Mayank Aamseek
c62dafb7c1
Bugfix/conversion factor * fixed default value * fixed conversion_factor prompt * post processing error fixed * fixed missing reimb primaries * Merged main into bugfix/conversion-factor Approved-by: Katon Minhas
925 lines
88 KiB
JSON
925 lines
88 KiB
JSON
[
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{
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"field_name": "SERVICE_TERM",
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"relationship": "one_to_n",
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"field_type": "reimbursement_primary",
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"prompt": "Describes the medical service or procedure that is being reimbursed. It can be very general (like 'Covered Services') or very specific (like 'CPT 98765')."
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},
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{
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"field_name": "REIMB_TERM",
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"relationship": "one_to_n",
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"field_type": "reimbursement_primary",
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"prompt": "Describes the method by which the price of the Service is calculated. It can be a simple dollar value (like '$100 per unit') or a percentage of some other value (like '100% of the Medicare Fee Schedule')."
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},
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{
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"field_name": "LESSER_OF_IND",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"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. Look for structure like 'lesser of A and B', 'A, not to exceed B', or similar. Return 'Y' if the methodology creates any functional comparison for payment selection, otherwise 'N'. If 'Y', then answer 'Y' for ALL components involved in any comparison structure, including nested or layered scenarios."
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},
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{
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"field_name": "AARETE_DERIVED_REIMB_METHOD",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"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, method of reimbursement is generally '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), Inpatient/IRF Prospective Payment System, method is generally 'Grouper'.\n- In case of Percent of Charge or Percentage of Billed, return 'Billed Charges'.\n- When reimbursement is Per Case, Per Unit, or similar, return 'Flat Rate'.\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, Charge master increase caps or limitations on provider pricing behavior are NOT reimbursement methodologies and should be ignored.\n\nChoose the most appropriate value from the valid values list. Never return 'N/A'.",
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"valid_values": "VALID_REIMB_METHODOLOGY"
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},
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{
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"field_name": "REIMB_FEE_RATE",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"prompt": "If the reimbursement rate is a flat fee (a specific dollar amount), what is that amount? If no flat fee is mentioned, return 'N/A'."
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},
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{
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"field_name": "REIMB_PCT_RATE",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"prompt": "What is the percentage rate of reimbursement? Extract the numeric percentage value (without % symbol).\n\nPRIORITIZE the primary percentage that directly describes the reimbursement rate. Look for percentages in different forms e.g., '50%', 'fifty percent', 'fifty percent (50%)'.\n\nIMPORTANT RULES:\n1. Extract the PRIMARY percentage rate that applies to the base payment calculation\n2. If multiple percentages are mentioned, prioritize the one that directly modifies the payment amount (e.g., '50% of the full DRG payment' → extract 50)\n3. If the text says 'plus' followed by a PERCENTAGE (e.g., 'plus 5%'), add that percentage to 100 (e.g., 'plus 5%' = 105), otherwise ignore it (e.g., 'plus $100').\n\nDEFAULT BEHAVIOR:\n- If no percentage is found AND no specific dollar amount is mentioned in the text, return 100 as default\n- If a specific dollar amount is mentioned (but no percentage), return 'N/A'\n- If both percentage and dollar amount are mentioned, extract the percentage value."
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},
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{
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"field_name": "REIMB_CONVERSION_FACTOR",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"prompt": "What is the conversion factor mentioned in the text? A conversion factor is a dollar amount or multiplier value used to determine payment for healthcare services, typically under a fee-for-service or Diagnosis-Related Group (DRG) reimbursement model. It serves as a multiplier that converts a relative value (such as a DRG weight or Relative Value Unit — RVU) into an actual payment amount. In the case of 'RBRVS', 'RVU', or American Society of Anesthesiology ('ASA'), any dollar amount mentioned refers to a conversion factor, and not to a flat fee rate. If no conversion factor is mentioned, return 'N/A'. If it is mentioned as a dollar amount, return it as a numeric value only (e.g., 1.25 for $1.25)."
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},
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{
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"field_name": "UNIT_OF_MEASURE",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"prompt": "Extract the unit of measure for flat rate or fee schedule reimbursements. Look for specific units like 'per day', 'per visit', 'per procedure', 'per ASA unit', 'case rate', etc. If a specific unit of measure is found and matches the valid values list, return that match. If a unit is mentioned but not in the valid values list, return 'Per Unit'. For flat rate methodologies where no specific unit is mentioned, default to 'Per Unit' regardless of whether procedure codes are present. For non-flat rate methodologies (percentages, bundled payments, etc.) where no unit is explicitly stated, return 'N/A'. Valid values are: {valid_values}. Don't assume units based on context; only extract explicitly stated units, except for the flat rate default rule.",
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"valid_values": "VALID_UNIT_OF_MEASURE"
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},
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{
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"field_name": "FEE_SCHEDULE",
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"relationship": "one_to_n",
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"field_type": "methodology_breakout",
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"prompt": "Write the full name of the Fee Schedule here. Include any secondary part of the fee schedule such as clinical lab, outpatient imaging, DMEPOS, encounter, surgeon, clinical diagnostic lab, parenteral and enteral nutrition (PEN), ASC, Part B Drug, Behavioral health, obstetrical, dental, transportation, etc. CHIP, STAR, and other Programs are not fee schedules. Allowed amounts or allowable charges that are not set by CMS, Medicaid, or Medicare do not constitute a fee schedule. Only use exact text from the Reimbursement Term."
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},
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{
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"field_name": "GLOBAL_LESSER_OF_STATEMENT",
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"relationship": "one_to_one",
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"field_type": "full_context_separate",
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"prompt": "Find 'Lesser of' language that applies to ALL Services in the contract. Be careful not to include 'Lesser of' phrasing that only applies to the specific Exhibit. If you find a true contract-wide global constraint, extract it exactly. Most contracts will return 'N/A' - only extract if genuinely global."
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},
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{
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"field_name": "GREATER_OF_IND",
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"relationship": "one_to_n",
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"field_type": "TBD",
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"prompt": "If the methodology text indicates that the reimbursement shall be the greater of two or more values, write 'Y' for this field. Otherwise, write 'N'."
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},
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{
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"field_name": "REIMB_DATES",
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"relationship": "one_to_n",
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"field_type": "dynamic_reimb_info",
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"prompt": "The date range, delineated by effective and termination dates, for which a Reimbursement Term applies. They may be labelled 'Effective Date' and 'Termination Date', or similar. They may also be presented as a range, like 'Date1 - Date2'. Lastly, there may be language simply describing a term, like 'Initial Term' or 'Renewal Term'. EXCLUDE dates written in the footer of the page. If multiple separate date ranges exist, capture each as a separate entry. Return each date or date range EXACTLY as it's written in the text.",
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"format": "date_range"
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},
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{
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"field_name": "AARETE_DERIVED_FEE_SCHEDULE",
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"relationship": "one_to_n",
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"field_type": "fee_schedule_breakout",
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"prompt": "What type of fee schedule is it? Choose from the following: {valid_values}. In case of Medicare, return 'CMS'. In case of Medicaid, return 'State'. Return 'Proprietary' when the payer has defined the fee schedule (e.g. 'payor’s Medicaid fee schedule', 'payor’s Medicare fee schedule', 'health plan fee schedule'). If fee schedule is not mentioned, write 'N/A'.",
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"valid_values": "VALID_AARETE_DERIVED_FEE_SCHEDULE"
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},
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{
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"field_name": "FEE_SCHEDULE_VERSION",
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"relationship": "one_to_n",
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"field_type": "fee_schedule_breakout",
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"prompt": "What version of the fee schedule is it? Look for a version number, a year, a date, or the words 'prevailing', 'current', or similar. Only use exact text from the methodology."
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},
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{
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"field_name": "AARETE_DERIVED_FEE_SCHEDULE_VERSION",
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"relationship": "one_to_n",
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"field_type": "fee_schedule_breakout",
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"prompt": "Identify the version of the fee schedule based on this priority order:\n\n1. Return the exact text if a version number (e.g., 'Version 5.2'), specific year (e.g., '2023'), or specific date (e.g., 'January 2023') is found.\n2. Return 'current' if terms like 'prevailing', 'in effect on the date of service', 'then-current', 'most current', or 'current' are used.\n3. If no explicit version or descriptive term is found, choose only from: ['current', 'year prior'].\n4. If nothing related to version is mentioned, return 'N/A'.",
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"valid_values": "VALID_AARETE_DERIVED_FEE_SCHEDULE_VERSION"
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},
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{
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"field_name": "LOB",
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"relationship": "one_to_n",
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"field_type": "dynamic_primary",
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"prompt": "A distinct, high-level category of health insurance coverage. Choose LOBs ONLY from the following values: {valid_values}. Do NOT extract Programs, Products, or other entities listed. Choose ONLY from the valid values presented. Only return values that are explicitly written - do NOT fill this value out by deducing the answer from sub-Programs that may fall under one of the valid answers. If only the sub-Program is seen, return 'N/A'.",
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"valid_values": "VALID_LOBS",
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"retrieval_question": "What Line of Business does this contract apply to?"
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},
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{
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"field_name": "AARETE_DERIVED_LOB",
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"relationship": "one_to_n",
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"field_type": "crosswalk",
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"prompt": "TBD",
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"crosswalk": "CROSSWALK_LOB",
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"base_field": "LOB"
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},
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{
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"field_name": "NETWORK",
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"relationship": "one_to_n",
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"field_type": "dynamic_primary",
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"prompt": "A type of managed care structures that defines what providers a patient can use. Choose Networks ONLY from the following values: {valid_values}. Only return values that are explicitly written.",
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"valid_values": "VALID_NETWORKS",
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"retrieval_question" : "What Network (HMO, PPO, etc) does this contract apply to?"
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},
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{
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"field_name": "AARETE_DERIVED_NETWORK",
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"relationship": "one_to_n",
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"field_type": "crosswalk",
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"prompt": "TBD",
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"crosswalk": "CROSSWALK_NETWORK",
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"base_field": "NETWORK"
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},
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{
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"field_name": "PRODUCT",
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"relationship": "one_to_n",
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"field_type": "dynamic_primary",
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"prompt": "The brand name of a health plan or product offered by the Payer. Do NOT include the name of the Payer itself (such as 'Molina', 'Centene' etc) - rather, look for the Product that these healthplans offer. Valid products include, but are not limited to, the following: {valid_values}. If any of the values in this list are mentioned, return them exactly as written in the list. Use reasonable judgment for obvious synonyms and equivalent terms.",
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"valid_values": "VALID_PRODUCTS",
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"retrieval_question": "What Product does this contract apply to?"
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},
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{
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"field_name": "AARETE_DERIVED_PRODUCT",
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"relationship": "one_to_n",
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"field_type": "TBD",
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"prompt": "TBD",
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"base_field": "PRODUCT"
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},
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{
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"field_name": "PROGRAM",
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"relationship": "one_to_n",
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"field_type": "dynamic_primary",
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"prompt": "The brand name of a health plan or product offered by the State or Federal government. List any Programs explicitly stated in the text. Choose ONLY from the following: {valid_values}. Note that 'Medicare' on it's own does NOT mean 'Medicare Advantage'. If only 'Medicare' is seen, do not write 'Medicare Advantage'. IMPORTANT - CHIP vs CHIPP distinction: 'CHIP' (Children's Health Insurance Program) is a valid standalone value. If you see 'CHIP HMO' or just 'CHIP' (without 'Perinate'), extract 'CHIP'. However, if you see 'CHIP Perinate' or 'CHIP-P' (Children's Health Insurance Program Perinate), extract 'CHIPP' (NOT 'CHIP'). These are two distinct programs - do not confuse them. Choose the answer from the list that most closely matches what is found in the text. Use reasonable judgment for obvious synonyms and equivalent terms (e.g., 'Medicare-Medicaid Program' matches 'Medicare-Medicaid Plan').",
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"valid_values": "VALID_PROGRAMS",
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"retrieval_question": "What Program(s) does this contract apply to?"
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},
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{
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"field_name": "AARETE_DERIVED_PROGRAM",
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"relationship": "one_to_n",
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"field_type": "crosswalk",
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"prompt": "TBD",
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"crosswalk": "CROSSWALK_PROGRAM",
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"base_field": "PROGRAM"
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},
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{
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"field_name": "CLAIM_TYPE_CD",
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"relationship": "one_to_n",
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"field_type": "exhibit_level",
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"prompt": "What is the Claim Type of the contract, exhibit, or services mentioned in the text? Choose ONLY from the following: {valid_values}.\n\nGuidelines:\n- Return 'Professional' if the text refers to services rendered by individual healthcare providers or provider groups (e.g., physician services, office visits, outpatient procedures).\n- Return 'Institutional' if the text refers to services provided by hospitals, facilities, or institutions (e.g., inpatient, outpatient facility, or surgery centers).\n- Return 'Ancillary' if the text refers to services such as Home Health, Durable Medical Equipment (DME), Laboratory, Radiology, Dialysis, Diagnostic Imaging, Genetic Testing, Blood Testing, Sleep Lab Services, Telemedicine, Behavioral or Mental Health, or other ancillary settings.\n- If multiple claim types are mentioned, return the one most closely associated with the compensation or service description in the context.\n- If no claim type is mentioned or cannot be determined, return 'N/A'.\nDo not infer or guess.",
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"valid_values": "VALID_CLAIM_TYPE",
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"keywords": [],
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"smart_chunking_methodology": "TBD",
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"allow_na": true
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},
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{
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"field_name": "AARETE_DERIVED_CLAIM_TYPE_CD",
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"base_field": "CLAIM_TYPE_CD",
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"relationship": "one_to_n",
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"field_type": "crosswalk",
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"valid_values": "TBD",
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"prompt": "",
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"crosswalk": "CROSSWALK_CLAIM_TYPE_CD"
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},
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{
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"field_name": "CONTRACT_TITLE",
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"relationship": "one_to_one",
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"field_type": "smart_chunked",
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"prompt": "What is the complete title of the contract or the document? It is generally written in CAPITAL LETTERS and is generally found at the beginning of the document before a paragraph containing provider and payer name. It typically contains the words AGREEMENT, AMENDMENT, CONTRACT, ADDENDUM, MEMORANDUM, LETTER, PROVIDER or REQUEST. In case of agreement, typical structure is the provider name, followed by the phrase with agreement, followed potentially by a number signifying a version of the contract. In case of amendment, typical structure is word amendment followed by number, followed by the phrase with agreement. Extract the complete title of the contract or document as accurately as possible. Ensure: All leading characters are included for each word (e.g. 'NETWORK' instead of 'ETWORK'). Spaces between words are preserved in phrases (e.g., 'PROVIDER COLLABORATION' instead of 'PROVIDERCOLLABORATION'). If text appears incomplete or lacks spacing, use logical patterns like capitalization or common formatting rules to infer and correct the output. Replace new lines and line breaks with space.",
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"keywords": [
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"AGREEMENT",
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"AMENDMENT",
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"ADDENDUM",
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"PROVIDER",
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"CONTRACT",
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"MEMORANDUM",
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"LETTER",
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"REQUEST",
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"EFFECTIVE"
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],
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"methodology": "hierarchy",
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"case_sensitive": "False",
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"retrieval_question": "What is the title or name of this contract, agreement, amendment, addendum, memorandum, or document? Contract title in capital letters at the beginning. Provider agreement, amendment to agreement, contract title, document title, addendum title."
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},
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{
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"field_name": "CONTRACT_AMENDMENT_NUM",
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"relationship": "one_to_one",
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"field_type": "smart_chunked",
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"prompt": "Extract the amendment number if this document is an amendment to a contract. Follow these guidelines:\n1. Look for phrases like 'Amendment No. X', 'X Amendment', 'Amendment X to the Agreement', 'Xth Amendment' in the document title, preamble, or header sections.\n2. Return only the numeric value (e.g., for 'Amendment No. 3' return '3').\n3. If the amendment number is written as a word (e.g., 'First Amendment'), convert it to a number (e.g., '1').\n4. If the amendment number is an alphanumeric value, return the whole value (e.g., for '2A' return '2A').\n5. If the amendment number uses Roman numerals (e.g., 'Amendment IV'), convert it to a number (e.g., '4').\n6. If the amendment number includes decimal points (e.g., 'Amendment 2.1'), return the full numeric value (e.g., '2.1').\n7. If multiple amendment numbers appear, return the one most clearly associated with the current document.\n8. If the document is an amendment but the number cannot be determined, return 'UNKNOWN'.\n9. If the document is not an amendment, return 'N/A'.\n10. If the Amendment number contains any leading zeroes(e.g. '001'), Drop all leading zeros (e.g. '1').",
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"retrieval_question": "What is the amendment number of this document? Amendment No., Amendment Number, ordinal amendment, numbered amendment? Amendment to agreement, amendment to contract."
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},
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{
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"field_name": "PROVIDER_STATE",
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"relationship": "one_to_one",
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"field_type": "smart_chunked",
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"prompt": "What US state(s) is the provider based in or where does this contract apply? Look for:\n\n1. Any provider-related address information (payment address, mailing address, service location, etc.)\n2. State names or standard 2-letter abbreviations in provider contact details\n3. Language indicating governing law or jurisdiction (e.g., 'governed by the laws of [State]')\n4. Service area or coverage area references\n5. Provider licensing information mentioning a specific state\n\nFirst extract all provider-related states found from the above scenarios in a list.\n\nThen extract the payor's state information in the same way (usually a single state).\n\nAfter extraction:\n1. Compare the provider states list with the payor state.\n2. If there is a match, return only the matching state in a single-item list.\n3. If there is no match, return all provider states in a properly formatted list with each state as a string in the list.\n\nReturn state names exactly as they appear in the document (full state name or 2-letter abbreviation).\n\nIf no state can be determined, return 'N/A'.",
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"retrieval_question": "What US state is the provider based in or located in? What state does this contract apply to? What state is mentioned in the provider's address, service area, or licensing information?"
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},
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{
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"field_name": "PROVIDER_PAYMENT_ADDRESS",
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"relationship": "TBD",
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"field_type": "TBD",
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"prompt": "Identify the US state mentioned in the provider's PAYMENT address located in the signature section. Return the state exactly as it appears in the document (full state name or standard 2-letter abbreviation). If no state can be determined, return 'N/A'.",
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"retrieval_question": "What US state is the provider's PAYMENT address located in? Which state is mentioned in the provider's payment address?"
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},
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{
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"field_name": "PROVIDER_MAILING_ADDRESS",
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"relationship": "TBD",
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"field_type": "TBD",
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"prompt": "Identify the US state mentioned in the provider's MAILING address within the signature section. Return the state exactly as it appears in the document (full state name or standard 2-letter abbreviation). If no state can be determined, return 'N/A'.",
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"retrieval_question": "What US state is the provider's MAILING address located in? Which state is mentioned in the provider's mailing address?"
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},
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{
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"field_name": "PAYER_STATE",
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"relationship": "one_to_one",
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"field_type": "smart_chunked",
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"prompt": "What US state is the payer based in or incorporated in? Look for:\n\n1. Payer address information in the contract header, preamble, or signature sections\n2. State names or abbreviations in payer contact information\n3. State of incorporation or principal place of business\n4. Payer headquarters location\n5. Payer licensing information that mentions a specific state\n\nReturn the full state name (e.g., 'California', 'Texas', 'New York') or standard 2-letter abbreviation (e.g., 'CA', 'TX', 'NY') as it appears in the document.\n\nIf multiple states are mentioned, prioritize:\n1. The state in the payer's primary/headquarters address\n2. The state of incorporation\n3. The state most frequently referenced for the payer organization\n\nIf no state can be determined, return 'N/A'.",
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"retrieval_question": "What US state is the payer based in, incorporated in, or headquartered in? What state is mentioned in the payer's address or principal place of business?"
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},
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{
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"field_name": "PAYER_NAME",
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"relationship": "one_to_one",
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"field_type": "smart_chunked",
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"prompt": "What is the name of the payer that is a party to the contract as stated in the Preamble?",
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"retrieval_question": "What is the name of the payer, health plan, insurance company, or payor that is a party to this contract? Payer name in the preamble, parties section, or beginning of agreement."
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},
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{
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"field_name": "TIN",
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"relationship": "one_to_one",
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"field_type": "provider_info",
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"prompt": "What is the Tax Identification Number (TIN)? A TIN is typically a 9-digit number that may be formatted as XXX-XX-XXXX or XXXXXXXXX or XX-XXXXXXX or XX-XXXX-XXX. Look for it near labels like 'Tax ID', 'EIN', 'Employer ID', or 'TIN'. It may also unlabeled, in the header or footer of the page. Do not modify any formatting - return exactly as it appears in the document. Do NOT return a 9-digit number if it is clearly associated with any label other than those listed above. Such numbers must not be treated as a TIN."
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},
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{
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"field_name": "NPI",
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"relationship": "one_to_one",
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"field_type": "provider_info",
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"prompt": "What is the National Provider Identifier (NPI)? An NPI is a unique 10-digit identification number for healthcare providers. Look for it near provider information sections. NEVER fill a number here that is not 10-digits."
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},
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{
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"field_name": "NAME",
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"relationship": "one_to_one",
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"field_type": "provider_info",
|
||
"prompt": "Return ONLY the full name of the provider associated with this TIN and NPI as it appears in the document. If no actual name is given, return 'N/A' (do not return placeholders like 'provider' or 'provider name'). Do not extract any other names apart from the provider name."
|
||
},
|
||
{
|
||
"field_name": "PROVIDER_NAME",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "Extract the PROVIDER organization name(s) from the retrieved contract text.\n\nThe provider is the healthcare organization entering into the agreement (NOT the payer/insurance company like Highmark, Aetna, UnitedHealthcare, Blue Cross Blue Shield, etc.).\n\nGUIDELINES:\n1. Look for the provider name in phrases like:\n - 'This Agreement is between [PAYER] and [PROVIDER]'\n - 'Agreement between [PAYER] and [PROVIDER]'\n - 'by and between [PAYER] and [PROVIDER]'\n - '[PROVIDER] (hereinafter referred to as \"Provider\")'\n - 'Provider: [PROVIDER]'\n2. The provider name often appears in the opening paragraph or preamble of the contract.\n3. Return the EXACT provider name as it appears in the document, including legal suffixes (LLC, Inc., P.C., etc.).\n4. If the provider name includes 'd/b/a' (doing business as), return the FULL name including the d/b/a portion.\n5. If MULTIPLE provider organization names appear in the contract (e.g., multiple entities entering the agreement), return ALL of them separated by ' | '.\n - Example: 'Provider Group A, LLC | Provider Group B, P.C. | Provider Group C d/b/a City Medical'\n6. Do NOT return:\n - The payer/insurance company name\n - Individual physician names (unless that is the practice name)\n - Department names only\n - Addresses or other metadata\n7. If the provider name cannot be determined from the retrieved text, return 'N/A'.\n\nBriefly explain your reasoning. Return ONLY the provider name(s) separated by ' | ' if multiple, nothing else.",
|
||
"retrieval_question": "What is the provider organization name? Agreement between payer and provider. This agreement is made between. By and between. Hereinafter referred to as Provider. Provider name in contract preamble. Provider party to the agreement. Healthcare organization entering agreement."
|
||
},
|
||
{
|
||
"field_name": "REIMB_PROV_TIN",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_reimb_info",
|
||
"prompt": "The TIN (Tax ID Number) of a healthcare provider. This is a 9-digit number, often of the format XX-XXXXXXX. If there are multiple TINs that apply, provide them ALL in a comma-separated list."
|
||
},
|
||
{
|
||
"field_name": "REIMB_PROV_NPI",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_reimb_info",
|
||
"prompt": "The NPI (National Provider Identifier). This is a 10-digit number. If there are multiple NPIs that apply, provide them all in a comma-separated list."
|
||
},
|
||
{
|
||
"field_name": "REIMB_PROV_NAME",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_reimb_info",
|
||
"prompt": "The name of a given Provider. This may be the name of a Doctor, Hospital, Clinic, or any other provider entity - not a Payer or insurance plan. If there are multiple Provider Names that apply, provide them all in a comma-separated list."
|
||
},
|
||
{
|
||
"field_name": "EFFECTIVE_DT",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "Please analyze the following contract and extract ONLY the effective date of the CURRENT contract or CURRENT amendment. THE DATE MAY OR MAY NOT BE EXPLICITLY LABELED AS AN EFFECTIVE DATE. Follow these retrieval rules in order:\n\n[RETRIEVAL RULES]\nLOOK FOR dates that appear after these common phrases but not limited to (case-insensitive matching):\n'Effective Date:' FOLLOWED BY a date\n'is entered into as of' FOLLOWED BY a date\n'is made and entered into as of the' FOLLOWED BY a date\n'effective as of' FOLLOWED BY a date\n'shall begin on' FOLLOWED BY a date\n'Effective Date of Agreement:' FOLLOWED BY a date\n'Effective Date of Amendment' FOLLOWED BY a date\n'made this' FOLLOWED BY a date\n'made and entered into' FOLLOWED BY a date\n\nALSO LOOK FOR dates in phrases that semantically indicate an effective date (may or may not be explictly labelled as effective date), even if they do not exactly match the phrases above.\nExamples include but ARE NOT LIMITED TO:\nPhrases indicating when a contract or amendment begins or takes effect, Phrases specifying the start date of the contract or amendment, Phrases defining when the contract or amendment becomes operational, or Any phrase indicating contract or amendment creation or execution date.\n\nIt is possible that the contract will specify that the effective date is derived from elsewhere in the contract. One specific case is outlined:\n\nSIGNATURE DATE HANDLING:\nPRIMARY RULE: DO NOT USE signature dates unless STRICTLY meeting the criteria below\nWHEN TO USE a signature date: ONLY IF that SPECIFIC signature date has an EXPLICIT statement marking IT as the effective date\nHere are some example scenarios:\n✓ USE: 'Effective Date: 1/13/2024' + 'Date: [blank]' below\n✓ USE: 'Effective Date of Agreement: 2/15/2016' + 'Date: [blank]' below\n\nWHEN NOT TO USE a signature date:\n- Even if there is an empty effective date section or field nearby\nHere are some example scenarios but not limited to:\n✗ DO NOT USE: 'Date: 1/1/2024' + 'Effective Date: [blank]' below\n✗ DO NOT USE: 'Effective Date: [blank]' + 'Date: 1/1/2024' below\n\nSECONDARY RULE – UNREFERENCED DATE NEAR “EFFECTIVE DATE:” LABEL:\nIf no explicit effective date is found in the contract, and the “Effective Date:” label appears with a blank or empty field, you MAY consider a nearby date as the effective date ONLY IF ALL of the following conditions are true:\n- The nearby date is NOT referenced by any signature, title, or labeled field (i.e., it is unassigned or free-floating)\n- Other nearby dates ARE explicitly labeled (e.g., under “Date” near signature lines or roles)\n- The unassigned date appears directly under or beside the “Effective Date:” label\n- The document does not provide a clearer effective date elsewhere\n\nIn such cases, treat the unreferenced date near the “Effective Date:” label as the effective date. Preserve the date's exact format as it appears.\n\n[OUTPUT DATE HANDLING]\nCRITICAL - DATE FORMAT PRESERVATION:\n- You MUST preserve the EXACT format of the date AS IT APPEARS in the document\n- DO NOT modify, standardize, or reformat the date in ANY way\n- Preserve ALL original: Spacing (including multiple spaces), punctuation, separators (commas, hyphens, forward slashes, etc.), leading/trailing spaces, or partial or incomplete dates\n\nExamples of EXACT DATE preservation:\n✓ If document shows: '3-1 , , 03' → return |3-1 , , 03|\n✓ If document shows: 'June 1st,2010' → return |June 1st,2010|\n✓ If document shows: 'Feb 1st day of , 10' → return |Feb 1st day of , 10|\n✓ If document shows: '6 /1/ 2010' → return |6 /1/ 2010|\n✓ If document shows: '12-1-20' → return |12-1-20|\n✓ If document shows: 'made this day of Jan, 2009' → return |day of Jan, 2009|\n✓ If document shows: 'to be effective as of , 20 ( the 'Effective Date').' → return |, 20|\n\nIt is POSSIBLE that the intended effective date could be blank (left blank, not filled), empty, incomplete, or partial. DO NOT ASSUME/INFER anything about the date or its components.\nReturn N/A only if NO valid effective date is found (e.g. cases with blank/empty/incomplete dates/placeholder values).\n\nIF MULTIPLE matches are retrieved:\n- VERIFY that you have PRECISELY followed the retrieval rules\n- PRIORITIZE the effective date of the CURRENT contract or CURRENT amendment over any attachment or exhibit\n- ONLY IF multiple valid effective dates for the CURRENT contract/amendment are found, SELECT the LATEST one\n- MAINTAIN the EXACT FORMAT of the selected date as it appears in the document\n\nBefore providing the final answer, SHOW your reasoning:\n- LIST ALL dates found that match patterns in the retrieval rules\n- For EACH date found:\n* EXPLAIN why it is considered for effective date or not\n* Include the EXACT text snippet where the date was found\n- JUSTIFY your final date selection or why N/A is being returned\n\nFinal Answer Format:\n- Your answer MUST be ENCLOSED in |pipes|\n- The text between the pipes MUST be an EXACT COPY of how the date appears in the document\n- DO NOT add or remove ANY characters, spaces, or formatting",
|
||
"keywords": [
|
||
"effective date",
|
||
"effective date:",
|
||
"entered into",
|
||
"shall be effective",
|
||
"will become effective",
|
||
"signature page"
|
||
],
|
||
"format": "date",
|
||
"retrieval_question": "What is the effective date of this contract or amendment? When does this agreement take effect, commence, begin, or become operational? Effective date, entered into as of, made this, made and entered into, shall begin on, commences on, commencement date, start date."
|
||
},
|
||
{
|
||
"field_name": "AARETE_DERIVED_EFFECTIVE_DT",
|
||
"base_field": "EFFECTIVE_DT",
|
||
"relationship": "one_to_one",
|
||
"field_type": "date_inferred",
|
||
"prompt": ""
|
||
},
|
||
{
|
||
"field_name": "TERMINATION_DT",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "What is the initial contract or amendment termination date? Look within the Term or Term and Termination section or wherever applicable. Extract the specific end date of the initial term before any renewals or extensions. \nOutput Format Rules: \n- If an exact specific date is mentioned: Output the date (e.g., '12/31/2024') \n- If described using terminology like duration or recurring period: Output the exact terminology (e.g., 'three years from the contract effective date', 'year to year') \n- If multiple dates or conditions are mentioned, prioritize the initial termination date before any automatic renewals. \n - Do not modify, transform, or calculate dates. Example Outputs: - For specific date: '12/31/2014' - For duration: 'three years from the contract effective date' - For recurring period: 'year to year' - For conditional termination: 'upon execution of new FPA or 12/31/2014, whichever is earlier'",
|
||
"keywords": [
|
||
"term and termination",
|
||
"Term",
|
||
"Initial Term"
|
||
],
|
||
"format": "date",
|
||
"retrieval_question": "What is the initial contract or amendment termination date? What is the end date, expiration date, or date when the initial term concludes? When does the contract terminate before any renewals?"
|
||
},
|
||
{
|
||
"field_name": "AARETE_DERIVED_TERMINATION_DT",
|
||
"base_field": "TERMINATION_DT",
|
||
"relationship": "one_to_one",
|
||
"field_type": "date_inferred",
|
||
"prompt": "TBD",
|
||
"keywords": [
|
||
"TERM AND TERMINATION",
|
||
"Term and Termination",
|
||
"Term and termination",
|
||
"term and termination",
|
||
"Term"
|
||
],
|
||
"methodology": "or",
|
||
"case_sensitive": "True"
|
||
},
|
||
{
|
||
"field_name": "AUTO_RENEWAL_IND",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "This pertains to the term and termination section of the contract. If this contract automatically renews, answer Y. If this contract will remain in effect unless terminated, answer Y. Otherwise, answer N. If you cannot determine answer N.",
|
||
"keywords": [
|
||
"Renew",
|
||
"renew",
|
||
"Auto renew",
|
||
"auto renew",
|
||
"automatically renew",
|
||
"evergreen",
|
||
"Evergreen"
|
||
],
|
||
"methodology": "or",
|
||
"case_sensitive": "True",
|
||
"retrieval_question": "Does this contract automatically renew, auto-renew, continue automatically, or remain in effect unless terminated by either party? Is this an evergreen contract or does it renew for successive terms or renewal periods?"
|
||
},
|
||
{
|
||
"field_name": "AUTO_RENEWAL_TERM",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "If the contract automatically renews, what is the length of the renewal term? This pertains to the term and termination section of the contract. The response should be a numerical representation of the renewal period with no punctuation. Acceptable formats are '1 year' or '12 months' (both representing the same duration). 'Year to year' and 'year' should be interpreted as '1 year'. If the contract automatically renews but the length of the renewal term is not specified, default to '1 year'. Only return the length of time for the renewal with no additional context.",
|
||
"keywords": [
|
||
"Renew",
|
||
"renew",
|
||
"Auto renew",
|
||
"auto renew",
|
||
"automatically renew",
|
||
"evergreen",
|
||
"Evergreen"
|
||
],
|
||
"methodology": "or",
|
||
"case_sensitive": "True",
|
||
"retrieval_question": "What is the length, duration, or period of the automatic renewal term, successive renewal term, or additional renewal period? How long is each renewal period or renewal term in years or months?"
|
||
},
|
||
{
|
||
"field_name": "PROV_TAXONOMY_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_code",
|
||
"prompt": "10-character alphanumeric codes used to classify providers by type, classification, and area of specialization. They may be listed as 'Taxonomy Code', 'Provider Taxonomy Code', or similar terms. Examples include '207Q00000X', '207R00000X', '207L00000X'."
|
||
},
|
||
{
|
||
"field_name": "PROV_TAXONOMY_CD_DESC",
|
||
"base_field": "PROV_TAXONOMY_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "TBD",
|
||
"prompt": "TBD"
|
||
},
|
||
{
|
||
"field_name": "PROV_SPECIALTY_CD",
|
||
"base_field": "PROV_SPECIALTY_CD_DESC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_code",
|
||
"prompt": "2-digit codes from 01-99. They may also have a letter as the first digit such as A1, C2, etc. They may be listed as 'Specialty Code', 'Provider Specialty', or similar. If no codes are explicitly written in the text, return N/A.",
|
||
"crosswalk": "CROSSWALK_PROV_SPECIALTY_CD"
|
||
},
|
||
{
|
||
"field_name": "PROV_SPECIALTY_CD_DESC",
|
||
"base_field": "PROV_SPECIALTY_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "TBD",
|
||
"prompt": "",
|
||
"valid_values": "VALID_PROV_SPECIALTY",
|
||
"crosswalk": "CROSSWALK_PROV_SPECIALTY_CD"
|
||
},
|
||
{
|
||
"field_name": "PLACE_OF_SERVICE_CD",
|
||
"base_field": "PLACE_OF_SERVICE_CD_DESC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_code",
|
||
"prompt": "2-digit numeric codes. They may be listed as 'POS' or 'Place of Service'. If no codes are explicitly written in the text, return N/A.",
|
||
"crosswalk": "CROSSWALK_PLACE_OF_SERVICE_CD"
|
||
},
|
||
{
|
||
"field_name": "PLACE_OF_SERVICE_CD_DESC",
|
||
"base_field": "PLACE_OF_SERVICE_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "TBD",
|
||
"prompt": "",
|
||
"valid_values": "VALID_PLACE_OF_SERVICE",
|
||
"crosswalk": "CROSSWALK_PLACE_OF_SERVICE_CD"
|
||
},
|
||
{
|
||
"field_name": "BILL_TYPE_CD",
|
||
"base_field": "BILL_TYPE_CD_DESC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_code",
|
||
"prompt": "4-character alphanumeric codes. The first character is often a leading zero, which may or may not be included. The last character may either be a digit 0-9, or the letter X. If no codes are explicitly written in the text, return N/A.",
|
||
"crosswalk": "CROSSWALK_BILL_TYPE_CD"
|
||
},
|
||
{
|
||
"field_name": "BILL_TYPE_CD_DESC",
|
||
"base_field": "BILL_TYPE_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "TBD",
|
||
"prompt": "",
|
||
"valid_values": "VALID_BILL_TYPE",
|
||
"crosswalk": "CROSSWALK_BILL_TYPE_CD"
|
||
},
|
||
{
|
||
"field_name": "PATIENT_AGE_RANGE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "dynamic_reimb_info",
|
||
"prompt": "List any patient age ranges described in the text that relate to a reimbursement term. Write the age ranges mentioned in the format 'X-Y' (e.g., '0-18', '18-65'). If the age range is not specified but the text indicates a specific age group (e.g., 'pediatric', 'adult'), return that exact text instead. If an age is listed as simply 'Over X', write 'X-None', to indicate that there is no upper bound to the age range. If no age ranges are mentioned, return N/A."
|
||
},
|
||
{
|
||
"field_name": "DEFAULT_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "non_prompt",
|
||
"prompt": "DEFAULT_INDICATOR:\nIndicates whether this methodology serves as a default/fallback payment rate when no other payment methods apply. The default/fallback payment rate is typically a low rate and based on billed charges. This is an 'end-of-the-line' reimbursement when no other methodologies apply.\n\nOutput 'Y' ONLY if the methodology meets BOTH these criteria:\n1. Contains language indicating it applies to services not covered elsewhere, such as:\n - 'services not listed in the fee schedule'\n - 'services for which no other payment method is specified'\n - 'all other services'\n - 'services not otherwise specified'\n2. Is clearly a secondary/fallback option, NOT the primary/base reimbursement method, as indicated by:\n - Position in the contract (appears after primary methodology is defined)\n - Lower reimbursement rate than the base methodology (typically 50-60% of charges)\n - Explicit 'default' or 'fallback' terminology\n - Applies to a minor subset of services (not the majority of contract services)\n\nOutput 'N' if ANY of these are true:\n- The methodology is the primary/base reimbursement approach, even if defined by exclusion\n- The methodology applies to specific listed services/procedures\n- The methodology offers standard rates comparable to other contract methodologies\n- No default/fallback language is present\n\nExample of TRUE default (Y): 'For any services not specifically listed in Exhibits A-D, reimbursement shall be 50% of billed charges.'\nExample of base methodology defined by exclusion (N): 'Covered Services not included in the Service Categories in Table 1 shall be reimbursed at 100% of the Medicare fee schedule.'"
|
||
},
|
||
{
|
||
"field_name": "PROCEDURE_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify all Procedure (CPT or HCPCS) Codes in the text: - CPT codes are exactly 5 numeric digits (00100-99999) - HCPCS codes are 1 letter followed by 4 numbers (A0000-V9999)."
|
||
},
|
||
{
|
||
"field_name": "CPT4_PROC_MOD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify all CPT code modifiers in the text: Identify CPT modifiers in the text: - Modifiers are 2-character codes (alphanumeric) appended to the end of a five-character Procedure code."
|
||
},
|
||
{
|
||
"field_name": "REVENUE_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify all Revenue codes (Rev codes) in the text: - 3-4 digit numeric codes - May have 'X' as a wildcard character - Start with digits 0-9."
|
||
},
|
||
{
|
||
"field_name": "DIAG_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify diagnosis codes (ICD-10) in the text: - 3-7 characters in length - First character must be a letter - Characters 2-3 must be numbers - Characters 4-7 (if present) can be numbers or letters."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_TYPE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract grouper methodologies (MS-DRG, APR-DRG, APC, APG, etc.) from the text. Apply these standardization rules:\n1) Normalize Variations: Convert all 'MS-DRG' variants (e.g., MSDRG, Surgical MSDRGs) to 'MS-DRG'. Convert all 'APR-DRG' variants (e.g., APRDRG, Enhanced APR-DRG) to 'APR-DRG'.\n2) Handle Generic vs. Specific: If a specific type (MS-DRG/APR-DRG) is present alongside generic 'DRG', extract ONLY the specific type. For other variants (Ohio Medicaid DRG, etc.), extract only 'DRG'.\n3) System Mapping: Map any 'OPPS' references to 'APC'. Map any 'Inpatient/IRF Prospective Payment System' references to 'MS-DRG'.\n4) Formatting: Do not return full names, brackets, or empty strings. Return N/A if none found."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify grouper codes (DRGs) in the text: - Basic format: 3 digits (like 123) - May include severity/risk indicators (like 123-1) - May include decimal points (like 123.4) - Maximum length of 5 characters."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_CD_DESC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "TBD",
|
||
"prompt": "Identify any descriptions associated with the grouper codes referenced for reimbursements. This may include the full name of the grouper, such as 'MS-DRG 123 - Heart Failure with Major Complications'. If no description is provided, return N/A."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_VERSION",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract the exact grouper version phrase (e.g., 'MS-DRG Version 40', 'APR-DRG Version 34', 'APC 2023', 'DRG v38'). If no specific version is listed, fallback to descriptive grouper types (e.g., 'Ohio Medicaid DRG', 'Michigan Medicaid APC Rates'). Return N/A if neither are found."
|
||
},
|
||
{
|
||
"field_name": "AARETE_DERIVED_GROUPER_VERSION",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract only the version number, year, or 'current' indicator from grouper references. \n- Target formats: 2-digit numbers (40), 4-digit years (2024), or the word 'current'.\n- Output: Return just the value. Return N/A if unspecified."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_ALTERNATIVE_LEVEL_OF_CARE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract text referencing 'alternative level of care' (ALC) or patients ready for discharge but requiring alternative placement (e.g., 'no longer requiring intensive inpatient services'). Return exact text or N/A."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_SEVERITY_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Does the Service and Methodology contain any grouper severity level information that influences reimbursement? Look for references to severity levels, complications/comorbidities (CC/MCC), acuity levels, risk adjustments, or clinical complexity indicators within grouper systems. Return Y if severity information is present, N if explicitly absent, or N/A if no grouper methodology is mentioned."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_SEVERITY",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract any contract language from the Service and Methodology that references severity levels within grouper systems that influence reimbursement. Look for terms like 'severity level', 'severity of illness', 'acuity level', 'DRG acuity level', 'complications and comorbidities', 'CC/MCC', 'risk adjustment', 'clinical complexity', 'with/without complications', or similar severity-related language. Extract the exact language as it appears. If the severity references are codes or levels, include the grouper type context (APR-DRG, MS-DRG, APC, etc.) with the severity information. Return N/A if no severity levels are specified."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_RISK_OF_MORTALITY_SUBCLASS",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract any language from the Service and Methodology that references patient risk of mortality subclasses or mortality-based adjustments within grouper systems that impact reimbursement. Look for terms like 'risk of mortality', 'mortality subclass', 'mortality adjustment', 'ROM', 'mortality risk level', 'death probability', 'mortality indicator', or similar mortality-related classifications used by grouper methodologies. Extract the exact language as it appears. Return N/A if no risk of mortality language is specified."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_TRANSFER_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract any language from the Service and Methodology that references patient transfers between facilities and their impact on grouper-based reimbursement. Look for terms like 'transfer DRG', 'transfer rules', 'transfer adjustment', 'transferred to/from another facility', 'inter-facility transfer', 'transfer payment', 'post-acute transfer', or similar transfer-related language that affects payment calculations. Extract the exact language as it appears. Return N/A if no transfer language is specified."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_READMISSIONS_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract any language from the Service and Methodology that references readmissions and their impact on reimbursement. Look for terms like 'readmission policy', 'readmission adjustment', 'readmission penalty', 'readmission reduction', '30-day readmission', 'unplanned readmission', 'readmission exclusion', or similar readmission-related language that affects payment. Extract the exact language as it appears. Return N/A if no readmission language is specified."
|
||
},
|
||
{
|
||
"field_name": "GROUPER_HAC_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "grouper_breakout",
|
||
"prompt": "Extract any language from the Service and Methodology that references Hospital-Acquired Conditions and their impact on reimbursement. Look for terms like 'hospital-acquired condition', 'HAC', 'preventable condition', 'HAC adjustment', 'HAC penalty', 'nosocomial infection', 'acquired condition', 'preventable complication', or similar hospital-acquired condition language that affects payment. Extract the exact language as it appears. Return N/A if no HAC language is specified."
|
||
},
|
||
{
|
||
"field_name": "NDC_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify National Drug Code (NDC) numbers present. Look for an 11-digit number of the format XXXXX-XXXX-XX."
|
||
},
|
||
{
|
||
"field_name": "CLAIM_ADMIT_TYPE_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify Admit Type codes in the text: - Single digit numeric codes (1-9) - Used to indicate hospital admission type."
|
||
},
|
||
{
|
||
"field_name": "CLAIM_STATUS_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "code_primary_breakout",
|
||
"prompt": "Identify Claim Status codes in the text. Look for numbers between 1-999 that refer specifically to the status of a claim being submitted."
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Outlier payments are payment adjustments that provide additional supplemental reimbursement on top of base payments when claims exceed predetermined cost, day, or resource thresholds for unusually high-cost or high-resource cases. These outlier payments apply only to inpatient services and never apply to outpatient services. Extract the exact language that defines conditions and thresholds for outlier payments for inpatient services. Look for specific dollar amounts, day counts, percentages, or other metrics that trigger payments for outlier payments. Also look for any services, codes, or conditions excluded from outlier payments. Look for terms like 'outlier payments', 'outlier threshold', 'unusually high-cost cases', 'extended stay supplements', 'exceptional circumstances payments', 'high-resource case adjustments'. Only extract terms that are explicitly described as outlier payments. Return the exact contract language or 'N/A'.",
|
||
"breakout_template": "OUTLIER_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_FIRST_DOLLAR_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Determine whether the outlier payment is calculated on the entire claim amount (first dollar) or only on the portion exceeding the predetermined threshold from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **First Dollar Indicators (Y)**: Language suggesting payment applies to the entire claim when threshold is met:\n - 'X% of total charges when threshold is met'\n - 'X% of entire claim amount'\n - 'X% of all charges upon meeting criteria'\n - 'Full claim paid at X% rate when outlier triggered'\n\n2. **Excess-Only Indicators (N)**: Language suggesting payment applies only to amounts above threshold:\n - 'X% of charges exceeding the threshold'\n - 'X% of costs above the limit'\n - 'X% of excess charges over threshold'\n - 'Payment on amounts in excess of predetermined limit'\n\n3. **Calculation Method**: Contract language describing how the outlier payment amount is determined and what base amount is used for calculation\n\n**Common Indicator Phrases**:\n- **First Dollar (Y)**: 'total charges', 'entire claim', 'full amount', 'complete claim', 'all charges when', 'total cost when threshold met'\n- **Excess Only (N)**: 'exceeding the threshold', 'above the limit', 'excess charges', 'amounts over', 'portion exceeding', 'costs in excess of'\n\n**Decision Logic**:\n- **'Y'** = Outlier payment calculated on entire claim amount when threshold is met\n- **'N'** = Outlier payment calculated only on the portion exceeding the threshold\n- **'UNKNOWN'** = Information should be present but cannot be determined from contract language\n- **'N/A'** = Information is not relevant to this contract\n\n**Instructions**: Analyze the contract language to determine the calculation basis for outlier payments. Return a single indicator based on whether the payment applies to the full claim or only the excess portion.\n\n**Format**: Single character response ('Y', 'N', or 'N/A')"
|
||
},
|
||
{
|
||
"field_name": "RANGE_NBR_DAYS",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Extract the specific period (measured in days) that defines the window of time during which outlier payments are calculated from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **Calculation Period**: Specific number of days that define the outlier payment calculation window (e.g., '30 days', '60 days', '90 days')\n2. **Time Window Language**: Phrases describing the duration for outlier calculation (e.g., 'outlier period of X days', 'calculation window of X days', 'X-day outlier range')\n3. **Range Definitions**: Contract language that establishes the time frame for outlier assessment (e.g., 'days 1-30', 'within 60-day period', 'over 90-day span')\n4. **Unit Conversion**: If expressed in other time units, convert to days (e.g., 'two weeks' = '14 days', 'one month' = '30 days')\n\n**Common Indicator Phrases**: Look for 'number of days', 'days in range', 'days in the window', 'outlier period', 'calculation period', 'outlier range', 'time window', 'day range', 'period of X days', and similar time-based terminology.\n\n**Context**: This represents the specific timeframe during which outlier calculations are performed, distinct from threshold days that trigger eligibility.\n\n**Instructions**: Extract only the numerical value representing the number of days in the outlier calculation period. Convert other time units to days when necessary. If multiple calculation periods exist for different scenarios, return all values separated by commas. If no specific number of days is mentioned, return 'N/A'.\n\n**Format**: Numerical value only (e.g., '30', '60', '30,90' for multiple periods)"
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_FIXED_LOSS_NBR_DAYS_THRESHOLD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Extract the specific number of days that a patient's length of stay must exceed to qualify for outlier reimbursement from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **Exact Day Count**: Specific numeric values representing the minimum length of stay threshold (e.g., '10 days', '15 days', '30 days', 'exceeds 7 days')\n2. **Threshold Language**: Phrases establishing day-based criteria for outlier payments (e.g., 'length of stay exceeding X days', 'stays longer than X days', 'after X days', 'beyond X day threshold')\n3. **Unit Conversion**: If expressed in other time units, convert to days (e.g., 'three weeks' = '21 days', 'two months' = '60 days')\n4. **Multiple Thresholds**: Different day thresholds for different scenarios - extract all relevant day counts\n\n**Common Indicator Phrases**: Look for 'length of stay requirement', 'minimum stay', 'LOS threshold', 'day outlier threshold', 'length of stay exceeding', 'stays longer than', 'after [number] days', 'beyond [number] days', 'exceeds [number] days', 'over [number] days', 'more than [number] days', and similar day-based terminology.\n\n**Instructions**: Return only the numeric day value(s) that represent the threshold before outlier payments can potentially qualify. If multiple day thresholds exist, return all values separated by commas. If no specific number of days is mentioned, return 'N/A'.\n\n**Format**: Numeric value only (e.g., '10', '15', '7,14' for multiple thresholds)"
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_FIXED_LOSS_THRESHOLD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Extract the specific dollar value or threshold amount that represents the minimum by which claim costs must exceed standard reimbursement to trigger outlier payment eligibility from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **Fixed Dollar Amounts**: Specific monetary values that must be exceeded (e.g., '$25,000', '$50,000', '$100,000')\n2. **Percentage-Based Thresholds**: Percentage values above standard payment (e.g., '150% of DRG rate', '200% of base payment', '120% of allowed amount')\n3. **Excess Amount Calculations**: Language describing how much costs must exceed base payment (e.g., 'costs exceeding payment by $X', 'loss amount above $X')\n4. **Multiple Thresholds**: Different threshold amounts for different scenarios or service types\n\n**Common Indicator Phrases**: Look for 'fixed loss charge threshold', 'outlier charge threshold', 'cost outlier charge threshold', 'stop-loss charge threshold', 'costs exceeding', 'charges above', 'threshold amount', 'loss threshold', 'outlier threshold', 'excess costs over', 'charges in excess of', and similar cost-based terminology.\n\n**Distinguish From**: This field captures cost/charge thresholds (dollar amounts or percentages), NOT day-based thresholds which are captured separately.\n\n**Instructions**: Return the specific threshold value that determines when a claim qualifies for additional outlier reimbursement. Include the unit ($ for dollar amounts, % for percentages). If multiple thresholds exist, return all values separated by commas. If no threshold is specified, return 'N/A'.\n\n**Format**: Include units - '$25000', '150%', '$50000,200%' for multiple thresholds"
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Extract the percentage rate applied to outlier reimbursement, whether applied to the portion of charges or costs exceeding the threshold (excess amount) OR to the total claim amount in an outlier case. Focus on identifying:\n\n**What to Look For:**\n1. **Percentage Rates**: Specific percentage values applied either to excess amounts OR to total amounts for outlier cases (e.g., '80%', '75%', '90%', '106%').\n2. **Rate Application Language**: Phrases describing how the rate applies, such as:\n - Excess application: '80% of charges exceeding threshold', '75% of costs above limit', '90% of excess charges'.\n - Total application: '80% of total charges', '90% of allowed amount for outlier cases', '106% of allowable amount'.\n3. **Decimal Conversions**: Convert decimal rates to whole percentages (e.g., '0.75' becomes '75', '0.80' becomes '80').\n4. **Multiple Rates**: Different percentage rates for different thresholds, tiers, or scenarios.\n\n**Common Indicator Phrases**: Look for 'percentage of charges', 'percent of costs', 'rate applied to excess', '% of charges exceeding', '% of costs above', 'percent of excess charges', 'percent of total charges', 'reimbursement rate of', 'percentage applied to allowable amount', and similar terminology.\n\n**Calculation Context**: This rate may be applied to (a) the amount exceeding the outlier threshold, OR (b) the total claim amount in an outlier case. Capture both types.\n\n**Instructions**: Extract only the numerical percentage value(s) (without the % symbol). If multiple rates exist for different scenarios, return all values separated by commas. Convert decimals to whole percentages. If no percentage rate is specified, return 'N/A'.\n\n**Format**: Numerical value only without % symbol (e.g., '75', '80', '75,90')."
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_MAXIMUM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "What is the maximum dollar amount that can be reimbursed for an outlier claim, regardless of actual costs incurred? Extract any outlier terms or reimbursement methodology language that sets a reimbursement cap or maximum limit specifically for qualifying outlier claims. This can be either a fixed dollar amount or a payment per unit in excess maximum. Look for 'maximum outlier payment', 'outlier payment shall not exceed', 'outlier cap', 'outlier reimbursement limited to', 'outlier payment capped at'. IMPORTANT: Do NOT include general payment caps like 'shall not exceed billed charges' or overall reimbursement limits - only extract maximums that specifically apply to the outlier payment portion.\n\nExamples:\n- '$6,049 per diem for Obstetrical Services Days in Excess of 8 day Threshold' → Extract: $6049\n- '$6,368 for Cardiac Services Days in Excess of 12 days threshold' → Extract: $6368\n\nReturn dollar amount only (e.g. '$500000') or 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_MAXIMUM_FREQUENCY",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "If there is a cap on the total amount to be paid for outlier claims, what is the frequency of that cap? This may be per claim, per day (per diem), or per admission. The outlier maximum can be either a fixed dollar amount or a payment per unit in excess maximum. Look for terms like 'maximum outlier payment per claim', 'outlier payment shall not exceed per day', or similar phrasing.\n\nExamples:\n- '$6,049 per diem for Obstetrical Services Days in Excess of 8 day Threshold' → Extract: per diem\n- '$6,368 for Cardiac Services Days in Excess of 12 days threshold' → Extract: per day (inferred from 'days in excess')\n\nNote: When frequency is not explicitly mentioned but can be inferred from context (e.g., 'days in excess of threshold' implies 'per day'), extract the inferred frequency.\n\nReturn the exact phrase used in the contract (e.g., 'per admission', 'per claim', 'per day', 'per case', 'per stay'). If not specified, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_EXCLUSION_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "outlier_breakout",
|
||
"prompt": "Extract specific codes listed in the contract that are excluded from outlier reimbursement eligibility, even if cost or length thresholds are met, from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **Code Types**: CPT codes, HCPCS codes, DRG codes, revenue codes, ICD diagnosis codes, or procedure codes that are explicitly excluded\n2. **Exclusion Lists**: Specific code numbers or ranges that are not eligible for outlier payments (e.g., 'CPT 12345', 'DRG 470-472', 'Revenue Code 0370')\n3. **Code Categories**: Groups of codes excluded by category (e.g., 'all psychiatric DRGs', 'experimental procedure codes', 'rehabilitation revenue codes')\n4. **Individual vs Range**: Both single codes and code ranges that are excluded from outlier calculations\n\n**Common Indicator Phrases**: Look for 'excluding the following codes', 'codes not eligible for outlier payments', 'outlier exclusions', 'excluded from outlier calculation', 'not applicable to codes', 'codes exempt from outlier', 'outlier payments do not apply to', and similar exclusion terminology.\n\n**Instructions**: Extract only the specific codes that are explicitly excluded from outlier reimbursement. Include code prefixes (CPT, DRG, etc.) when specified. If multiple codes are excluded, list all codes separated by commas. If the contract excludes codes but doesn't specify the actual code numbers, describe the exclusion category. If no codes are specifically excluded, return 'N/A'.\n\n**Format**: Include code type when specified (e.g., 'CPT 12345, DRG 470, Revenue Code 0370' or 'All psychiatric DRGs')"
|
||
},
|
||
{
|
||
"field_name": "OUTLIER_EXCLUSION_CD_DESC",
|
||
"relationship": "TBD",
|
||
"field_type": "TBD",
|
||
"prompt": "Extract the description of the specific codes listed in the contract that are excluded from outlier reimbursement eligibility, providing the explanatory text associated with each excluded code from the service description and reimbursement methodology or outlier terms. Focus on identifying:\n\n**What to Look For:**\n1. **Code Descriptions**: Specific explanations provided for each excluded code (e.g., 'Experimental surgical procedure', 'Routine laboratory tests', 'Rehabilitation services')\n2. **Service Categories**: Descriptive text explaining the type of services represented by excluded codes (e.g., 'Physical therapy services', 'Diagnostic imaging', 'Outpatient procedures')\n3. **Exclusion Rationale**: Contract language explaining why certain codes are excluded (e.g., 'Non-acute care services', 'Elective procedures', 'Preventive care services')\n4. **Associated Descriptions**: Text that directly correlates with the codes identified in OUTLIER_EXCLUSION_CD\n\n**Common Description Types**: Look for service descriptions, procedure explanations, diagnostic categories, treatment types, or administrative reasons provided alongside excluded codes.\n\n**Instructions**: For each code identified in OUTLIER_EXCLUSION_CD, extract the specific description of that code as provided in the contract. Only include descriptions that are directly associated with excluded codes. Match descriptions to their corresponding codes when possible. If the contract lists excluded codes without descriptions, return 'N/A'.\n\n**Format**: Provide descriptions in the same order as codes listed in OUTLIER_EXCLUSION_CD, separated by commas (e.g., 'Experimental surgical procedure, Routine diagnostic tests, Rehabilitation services')"
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Describes financial safety net provisions primarily designed to protect providers against extreme losses. May apply at individual claim or aggregate levels and typically has higher thresholds than standard outlier provisions. Look for provisions specifically labeled as 'Stop Loss' that function separately from the standard payment methodology. (e.g. compensate Provider 120% of the published Medicaid Rate once claim exceeds a payable amount of $300,000)",
|
||
"breakout_template": "STOP_LOSS_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_FIRST_DOLLAR_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "Is the stop-loss payment calculated on the entire claim amount (first dollar) or only on the portion exceeding the predetermined fixed-loss threshold? If the payment applies to the entire claim when the threshold is met, write 'Y'. If the payment applies only to the excess amount above the threshold, write 'N'. For example, language like 'Hospital will be paid X% of total charges when threshold is met' suggests first dollar (Y), while 'Hospital will be paid X% of charges exceeding the threshold' indicates threshold-only (N). If this information should be present but is not found, write 'UNKNOWN'. If this information is not relevant to the contract, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_RANGE_NBR_DAYS",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "What is the specific period considered when calculating stop-loss payments? This defines a window of time (measured in days) during which the stop-loss payment is calculated. Look for terms like 'number of days', 'days in range', 'days in the window', or 'stop-loss period'. If no specific number of days is mentioned, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_FIXED_LOSS_THRESHOLD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "What is the threshold amount to be compared to the cost of the claim, whereby if the cost exceeds the threshold, the stop-loss payment is calculated on the excess amount? This may be a percentage or a dollar value. Look for terms like 'fixed loss threshold', 'stop loss threshold', 'cost threshold', or 'stop-loss trigger amount'. If no threshold is specified, write 'N/A'.\n\nExamples:\n1. 'For inpatient services, if the total billed charges exceed the stop-loss threshold of $100,000, Hospital shall be reimbursed at 75% of charges for the amount exceeding the threshold.' → Extract: '$100,000'\n\n2. 'The fixed loss threshold shall be 150% of the applicable Medicare MS-DRG reimbursement rate for the admission.' → Extract: '150% of the applicable Medicare MS-DRG reimbursement rate'\n\n3. 'For the contract year beginning January 1, 2024, the stop-loss threshold shall be $90,000 per admission, subject to annual increases of 3% for each subsequent year.' → Extract: '$90,000 per admission, subject to annual increases of 3%'"
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_PCT_RATE_ON_EXCESS_CHARGES",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "What is the percent rate that is applied to costs that exceed the stop-loss threshold? Look for terms like 'percentage of charges', 'percent of costs', 'rate applied to excess', or similar phrasing. Extract only the numerical percentage (e.g., '75' from '75% of charges exceeding the threshold'). If expressed as a decimal (e.g., 0.75), convert to a whole percentage number (75)."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_MAXIMUM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "If there is a cap on the total amount to be paid for stop loss claims (whether per claim, per day, or per admission), write that cap here. Include the exact language from the contract that specifies the cap. Look for terms like 'maximum stop-loss payment', 'stop-loss payment shall not exceed', 'stop-loss cap', or similar phrasing. If there is not, write N/A."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_MAXIMUM_FREQUENCY",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "If there is a cap on the total amount to be paid for stop-loss claims, what is the frequency of that cap? This may be per claim, per day (per diem), or per admission. Look for terms like 'maximum stop-loss payment per claim', 'stop-loss payment shall not exceed per day', or similar phrasing. Return the exact phrase used in the contract (e.g., 'per admission', 'per claim', 'per day', 'per case', 'per stay'). If not specified, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_DAILY_MAX_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "What is the maximum amount that can be paid for stop-loss claims per day? This is different from the overall stop-loss cap as it specifically limits daily payments. Look for terms like 'daily maximum', 'daily cap', 'per day limit', 'maximum per diem', or 'not to exceed per day'. Include the exact language from the contract that specifies the daily maximum rate, including any currency symbols or percentage values. For example, '$10,000 per day maximum' or '120% of charges per day, not to exceed $15,000'. If no daily maximum is specified, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_EXCLUSION_CD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "If the text specifies that any codes are to be excluded from the stop-loss calculation, write those codes here. Look specifically for CPT, HCPCS, DRG, revenue codes, or ICD diagnosis codes that are explicitly excluded. Look for phrases like 'excluding the following codes', 'codes not eligible for stop-loss payments', or 'stop-loss exclusions'. If not, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "STOP_LOSS_EXCLUSION_CD_DESC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "stop_loss_breakout",
|
||
"prompt": "For each code identified in STOP_LOSS_EXCLUSION_CD, extract the specific description of that code as provided in the contract. For example, if a contract excludes CPT 12345 and describes it as 'Experimental surgical procedure', return 'Experimental surgical procedure' as the description. Only include descriptions that are directly associated with excluded codes. If the contract lists excluded codes without descriptions, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "SEQUESTRATION_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Describes a government-mandated reduction in federal spending for a period of time. Look for the term 'Sequestration'.",
|
||
"breakout_template": "SEQUESTRATION_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "SEQUESTRATION_START_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "sequestration_breakout",
|
||
"prompt": "What is the Effective Date of the sequestration reduction? If none is specified, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "SEQUESTRATION_END_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "sequestration_breakout",
|
||
"prompt": "What is the Termination Date of the sequestration reduction? If none is specified, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "DISCOUNT_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Describes a discount applied to the payment. The description must include the term 'Discount' and should specify the discount amount, percentage, or type.",
|
||
"breakout_template": "DISCOUNT_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "DISCOUNT_PERCENT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "discount_breakout",
|
||
"prompt": "What is the discount to be applied to the normal rate? Write only the percentage value."
|
||
},
|
||
{
|
||
"field_name": "DISCOUNT_RATE_CHANGE_INTERVAL",
|
||
"relationship": "one_to_n",
|
||
"field_type": "discount_breakout",
|
||
"prompt": "What is the rate change interval of the discount?"
|
||
},
|
||
{
|
||
"field_name": "DISCOUNT_START_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "discount_breakout",
|
||
"prompt": "If there is a date range for which the discount applies, write the start date here, in YYYY/MM/DD format."
|
||
},
|
||
{
|
||
"field_name": "DISCOUNT_END_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "discount_breakout",
|
||
"prompt": "If there is a date range for which the discount applies, write the end date here, in YYYY/MM/DD format."
|
||
},
|
||
{
|
||
"field_name": "PREMIUM_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Describes a premium to the payment. Look for the term 'Premium'. Classify as a premium only if the text explicitly indicates an increase or addition to the standard payment rate, such as 'an additional premium of X%', 'a premium rate of Y% above standard', or 'premium payment terms apply'.",
|
||
"breakout_template": "PREMIUM_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "PREMIUM_PERCENT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "premium_breakout",
|
||
"prompt": "What is the discount to be applied to the normal rate? Write only the percentage value."
|
||
},
|
||
{
|
||
"field_name": "PREMIUM_RATE_CHANGE_INTERVAL",
|
||
"relationship": "one_to_n",
|
||
"field_type": "premium_breakout",
|
||
"prompt": "What is the rate change interval of the premium?"
|
||
},
|
||
{
|
||
"field_name": "PREMIUM_START_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "premium_breakout",
|
||
"prompt": "If there is a date range for which the premium applies, write the end date here, in YYYY/MM/DD format."
|
||
},
|
||
{
|
||
"field_name": "PREMIUM_END_DT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "premium_breakout",
|
||
"prompt": "If there is a date range for which the premium applies, write the end date here, in YYYY/MM/DD format."
|
||
},
|
||
{
|
||
"field_name": "ADDITION_MAX_FEE_RATE_INC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "addition_breakout",
|
||
"prompt": "What is the maximum additional fee amount mentioned in the reimbursement text? Look for fixed dollar amounts added to base rates (e.g., $400.00 above, $200 additional). If multiple amounts are mentioned, return the highest value. Provide the exact dollar value. if no dollar amount is mentioned, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "ADDITION_MAX_PCT_RATE_INC",
|
||
"relationship": "one_to_n",
|
||
"field_type": "addition_breakout",
|
||
"prompt": "What is the maximum additional percentage amount mentioned in the reimbursement text? Look for percentage-based supplements added to base rates (e.g., 10% above, 5% additional). If multiple percentages are mentioned, return the highest value. Provide the exact percentage value. if no percentage is mentioned, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "ADDITION_RATE_CHANGE_TIMELINE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "addition_breakout",
|
||
"prompt": "When and how frequently do the additional payment amounts change according to the reimbursement text? Look for timeline information related to supplemental payments or add-on fees. Provide exact text from the document. If no specific timeline is mentioned, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "AARETE_DERIVED_ADDITION_RATE_CHANGE_TIMELINE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "addition_breakout",
|
||
"prompt": "When and how frequently do the additional payment amounts change according to the reimbursement text? Look for timeline information related to supplemental payments or add-on fees. Take exact text from the document and convert it to standardized timeline format. For annual or shorter intervals, use the number followed by 'months' (e.g., '12 months', '3 months'). For intervals longer than annual, use the number followed by 'years' (e.g., '2 years', '3 years'). If no specific timeline is mentioned, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "TRIGGER_CAP_THRESHOLD_AMT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "trigger_cap_breakout",
|
||
"prompt": "What is the payment cap once triggered? This can be a percentage, dollar amount, or fee schedule reference. For 'lesser of' statements, identify the more restrictive/cap component. Return the complete descriptive phrase as it appears in the methodology. Examples: '70% of billed charges', '$1000', 'Medicare rate', 'Provider's allowable charge master rate'. If a dollar amount, return just the number (e.g., '1000'). Ignore explanatory clauses that define what something 'equals'. If no trigger cap threshold amount is found, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "TRIGGER_BASE_THRESHOLD",
|
||
"relationship": "one_to_n",
|
||
"field_type": "trigger_cap_breakout",
|
||
"prompt": "Extract the defined quantitative threshold from the following reimbursement text that triggers a change in payment methodology. This threshold can be a dollar amount, number of days, visits, procedures, or any other measurable unit (but not qualitative condition) that causes a different type of reimbursement to apply. Look for phrases such as 'Days in excess of threshold', 'exceeds the specified threshold of', 'charges exceed $X', 'above X days, a new payment applies', 'over X visits, payment is Y', or 'once the threshold of X is reached'. Convert number words to digits, and remove commas from numbers. Return the numeric value along with its appropriate unit (e.g., '$', 'days', 'visits', 'months', etc.). Only return thresholds that cause a shift in payment calculation. If no such threshold is found, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "RATE_ESCALATOR_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "A rate escalator is a payment mechanism where reimbursement rates automatically increase over time after an initial term or period. Extract the complete sentence or clause from the reimbursement text that describes this rate escalation mechanism, including when it starts and how it applies. Use exact text from the document.",
|
||
"breakout_template": "RATE_ESCALATOR_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "RATE_ESCALATOR_MAX_RATE_INC_PCT",
|
||
"relationship": "one_to_n",
|
||
"field_type": "rate_escalator_breakout",
|
||
"prompt": "What is the maximum rate increase mentioned in the reimbursement text? This could be annual, biennial, or any other period. If multiple rates are mentioned, return the maximum rate. Provide the numerical percent value without percent symbol."
|
||
},
|
||
{
|
||
"field_name": "RATE_ESCALATOR_RATE_CHANGE_TIMELINE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "rate_escalator_breakout",
|
||
"prompt": "Extract the exact text from the reimbursement that describes when rate increases begin and how frequently they occur. Include the complete timeline phrase showing the starting point and frequency (e.g., 'beginning on the anniversary of the effective date and each year thereafter'). Use the precise wording from the document. If no specific timeline is mentioned, return 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "FACILITY_ADJUSTMENT_TERM",
|
||
"relationship": "one_to_n",
|
||
"field_type": "special_case_check",
|
||
"prompt": "Extract any language in the Exhibit that relates to Disproportionate Share Hospital ('DSH'), Direct Graduate Medical Education ('GME'), Indirect Medical Education('IME'), New Technology Add-on Payment ('NTAP'), or Uncompensated Care ('UC'). Extract the full sentence or sentences.",
|
||
"breakout_template": "FACILITY_ADJUSTMENT_BREAKOUT"
|
||
},
|
||
{
|
||
"field_name": "DSH_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "Are adjustments for Disproportionate Share Hospitals (DSH) included in the reimbursement? Return 'Y' or 'N'."
|
||
},
|
||
{
|
||
"field_name": "DSH_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If DSH adjustments are included, and they are listed as a % Rate, write that % rate here. If DSH is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "DSH_FEE_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If DSH adjustments are included, and they are listed as a $ value, write that $ value here. If DSH is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "IME_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "Are adjustments for Indirect Medical Education (IME) included in the reimbursement? Return 'Y' or 'N'."
|
||
},
|
||
{
|
||
"field_name": "IME_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If IME adjustments are included, and they are listed as a % Rate, write that % rate here. If IME is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "IME_FEE_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If IME adjustments are included, and they are listed as a $ value, write that $ value here. If IME is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "NTAP_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "Are adjustments for New Technology Add-On Payments (NTAP) included in the reimbursement? Return 'Y' or 'N'."
|
||
},
|
||
{
|
||
"field_name": "NTAP_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If NTAP adjustments are included, and they are listed as a % Rate, write that % rate here. If NTAP is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "NTAP_FEE_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If NTAP adjustments are included, and they are listed as a $ value, write that $ value here. If NTAP is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "UC_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "Are adjustments for Uncompensated Care ('UC') included in the reimbursement? Return 'Y' or 'N'."
|
||
},
|
||
{
|
||
"field_name": "UC_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If UC adjustments are included, and they are listed as a % Rate, write that % rate here. If UC is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "UC_FEE_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If UC adjustments are included, and they are listed as a $ value, write that $ value here. If UC is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "GME_IND",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "Are adjustments for Graduate Medical Education (GME) included in the reimbursement? Return 'Y' or 'N'."
|
||
},
|
||
{
|
||
"field_name": "GME_PCT_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If GME adjustments are included, and they are listed as a % Rate, write that % rate here. If GME is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "GME_FEE_RATE",
|
||
"relationship": "one_to_n",
|
||
"field_type": "facility_adjustment_breakout",
|
||
"prompt": "If GME adjustments are included, and they are listed as a $ value, write that $ value here. If GME is not included, write 'N/A'."
|
||
},
|
||
{
|
||
"field_name": "NUM_AVAILABLE_SIGNATORY_LINE_COUNT",
|
||
"relationship": "one_to_one",
|
||
"field_type": "smart_chunked",
|
||
"prompt": "Count the total number of signature lines in the document. A signature line refers to any line or section intended for a party to sign, typically accompanied by but not limited to a date, designation, or name of the signee or entity. Include all distinct signature lines for individuals and entities. If none are present, return 0.",
|
||
"retrieval_question": "Identify all sections in the document that require a signature from any party. This includes any designated space or instruction for signing, such as fields labeled Signature, Date, Name, Designation, Title, or Entity details. Return every distinct signature-related section for all parties involved, including signature blocks, acknowledgment areas, and authorization sections."
|
||
}
|
||
] |