Medplum

// SPDX-FileCopyrightText: Copyright Orangebot, Inc. and Medplum contributors // SPDX-License-Identifier: Apache-2.0 import { CPT } from '@medplum/core'; import type { ChargeItem, Claim, Coverage } from '@medplum/fhirtypes'; import { MockClient } from '@medplum/mock'; import { describe, expect, test, beforeEach, vi, afterEach } from 'vitest'; import * as coverageModule from './coverage'; import { createClaimFromEncounter, getCptChargeItems } from './claims'; describe('claims utils', () => { let medplum: MockClient; beforeEach(() => { medplum = new MockClient(); }); afterEach(() => { vi.restoreAllMocks(); }); describe('getCptChargeItems', () => { test('filters charge items to CPT codings and preserves modifiers', () => { const cptItem: ChargeItem = { resourceType: 'ChargeItem', id: 'charge-1', code: { text: 'Test CPT', coding: [ { system: CPT, code: '1234' }, { system: 'http://example.com', code: 'other' }, ], }, priceOverride: { value: 42 }, extension: [ { url: 'http://hl7.org/fhir/StructureDefinition/chargeitem-modifier', valueCodeableConcept: { coding: [{ code: '59' }] }, }, ], status: 'billable', subject: { reference: 'Patient/patient-1' }, }; const nonCptItem: ChargeItem = { resourceType: 'ChargeItem', id: 'charge-2', code: { coding: [{ system: 'http://example.com', code: 'not-cpt' }] }, status: 'billable', subject: { reference: 'Patient/patient-1' }, }; const items = getCptChargeItems([cptItem, nonCptItem], { reference: 'Encounter/enc-1' }); expect(items).toHaveLength(1); expect(items[0]).toEqual( expect.objectContaining({ sequence: 1, encounter: [{ reference: 'Encounter/enc-1' }], productOrService: expect.objectContaining({ coding: [{ system: CPT, code: '1234' }], text: 'Test CPT', }), modifier: [{ coding: [{ code: '59' }] }], net: { value: 42 }, }) ); }); }); describe('createClaimFromEncounter', () => { const chargeItems: ChargeItem[] = [ { resourceType: 'ChargeItem', id: 'charge-1', code: { coding: [{ system: CPT, code: '1111' }], text: 'Visit' }, priceOverride: { value: 25 }, status: 'billable', subject: { reference: 'Patient/patient-1' }, }, ]; test('creates claim using existing coverage', async () => { const coverage: Coverage = { resourceType: 'Coverage', id: 'coverage-1', status: 'active', beneficiary: { reference: 'Patient/patient-1' }, payor: [{ reference: 'Organization/organization-1' }], }; const claim: Claim = { resourceType: 'Claim', id: 'claim-1', status: 'draft', type: { coding: [{ code: 'professional' }] }, use: 'claim', created: new Date().toISOString(), patient: { reference: 'Patient/patient-1' }, provider: { reference: 'Practitioner/practitioner-1' }, priority: { coding: [{ code: 'normal' }] }, insurance: [{ sequence: 1, focal: true, coverage: { reference: 'Coverage/coverage-1' } }], item: [ { sequence: 1, encounter: [{ reference: 'Encounter/encounter-1' }], productOrService: { coding: [{ system: CPT, code: '1111' }], text: 'Visit' }, net: { value: 25 }, }, ], total: { value: 25 }, }; vi.spyOn(medplum, 'searchResources').mockResolvedValue([coverage] as any); const createSpy = vi.spyOn(medplum, 'createResource').mockResolvedValue(claim as any); const result = await createClaimFromEncounter( medplum as any, 'patient-1', 'encounter-1', 'practitioner-1', chargeItems ); expect(createSpy).toHaveBeenCalledWith( expect.objectContaining({ insurance: [ expect.objectContaining({ coverage: { reference: 'Coverage/coverage-1' }, }), ], patient: { reference: 'Patient/patient-1' }, provider: expect.objectContaining({ reference: 'Practitioner/practitioner-1' }), total: { value: 25 }, }) ); expect(result).toBe(claim); }); test('creates self-pay coverage when no coverage exists', async () => { vi.spyOn(medplum, 'searchResources').mockResolvedValue([] as any); const createdCoverage: Coverage = { resourceType: 'Coverage', id: 'coverage-self', status: 'active', beneficiary: { reference: 'Patient/patient-1' }, payor: [{ reference: 'Organization/organization-1' }], }; const coverageSpy = vi.spyOn(coverageModule, 'createSelfPayCoverage').mockResolvedValue(createdCoverage); vi.spyOn(medplum, 'createResource').mockResolvedValue({ resourceType: 'Claim' } as any); await createClaimFromEncounter(medplum as any, 'patient-1', 'enc-1', 'prac-1', chargeItems); expect(coverageSpy).toHaveBeenCalledWith(medplum, 'patient-1'); }); }); });