Class: Formulary::PayerInsurancePlanFactory

Inherits:
Object
  • Object
show all
Defined in:
lib/formulary/payer_insurance_plan_factory.rb

Overview

Class to build PayerInsurancePlan resources from a QHPPlan

Instance Attribute Summary collapse

Instance Method Summary collapse

Constructor Details

#initialize(plan) ⇒ PayerInsurancePlanFactory

Returns a new instance of PayerInsurancePlanFactory.



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 11

def initialize(plan)
  @plan = plan
end

Instance Attribute Details

#plan ⇒ Object (readonly)

Returns the value of attribute plan.



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 9

def plan
  @plan
end

Instance Method Details

#benefit_tier(tier, pharmacy_type) ⇒ Object (private)

Benefit per tier in a given pharmacy type



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 362

def benefit_tier(tier, pharmacy_type)
  current_cost = nil
  tier.cost_sharing.each do |cost|
    if cost.pharmacy_type != pharmacy_type
      current_cost = cost
    end
  end

  benefit_tier_cost(tier, current_cost)
end

#benefit_tier_cost(tier, cost) ⇒ Object (private)

Cost sharing benefit of a given tier



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 374

def benefit_tier_cost(tier, cost)
  return if tier.nil? || cost.nil?

  {
    type: specific_cost_category(tier.name),
    cost: [
      copay_cost(cost),
      coinsurance_cost(cost),
    ],
  }
end

#benefits(pharmacy_type) ⇒ Object (private)

Returns cost benefits [Array] per tier and pharmacy_type.

Returns:

  • cost benefits [Array] per tier and pharmacy_type



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 357

def benefits(pharmacy_type)
  plan.tiers.map { |tier| benefit_tier(QHPDrugTier.new(tier), pharmacy_type) }
end

#build ⇒ Object 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 15

def build
  name.strip!

  FHIR::InsurancePlan.new(
    id: PAYER_PLAN_ID_PREFIX + plan.id,
    meta: meta,
    text: text,
    identifier: identifier,
    status: "active",
    name: name,
    type: type,
    period: period,
    coverageArea: coverageArea,
    contact: contact,
    coverage: coverage,
    plan: plans,
  )
end

#coinsurance_cost(cost) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 416

def coinsurance_cost(cost)
  return if cost.nil?
  {
    type: cost_type("coinsurance"),
    qualifiers: coinsurance_option(cost.coinsurance_option),
    value: {
      value: cost.coinsurance_rate * 100,
      system: UCUM_SYSTEM,
      code: "%",

    },
  }
end

#coinsurance_option(option) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 454

def coinsurance_option(option)
  return if option.nil?
  {
    coding: [
      {
        system: COST_SHARE_SYSTEM,
        code: option.downcase,
        display: COST_SHARE_OPTION_DISPLAY[option.downcase],
      },
    ],
  }
end

#contact ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 111

def contact
  contact_list = [
    marketing_contact,
    summary_contact,
    formulary_contact,
    email_contact,
  ].compact

  return contact_list if !contact_list.empty?
end

#copay_cost(cost) ⇒ Object (private)

Returns copay details.

Returns:

  • copay details



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 402

def copay_cost(cost)
  return if cost.nil?
  {
    type: cost_type("copay"),
    qualifiers: copay_option(cost.copay_option),
    value: {
      value: cost.copay_amount,
      unit: "$",
      system: COPAY_AMOUNT_SYSTEM,
      code: COPAY_AMOUNT_CODE,
    },
  }
end

#copay_option(option) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 441

def copay_option(option)
  return if option.nil?
  {
    coding: [
      {
        system: COST_SHARE_SYSTEM,
        code: option.downcase,
        display: COST_SHARE_OPTION_DISPLAY[option.downcase],
      },
    ],
  }
end

#cost_type(value) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 430

def cost_type(value)
  {
    coding: [
      {
        system: BENEFIT_COST_TYPE_SYSTEM,
        code: value,
      },
    ],
  }
end

#coverage ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 233

def coverage
  [
    {
      extension: extension,
      type: coverage_type,
      benefit: [
        {
          type: {
            coding: [
              {
                system: PLAN_TYPE_SYSTEM,
                code: "drug",
              },
            ],
          },
        },
      ],
    },
  ]
end

#coverage_type ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 254

def coverage_type
  {
    coding: [
      {
        system: FORMULARY_TYPE_SYSTEM,
        code: FORMULARY_TYPE_CS_CODE,
        display: FORMULARY_TYPE_CS_DISPLAY,
      },
    ],
  }
end

#coverageArea ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 102

def coverageArea
  choice = ["Location/StateOfCTLocation", "Location/UnitedStatesLocation"]
  [
    {
      "reference": choice.sample,
    },
  ]
end

#email_contact ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 209

def email_contact
  value = plan.email_contact
  return if value.nil?

  {

    purpose: {
      coding: [
        {
          system: CONTACT_ENTITY_SYSTEM,
          code: CONTACT_PATINF_CODE,
          display: CONTACT_PATINF_DISPLAY,
        },
      ],
    },
    telecom: [
      {
        system: "email",
        value: value,
      },
    ],
  }
end

#extension ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 266

def extension
  [
    formulary_extension,
  ].flatten.compact
end

#formulary_contact ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 180

def formulary_contact
  value = plan.formulary_url
  return if value.nil?

  {

    purpose: {
      coding: [
        {
          system: CONTACT_ENTITY_SYSTEM,
          code: CONTACT_PATINF_CODE,
          display: CONTACT_PATINF_DISPLAY,
        },
        {
          system: PLAN_CONTACT_TYPE_CS,
          code: CONTACT_FORMULARY_CODE,
          display: CONTACT_FORMULARY_DISPLAY,
        },
      ],
    },
    telecom: [
      {
        system: "url",
        value: value,
      },
    ],
  }
end

#formulary_extension ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 272

def formulary_extension
  {
    url: FORMULARY_REFERENCE_EXTENSION,
    valueReference: {
      reference: "InsurancePlan/" + FORMULARY_ID_PREFIX + plan.id,
      type: "InsurancePlan",
    },
  }
end

#identifier ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 50

def identifier
  # TODO: Is this really an identifier?
  [{ value: PAYER_PLAN_ID_PREFIX + plan.id }]
end

#marketing_contact ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 122

def marketing_contact
  value = plan.marketing_url
  return if value.nil?

  {

    purpose: {
      coding: [
        {
          system: CONTACT_ENTITY_SYSTEM,
          code: CONTACT_PATINF_CODE,
          display: CONTACT_PATINF_DISPLAY,
        },
        {
          system: PLAN_CONTACT_TYPE_CS,
          code: CONTACT_MARKETING_CODE,
          display: CONTACT_MARKETING_DISPLAY,
        },
      ],
    },
    telecom: [
      {
        system: "url",
        value: value,
      },
    ],
  }
end

#meta ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 36

def meta
  {
    profile: [PAYER_INSURANCE_PLAN_PROFILE],
    lastUpdated: plan.last_updated + "T00:00:00Z",
  }
end

#name ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 55

def name
  names = plan.marketing_name.split(/\W+/)
  "#{names[0]} #{names[1]}"
end

#network_reference(value) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 312

def network_reference(value)
  return if value.nil?

  {
    display: value,
  }
end

#networks ⇒ Object (private)

Returns a list of networks [Array] or nil if no networks.

Returns:

  • a list of networks [Array] or nil if no networks



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 305

def networks
  networks = plan.network
  return if networks.nil? || networks.empty?

  networks.map { |network| network_reference(network) }
end

#period ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 94

def period
  current_year = Date.today.year
  {
    "start": "#{current_year}-01-01",
    "end": "#{current_year}-12-31",
  }
end

#pharmacy_network_type(pharmacy_type) ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 344

def pharmacy_network_type(pharmacy_type)
  {
    coding: [
      {
        system: PHARMACY_TYPE_SYSTEM,
        code: pharmacy_type,
        display: PHARMACY_TYPE_DISPLAY[pharmacy_type],
      },
    ],
  }
end

#plan_type ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 292

def plan_type
  {
    coding: [
      {
        system: PLAN_TYPE_SYSTEM,
        code: PLAN_TYPE_CODE,
        display: PLAN_TYPE_DISPLAY,
      },
    ],
  }
end

#plans ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 282

def plans
  [
    {
      type: plan_type,
      network: networks,
      specificCost: specific_costs,
    },
  ]
end

#specific_cost(pharmacy_type) ⇒ Object (private)

Constructs a specific drug cost per pharmacy type



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 337

def specific_cost(pharmacy_type)
  {
    category: pharmacy_network_type(pharmacy_type),
    benefit: benefits(pharmacy_type),
  }
end

#specific_cost_category(value) ⇒ Object (private)

Returns the tier category details.

Returns:

  • the tier category details



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 387

def specific_cost_category(value)
  return if value.nil?

  {
    coding: [
      {
        system: DRUG_TIER_SYSTEM,
        code: value.downcase,
        display: DRUG_TIER_DISPLAY[value.downcase],
      },
    ],
  }
end

#specific_costs ⇒ Object (private)

Constructs the list of cost sharing info per pharmacy type.



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 321

def specific_costs
  pharmacy_list = Array.new
  # Put all pharmacy types into an array
  plan.tiers.each do |tier|
    qhp_drug = QHPDrugTier.new(tier)
    qhp_drug.cost_sharing.each do |cost_sharing|
      if (!pharmacy_list.include?(cost_sharing.pharmacy_type))
        pharmacy_list.push(cost_sharing.pharmacy_type)
      end
    end
  end

  pharmacy_list.map { |pharmacy_type| specific_cost(pharmacy_type) }
end

#summary_contact ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 151

def summary_contact
  value = plan.summary_url
  return if value.nil?

  {

    purpose: {
      coding: [
        {
          system: CONTACT_ENTITY_SYSTEM,
          code: CONTACT_PATINF_CODE,
          display: CONTACT_PATINF_DISPLAY,
        },
        {
          system: PLAN_CONTACT_TYPE_CS,
          code: CONTACT_SUMMARY_CODE,
          display: CONTACT_SUMMARY_DISPLAY,
        },
      ],
    },
    telecom: [
      {
        system: "url",
        value: value,
      },
    ],
  }
end

#text ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 43

def text
  {
    status: "generated",
    div: %(<div xmlns="http://www.w3.org/1999/xhtml">#{name}</div>),
  }
end

#type ⇒ Object (private) 



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 60

def type
  {
    coding: [
      {
        system: INSURANCE_PRODUCT_TYPE_SYSTEM,
        code: type_code,
        display: type_display,
      },
    ],
  }
end

#type_code ⇒ Object (private)

Loosely mapping to provide examples of different types



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 73

def type_code
  if plan.marketing_name.include? " PPO "
    return "commppo"
  elsif plan.marketing_name.include? " HMO "
    return "commhmo"
  else
    return "mediadv"
  end
end

#type_display ⇒ Object (private)

Loosely mapping to provide examples of different types



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# File 'lib/formulary/payer_insurance_plan_factory.rb', line 84

def type_display
  if plan.marketing_name.include? " PPO "
    return "Commercial PPO"
  elsif plan.marketing_name.include? " HMO "
    return "Commercial HMO"
  else
    return "Medicare Advantage"
  end
end