/valid_carveouts.json | 4 ++-- 1 file changed, 2 insertions(+), 2 deletions(-) diff --git a/fieldExtraction/constants/mappings/valid_carveouts.json b/fieldExtraction/constants/mappings/valid_carveouts.json index 587ad10..5148c95 100644 --- a/fieldExtraction/constants/mappings/valid_carveouts.json +++ b/fieldExtraction/constants/mappings/valid_carveouts.json @@ -4,7 +4,7 @@ }, "mapping": { "BASE_COVERED_SERVICES": "Describes foundational payment methodologies for standard covered services, including primary coverage determinations. This refers to payment methodologies that establish the fundamental reimbursement structure, not exceptions or adjustments to it. Examples:\n- 'covered services'\n- 'Covered Services not included in the Service Categories in Table 1 shall be reimbursed at 100% of the Medicare fee schedule'\n- Primary coverage methodologies in dual products (e.g., 'services primary to Medicare', 'services primary to Medicaid')\n- Base reimbursement rates that form the foundation of the payment structure", - "PAYMENT_CARVEOUT": "Describes payments for specific services, procedures, or codes that are carved out from the base/foundational payment methodology with distinct payment terms. These are exceptions or specialty payments that differ from the standard approach. Examples include 'Radiology covered services', 'Anesthesia covered services', 'Pharmaceuticals' and 'HEMATOCRIT (CPT CODE: 85014)'. Do NOT classify as payment carveout if the service represents a foundational coverage determination (such as primary payer methodologies in dual products) rather than a true exception to standard payment.", + "PAYMENT_CARVEOUT": "Describes payments for specific services, procedures, level designations, or specific codes that are carved out from the base/foundational payment methodology with distinct payment terms. These are exceptions or specialty payments that differ from the standard approach. Examples include 'Radiology covered services', 'Anesthesia covered services', 'Pharmaceuticals' and 'HEMATOCRIT (CPT CODE: 85014)'. Do NOT classify as payment carveout if the service represents a foundational coverage determination (such as primary payer methodologies in dual products) rather than a true exception to standard payment.", "UNLISTED_CODE": "Describes payments for codes that are not listed on a fee schedule. This is similar to DEFAULT_TERM. Only populate with Y if the Service or Methodology specifically mentions Codes.", "NEVER_EVENT": "Indicates that Never Events (e.g. sepsis acquired while inpatient) will not be covered. This may be phrased as 'no liability' or 'no payment'.", "EXPERIMENTAL_INVESTIGATIONAL": "Describes payments for experimental and investigational procedures.", @@ -15,6 +15,6 @@ "PROFESSIONAL_COMPONENT": "If Modifier 26 (professional component) is present.", "DIAGNOSTIC_PROCEDURES": "Describes payments for diagnostic procedures.", "READMISSIONS": "Describes payment for subsequent admission with the same diagnostic category of codes as the initial admission.", - "DEFAULT_TERM": "Indicates whether this service/methodology serves as a default/fallback payment rate when no other payment methods mentioned anywhere in the contract apply. The default/fallback/'end-of-the-line' payment rate may be a lower rate, often based on billed charges. Do not classify as default if:\n- The methodology is the primary/base reimbursement approach, even if defined by exclusion\n- The methodology applies to specific listed services/procedures \n- No default/fallback language is present\n\nExample: 'For any services not specifically listed in Exhibits A-D, reimbursement shall be 50% of billed charges.'" + "DEFAULT_TERM": "Indicates whether this service/methodology serves as a default/fallback payment rate when no other payment methods mentioned anywhere in the contract apply. The default/fallback/'end-of-the-line' payment rate may be a lower rate, often based on billed charges. It may be specific to certain services or applicable to all services. Do not classify as default if:\n- The methodology is the primary/base reimbursement approach, even if defined by exclusion\n- No default/fallback language is present\n\nExamples: \n- 'For any services not specifically listed in Exhibits A-D, reimbursement shall be 50% of billed charges.' \n- 'If there is no payment rate under the Medicare Fee Schedule, [alternative rate applies].'" } } \ No newline at end of file