@ampath/esm-dha-workflow-app 4.0.0-next.44 → 4.0.0-next.445

package/src/billing/dashboard/v2/claim-workspace/claim-workspace.resource.ts

@@ -0,0 +1,282 @@
+/**
+ * Claim-creation workspace — data layer (DEMO STUBS).
+ *
+ * Mirrors the DHA/HIE eClaims pipeline so the workspace can be clicked through:
+ *   eligibility → sub-benefits → interventions → consent → visit/claim →
+ *   preauth → claim lines → preview → submit.
+ * Replace each stub with the real endpoint noted in the comments.
+ */
+
+export type Fund = 'SHIF' | 'UHC' | 'ECCIF';
+export type AccessPoint = 'OP' | 'IP';
+export type PaymentMechanism = 'FEE_FOR_SERVICE' | 'PER_DIEM' | 'CAPITATION';
+
+export interface EligibilityScheme {
+  schemeName: string;
+  active: boolean;
+}
+
+export interface EligibilityResult {
+  fullName: string;
+  crNumber: string;
+  schemes: EligibilityScheme[];
+}
+
+export interface Intervention {
+  code: string;
+  name: string;
+  subBenefit: string;
+  fund: Fund;
+  accessPoint: AccessPoint;
+  paymentMechanism: PaymentMechanism;
+  needsPreauth: boolean;
+  needsManualPreauthApproval: boolean; // true = elective
+  tariff: number;
+}
+
+const wait = (ms: number) => new Promise<void>((resolve) => setTimeout(resolve, ms));
+
+/** GET /api/v1/patients/eligibility */
+export async function checkEligibility(crNumber: string): Promise<EligibilityResult> {
+  await wait(500);
+  return {
+    fullName: 'Christian Mkuru Gray',
+    crNumber: crNumber || 'CR4098636401452-9',
+    schemes: [
+      { schemeName: 'SHIF', active: true },
+      { schemeName: 'UHC (PHC)', active: true },
+    ],
+  };
+}
+
+/** GET /api/v1/patients/sub-benefits + /benefits/interventions (flattened for the demo). */
+export async function getEligibleInterventions(): Promise<Intervention[]> {
+  await wait(400);
+  return [
+    {
+      code: 'SHA-02-011',
+      name: 'General consultation',
+      subBenefit: 'Outpatient care',
+      fund: 'SHIF',
+      accessPoint: 'OP',
+      paymentMechanism: 'FEE_FOR_SERVICE',
+      needsPreauth: false,
+      needsManualPreauthApproval: false,
+      tariff: 1500,
+    },
+    {
+      code: 'SHA-05-104',
+      name: 'Chest X-ray',
+      subBenefit: 'Diagnostic imaging',
+      fund: 'SHIF',
+      accessPoint: 'OP',
+      paymentMechanism: 'FEE_FOR_SERVICE',
+      needsPreauth: true,
+      needsManualPreauthApproval: false, // normal preauth
+      tariff: 4000,
+    },
+    {
+      code: 'SHA-07-330',
+      name: 'Cataract surgery',
+      subBenefit: 'Surgical services',
+      fund: 'SHIF',
+      accessPoint: 'OP',
+      paymentMechanism: 'FEE_FOR_SERVICE',
+      needsPreauth: true,
+      needsManualPreauthApproval: true, // elective preauth
+      tariff: 45000,
+    },
+    {
+      code: 'SHA-01-002',
+      name: 'General ward admission',
+      subBenefit: 'Inpatient care',
+      fund: 'SHIF',
+      accessPoint: 'IP',
+      paymentMechanism: 'PER_DIEM',
+      needsPreauth: false,
+      needsManualPreauthApproval: false,
+      tariff: 3000,
+    },
+    {
+      code: 'UHC-OP-001',
+      name: 'Primary care visit',
+      subBenefit: 'Primary healthcare',
+      fund: 'UHC',
+      accessPoint: 'OP',
+      paymentMechanism: 'CAPITATION',
+      needsPreauth: false,
+      needsManualPreauthApproval: false,
+      tariff: 800,
+    },
+  ];
+}
+
+export interface EncounterDiagnosis {
+  uuid: string;
+  display: string;
+  icd11Code: string;
+  certainty: 'CONFIRMED' | 'PRESUMED';
+}
+
+/**
+ * Diagnoses recorded on the patient's OpenMRS encounter, coded to ICD-11.
+ * In production these come from the encounter/visit diagnosis response
+ * (e.g. ETL `/patient/diagnosis` → AmrsVisitDiagnosis.icd11_code, or the
+ * encounter's `diagnoses[]`). The claim's ICD-11 array is picked from here.
+ */
+export async function getEncounterDiagnoses(): Promise<EncounterDiagnosis[]> {
+  await wait(350);
+  return [
+    { uuid: 'dx-1', display: 'Essential (primary) hypertension', icd11Code: 'BA00', certainty: 'CONFIRMED' },
+    { uuid: 'dx-2', display: 'Type 2 diabetes mellitus', icd11Code: '5A11', certainty: 'CONFIRMED' },
+    { uuid: 'dx-3', display: 'Acute upper respiratory infection', icd11Code: 'CA07', certainty: 'PRESUMED' },
+  ];
+}
+
+export interface ScenarioInfo {
+  key: string;
+  title: string;
+  preauth: 'none' | 'normal' | 'elective' | 'doctor';
+  dispatch: 'submit' | 'discharge';
+  lineMode: 'auto' | 'manual';
+}
+
+/** Resolve the DHA scenario from an intervention's flags (the flag-driven router). */
+export function resolveScenario(iv: Intervention): ScenarioInfo {
+  if (iv.fund === 'UHC' && iv.paymentMechanism === 'CAPITATION') {
+    return { key: '6', title: 'UHC OP Capitation', preauth: 'none', dispatch: 'submit', lineMode: 'manual' };
+  }
+  const dispatch: ScenarioInfo['dispatch'] = iv.accessPoint === 'IP' ? 'discharge' : 'submit';
+  if (iv.paymentMechanism === 'PER_DIEM') {
+    return { key: '1', title: 'SHIF IP Per Diem', preauth: 'none', dispatch, lineMode: 'auto' };
+  }
+  if (!iv.needsPreauth) {
+    return {
+      key: iv.accessPoint === 'IP' ? '1' : '6',
+      title: `SHIF ${iv.accessPoint} · no preauth`,
+      preauth: 'none',
+      dispatch,
+      lineMode: 'manual',
+    };
+  }
+  if (iv.needsManualPreauthApproval) {
+    return {
+      key: iv.accessPoint === 'IP' ? '3' : '4',
+      title: `SHIF ${iv.accessPoint} FFS Elective Preauth`,
+      preauth: 'elective',
+      dispatch,
+      lineMode: 'manual',
+    };
+  }
+  return {
+    key: iv.accessPoint === 'IP' ? '2' : '5',
+    title: `SHIF ${iv.accessPoint} FFS Normal Preauth`,
+    preauth: 'normal',
+    dispatch,
+    lineMode: 'manual',
+  };
+}
+
+export interface CompatibilityResult {
+  ok: boolean;
+  reason?: string;
+  requiresSwitch?: boolean; // per-diem: replace the existing active per-diem instead of adding
+}
+
+/**
+ * SHA combination rules (subset, applied instantly as interventions are added):
+ *  - a claim carries a single fund/scheme — no mixing SHIF with UHC/ECCIF;
+ *  - no duplicate interventions;
+ *  - only ONE active per-diem intervention at a time — a second is a SWITCH
+ *    (e.g. General ward → ICU), not an add.
+ * Replace with the live combination-rules check when available.
+ */
+export function checkCompatibility(selected: Intervention[], candidate: Intervention): CompatibilityResult {
+  if (selected.some((i) => i.code === candidate.code)) {
+    return { ok: false, reason: 'This intervention is already on the claim.' };
+  }
+  if (selected.length > 0 && selected[0].fund !== candidate.fund) {
+    return {
+      ok: false,
+      reason: `A claim can't mix funds — ${candidate.fund} can't be added to a ${selected[0].fund} claim.`,
+    };
+  }
+  if (candidate.paymentMechanism === 'PER_DIEM' && selected.some((i) => i.paymentMechanism === 'PER_DIEM')) {
+    return {
+      ok: false,
+      requiresSwitch: true,
+      reason: 'Only one active per-diem is allowed at a time. Switch the current per-diem instead of adding a second.',
+    };
+  }
+  return { ok: true };
+}
+
+/** Human label for a payment mechanism. */
+export function mechanismLabel(m: PaymentMechanism): string {
+  switch (m) {
+    case 'PER_DIEM':
+      return 'Per diem';
+    case 'FEE_FOR_SERVICE':
+      return 'Fee for service';
+    case 'CAPITATION':
+      return 'Capitation';
+  }
+}
+
+/** POST /api/v1/claims/authorize (biometric) or /api/v1/claims/otp — returns a consent token. */
+export async function captureConsent(method: 'biometric' | 'otp'): Promise<{ consentToken: string; authGuid?: string }> {
+  await wait(600);
+  return {
+    consentToken: `ct_${method}_${Math.floor(Math.random() * 1e6)}`,
+    authGuid: method === 'biometric' ? `guid_${Math.floor(Math.random() * 1e6)}` : undefined,
+  };
+}
+
+/** POST /api/v1/preauths then poll GET /api/v1/preauths until FINALISED. */
+export async function raisePreauth(consentToken: string, interventionCode: string): Promise<{ status: 'FINALISED' }> {
+  await wait(900);
+  return { status: 'FINALISED' };
+}
+
+/** Where the copay (shortfall above the SHA tariff) is collected. */
+export const COPAY_PAYERS = ['Cash', 'AAR', 'Jubilee', 'Britam', 'Madison', 'CIC'];
+
+export interface ClaimPreview {
+  previewId: string;
+  generatedAt: string;
+  documentName: string;
+}
+
+/**
+ * POST /api/v1/claims/preview — generate the provider claim preview.
+ * This must be run before submit. For fee-for-service / per-diem the preview
+ * document is auto-attached as the supporting attachment; capitation needs none.
+ */
+export async function previewClaim(consentToken: string): Promise<ClaimPreview> {
+  await wait(700);
+  return {
+    previewId: `PRV-${Math.floor(Math.random() * 1e6)}`,
+    generatedAt: new Date().toISOString(),
+    documentName: 'provider-claim-preview.pdf',
+  };
+}
+
+export interface CopayReceipt {
+  receiptNo: string;
+  documentName: string;
+  amount: number;
+}
+
+/**
+ * Generate the cash copay receipt from billing so it can be attached to the
+ * claim as supporting evidence. In production this comes from the billing
+ * receipt generator once the copay payment is recorded at the cashier.
+ */
+export async function generateCopayReceipt(amount: number): Promise<CopayReceipt> {
+  await wait(400);
+  return {
+    receiptNo: `RCPT-${Math.floor(100000 + Math.random() * 900000)}`,
+    documentName: 'cash-copay-receipt.pdf',
+    amount,
+  };
+}

package/src/billing/dashboard/v2/claims-accounting/bill-utils.ts

@@ -0,0 +1,134 @@
+/**
+ * Bill ↔ claim helpers.
+ *
+ * A bill is the ledger (line items). A SHA claim is the SHA-payable slice of that
+ * bill; the remainder is the patient's copay (cash). Cash-only payers have no
+ * claim at all — every line is paid out of pocket, before the service.
+ */
+import { type ClaimLine, type ShaClaim } from './claims-accounting.resource';
+
+export type PaymentMode = 'SHA' | 'CASH' | 'INSURANCE';
+
+export interface BillLineSplit {
+  line: ClaimLine;
+  lineTotal: number;
+  /** Amount the fund (SHA) pays for this line — capped at the tariff. */
+  shaCovered: number;
+  /** Amount the patient pays for this line (copay / cash). */
+  copay: number;
+  /** Who settles the patient portion at the point of service. */
+  payer: 'SHA' | 'Cash';
+}
+
+export interface BillSplit {
+  totalCharge: number;
+  shaCovered: number;
+  copay: number;
+  lines: BillLineSplit[];
+  /** SHA-payable lines only — this is what the claim carries. */
+  claimLines: ClaimLine[];
+}
+
+/**
+ * Split a bill's line items into the SHA-payable slice and the copay/cash slice.
+ *
+ * - SHA pays each line up to its tariff; any excess over tariff is a copay.
+ * - Cash / out-of-pocket insurance: the whole line is paid by the patient (no SHA).
+ * - Fully covered by SHA is just the case where every line's charge ≤ tariff (copay 0).
+ */
+export function splitBillForSha(lines: ClaimLine[], mode: PaymentMode = 'SHA'): BillSplit {
+  const split: BillLineSplit[] = [];
+  const claimLines: ClaimLine[] = [];
+  let totalCharge = 0;
+  let shaCovered = 0;
+  let copay = 0;
+
+  for (const line of lines) {
+    const lineTotal = line.unitPrice * line.quantity;
+    totalCharge += lineTotal;
+
+    if (mode === 'SHA') {
+      const covered = Math.min(line.unitPrice, line.tariff) * line.quantity;
+      const excess = lineTotal - covered;
+      shaCovered += covered;
+      copay += excess;
+      if (covered > 0) {
+        claimLines.push({ ...line, unitPrice: Math.min(line.unitPrice, line.tariff) });
+      }
+      split.push({ line, lineTotal, shaCovered: covered, copay: excess, payer: excess > 0 ? 'Cash' : 'SHA' });
+    } else {
+      // Cash / insurance out-of-pocket — the patient pays the whole line before service.
+      copay += lineTotal;
+      split.push({ line, lineTotal, shaCovered: 0, copay: lineTotal, payer: 'Cash' });
+    }
+  }
+
+  return { totalCharge, shaCovered, copay, lines: split, claimLines };
+}
+
+export type ClaimDocumentType = 'INVOICE' | 'COPAY_RECEIPT' | 'REFERRAL' | 'LAB_REQUEST' | 'OTHER';
+
+export interface ClaimDocument {
+  id: string;
+  name: string;
+  type: ClaimDocumentType;
+  /** System-produced (e.g. the invoice) vs. uploaded by staff. */
+  autoGenerated: boolean;
+  /** Whether an in-app preview is available (the invoice is rendered from the bill). */
+  previewable: boolean;
+}
+
+/**
+ * The supporting documents attached to a claim on submission. The invoice is
+ * always present and auto-generated from the bill; a copay receipt is added when
+ * there is a copay; anything staff uploaded is appended.
+ */
+export function buildClaimDocuments(claim: ShaClaim): ClaimDocument[] {
+  const split = splitBillForSha(claim.lines);
+  const invoiceNo = claim.bill?.billNo ?? claim.claimCode.replace('CLM', 'INV');
+
+  const docs: ClaimDocument[] = [
+    {
+      id: `${claim.id}-invoice`,
+      name: `${invoiceNo}.pdf`,
+      type: 'INVOICE',
+      autoGenerated: true,
+      previewable: true,
+    },
+  ];
+
+  if (split.copay > 0) {
+    docs.push({
+      id: `${claim.id}-copay`,
+      name: `${invoiceNo}-copay-receipt.pdf`,
+      type: 'COPAY_RECEIPT',
+      autoGenerated: false,
+      previewable: false,
+    });
+  }
+
+  for (const name of claim.attachments ?? []) {
+    const type: ClaimDocumentType = /referral/i.test(name)
+      ? 'REFERRAL'
+      : /lab|request/i.test(name)
+        ? 'LAB_REQUEST'
+        : 'OTHER';
+    docs.push({ id: `${claim.id}-${name}`, name, type, autoGenerated: false, previewable: false });
+  }
+
+  return docs;
+}
+
+const DOC_TYPE_LABEL: Record<ClaimDocumentType, string> = {
+  INVOICE: 'System invoice',
+  COPAY_RECEIPT: 'Copay receipt',
+  REFERRAL: 'Referral letter',
+  LAB_REQUEST: 'Lab request',
+  OTHER: 'Attachment',
+};
+
+export function claimDocumentLabel(type: ClaimDocumentType): string {
+  return DOC_TYPE_LABEL[type];
+}
+
+export const money = (n: number) => `KES ${n.toLocaleString('en-KE')}`;