diff --git a/fieldExtraction/src/prompts/investment_prompts.json b/fieldExtraction/src/prompts/investment_prompts.json index 160100b..7446d6c 100644 --- a/fieldExtraction/src/prompts/investment_prompts.json +++ b/fieldExtraction/src/prompts/investment_prompts.json @@ -15,7 +15,7 @@ "field_name": "LESSER_OF_IND", "relationship": "one_to_n", "field_type": "methodology_breakout", - "prompt": "If the methodology text explicitly describes reimbursement as being determined by selecting the smaller/lowest amount from two or more distinct reimbursement calculations or rate structures, write 'Y' for this field. \n\nThis includes language such as 'lesser of', 'lower of', 'minimum of', or equivalent comparative language that establishes multiple reimbursement pathways where the smallest amount is selected. \n\nWrite 'Y' only when there are multiple distinct reimbursement methodologies being compared (e.g., billed charges vs. fee schedule, different percentage calculations, brand vs. generic pricing). \n\nSPECIAL CASE: If the methodology contains the phrase 'At no time shall Plan pay an amount that exceeds Provider's billed charges' (or substantially similar language) AND there is at least one other reimbursement calculation present in the methodology, treat this as a 'lesser of' scenario comparing the other reimbursement method against Provider's billed charges. In this case, write 'Y'.\n\nDo NOT select 'Y' for:\n- Standard 'not to exceed' language (even when it involves comparing to a limit)\n- Cap or ceiling language without explicit comparison terms\n- Payment structures that reference multiple values but use limiting language rather than comparison language\n- The special case phrase when it appears alone without other reimbursement calculations\n\nOnly select 'Y' when the text explicitly uses comparison terminology to choose between options OR when the special case condition is met.\n\nOtherwise, write 'N'.\n\nAnswer 'Y' for all reimbursement methodologies involved in any 'lesser of' statements, including nested or layered structures." + "prompt": "Determine if the reimbursement methodology creates a functional comparison where the smaller/lowest amount from two or more distinct calculations is selected for payment.\n\n**EXPLICIT COMPARATIVE LANGUAGE:**\n• 'lesser of', 'lower of', 'minimum of'\n• 'whichever is less', 'whichever is lower', 'whichever is smaller'\n• 'the smaller of', 'the lowest of'\n\n**FUNCTIONAL COMPARISON THROUGH LIMITING LANGUAGE:**\n• 'not to exceed' + another calculation (creates comparison between calculation and cap)\n• 'up to a maximum of' + base methodology (creates comparison between rate and ceiling)\n• 'capped at' + underlying calculation (creates comparison between rate and limit)\n• 'subject to a limit of' + payment formula (creates comparison between formula result and limit)\n\n**SPECIAL CASE:**\nIf the methodology contains 'At no time shall Plan pay an amount that exceeds Provider's billed charges' (or substantially similar language) AND there is at least one other reimbursement calculation present, treat this as a functional comparison between the other calculation and billed charges.\n\n**WHAT QUALIFIES:**\n• Two or more distinct reimbursement calculations/rates where the smallest is selected\n• Payment methodologies with caps that create effective comparisons\n• Nested or layered structures involving multiple rate options\n\n**WHAT DOES NOT QUALIFY:**\n• Single calculation methods without comparison elements\n• Administrative limitations that don't create payment alternatives\n• Eligibility restrictions or service quantity limits\n• The special case phrase when it appears alone without other calculations\n\n**EXAMPLES:**\n• '80% of Medicare rates, not to exceed $500' → 'Y' (compares 80% calculation vs $500 cap)\n• 'Lesser of billed charges or fee schedule' → 'Y' (explicit comparison)\n• '90% of charges, maximum $1000 per day' → 'Y' (functional comparison)\n• 'Flat rate of $200' → 'N' (single calculation, no comparison)\n\nReturn 'Y' if the methodology creates any functional comparison for payment selection, otherwise 'N'.\n\nAnswer 'Y' for ALL components involved in any comparison structure, including nested or layered scenarios." }, { "field_name": "GLOBAL_LESSER_OF_STATEMENT", @@ -91,7 +91,7 @@ "field_name": "NOT_TO_EXCEED_IND", "relationship": "one_to_n", "field_type": "methodology_breakout", - "prompt": "Identify if there is a 'not to exceed' limitation in the reimbursement methodology:\n\n- Look for explicit limitation phrases:\n • 'not to exceed', 'NTE', 'not exceed'\n • 'shall not exceed', 'will not exceed', 'cannot exceed'\n • 'maximum of', 'max of'\n • 'up to', 'capped at', 'ceiling of', 'cap of'\n • 'limited to', 'subject to a limit of'\n\n- Look for implicit limitation language:\n • 'maximum allowable reimbursement'\n • Percentage calculations with explicit caps (e.g., \"13% up to a cap of $X\")\n • Payment formulas combined with ceiling amounts\n\n- These limitations may apply to:\n • Specific dollar amounts ($X, $X.XX)\n • Percentage rates with caps (X% up to $Y)\n • Per-unit/per-service maximums\n • Acquisition cost plus percentage limitations\n • Allowable charge percentages with explicit maximums\n\n- Key indicators to identify:\n • Any reimbursement rate that has a defined upper boundary\n • Payment calculations that include both a rate AND a maximum limit\n • Language establishing ceiling amounts for compensation\n • Formulas where payment cannot exceed a specified threshold\n\nReturn 'Y' if any reimbursement-related limitation or ceiling is found, 'N' if not." + "prompt": "Determine if this reimbursement component contains or is subject to a monetary payment limitation:\n\n**EXPLICIT LIMITATION PHRASES:**\n• 'not to exceed', 'NTE', 'shall not exceed', 'cannot exceed'\n• 'maximum of', 'max of', 'up to', 'capped at', 'ceiling of'\n• 'limited to', 'subject to a limit of'\n\n**IMPLICIT LIMITATIONS:**\n• Percentage calculations with explicit caps (e.g. '80% up to $500')\n• Payment formulas combined with ceiling amounts\n• Any reimbursement rate with a defined upper monetary boundary\n\n**COMPONENT ANALYSIS RULES:**\n• If ANY component in the methodology has a limitation, ALL components get 'Y'\n• If this component IS a cap/ceiling/maximum amount: Return 'Y'\n• If this component is SUBJECT TO a limitation: Return 'Y'\n• Consider only monetary payment limitations\n\n**EXCLUSIONS:**\n• Do not include administrative restrictions, eligibility limits, or service quantity limitations\n• Do not include payment timing constraints\n\n**EXAMPLES:**\n• '30% of charges, not to exceed $75' → Both components get 'Y'\n• '$75 maximum payment' → Gets 'Y' (is itself a limitation)\n• '80% of Medicare rates' → Gets 'N' (exact payment, not a limitation)\n\nReturn 'Y' if any monetary payment limitation exists in the methodology or if this component represents a monetary limitation itself, otherwise 'N'." }, { "field_name": "FEE_SCHEDULE",