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Merged in bugfix/reimb_method_grouper (pull request #805)

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bugfix/reimb_method_grouper to main

* modified grouper reimb_method

* Merged main into bugfix/reimb_method_grouper


Approved-by: Katon Minhas
This commit is contained in:
VenkataKrishna Reddy Avula
2025-12-11 20:54:47 +00:00
committed by Katon Minhas
parent 3bf8860ca6
commit c91435d2f1
1 changed files with 1 additions and 1 deletions
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fieldExtraction/src/prompts/investment_prompts.json
+1 -1
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@@ -21,7 +21,7 @@
"field_name": "AARETE_DERIVED_REIMB_METHOD",
"relationship": "one_to_n",
"field_type": "methodology_breakout",
"prompt": "What is the method of reimbursement? Choose only from the following valid values: {valid_values}.\nFollow these mapping rules:\n- If any of Medicare, Medicaid, Average Sales Price (ASP), AWP (Average Wholesale Price), WAC (Wholesale Acquisition Cost), RBRVS (Resource-Based Relative Value Scale), RVU (Relative Value Unit) or ASA (American Society of Anesthesiology) or any type of Fee Schedule is mentioned, return 'Fee Schedule'\n- In case of DRG, MS-DRG, AP-DRG, SDA (Standard Dollar Amount), APR-DRG, APG, EAPG, APC(Ambulatory Payment Classification)/OPPS(Outpatient Prospective Payment System) or Ambulatory Surgical Center (ASC), return 'Grouper'.\n- In case of Percent of Charge or Percentage of Billed, return 'Billed Charges'.\n- When reimbursement is defined on a per-day basis, the applicable method is Per Diem.\n- For mixed methodologies (e.g., 'cost plus 5% based on AWP'), prioritize the base method (AWP)\n\nImportant exceptions and additional rules:\n- Reimbursements with specific dollar values cannot be 'Fee Schedule'\n- Provider interest rates are not considered 'Flat Rate'.\n- Charge master increase caps or limitations on provider pricing behavior are NOT reimbursement methodologies and should be ignored.\n- Always return 'Grouper' as the priority value if any grouper-related codes or references (e.g., MS-DRG, APR-DRG, DRG, etc.) are present in the SERVICE or METHODOLOGY fields — regardless of any other reimbursement methods (such as case rate, per diem, or lesser-of comparisons) mentioned. \n\nIf no specific rule is matched, map to the most appropriate value from the given valid values.",
"prompt": "What is the method of reimbursement? Choose only from the following valid values: {valid_values}.\nFollow these mapping rules:\n- If any of Medicare, Medicaid, Average Sales Price (ASP), AWP (Average Wholesale Price), WAC (Wholesale Acquisition Cost), RBRVS (Resource-Based Relative Value Scale), RVU (Relative Value Unit) or ASA (American Society of Anesthesiology) or any type of Fee Schedule is mentioned, return 'Fee Schedule'.\n- In case of DRG, MS-DRG, AP-DRG, SDA (Standard Dollar Amount), APR-DRG, APG, EAPG, APC (Ambulatory Payment Classification)/OPPS (Outpatient Prospective Payment System) or Ambulatory Surgical Center (ASC), return 'Grouper'.\n- In case of Percent of Charge or Percentage of Billed, return 'Billed Charges'.\n- When reimbursement is defined on a per-day basis, the applicable method is Per Diem.\n- For mixed methodologies (e.g., 'cost plus 5% based on AWP'), prioritize the base method (AWP).\n\nImportant exceptions and additional rules:\n- Reimbursements with specific dollar values cannot be 'Fee Schedule'.\n- Provider interest rates are not considered 'Flat Rate'.\n- Charge master increase caps or limitations on provider pricing behavior are NOT reimbursement methodologies and should be ignored.\n- **Precedence rule (final):** If any grouper-related codes or references (e.g., DRG, MS-DRG, APR-DRG, APG, EAPG, APC/OPPS, SDA, ASC grouping, etc.) are present in the SERVICE or METHODOLOGY fields, return 'Grouper' — This **overrides all other mapping rules**, including explicit dollar amounts (normally 'Flat Rate'), Fee Schedule indicators, case rates, per diem references, or cost-based methodologies..\n- **Exception:** If the methodology explicitly maps to 'Billed Charges' (e.g., Percent of Charge, Percentage of Billed), then return 'Billed Charges' even if grouper codes are present.\n\nIf no specific rule is matched, map to the most appropriate value from the given valid values.",
"valid_values": "VALID_REIMB_METHODOLOGY"
},
{