crd

type Action struct {
	Type        string         `json:"type"`
	Description string         `json:"description,omitempty"`
	Resource    map[string]any `json:"resource"`
	// contains filtered or unexported fields
}

type Advice struct {
	Decides     bool       `json:"decides"`
	PolicyTitle string     `json:"policyTitle,omitempty"`
	Answer      string     `json:"answer,omitempty"` // approve, pend or deny
	Summary     string     `json:"summary,omitempty"`
	Missing     []string   `json:"missing,omitempty"`
	ToApprove   [][]string `json:"toApprove,omitempty"`
	// Questionnaire is the DTR questionnaire that asks for what is missing.
	Questionnaire string `json:"questionnaire,omitempty"`
}

type Card struct {
	UUID      string         `json:"uuid"`
	Summary   string         `json:"summary"`
	Detail    string         `json:"detail,omitempty"`
	Indicator string         `json:"indicator"`
	Source    map[string]any `json:"source"`
	Links     []Link         `json:"links,omitempty"`
	Extension map[string]any `json:"extension,omitempty"`
}

type Code struct {
	System  string `yaml:"system" json:"system"`
	Code    string `yaml:"code" json:"code"`
	Display string `yaml:"display,omitempty" json:"display,omitempty"`
}

type Contact struct {
	Name  string `yaml:"name,omitempty" json:"name,omitempty"`
	Phone string `yaml:"phone,omitempty" json:"phone,omitempty"`
	Email string `yaml:"email,omitempty" json:"email,omitempty"`
	URL   string `yaml:"url,omitempty" json:"url,omitempty"`
}

type Detail struct {
	// Code is from HL7's crd-coverage-detail code system: allowed-quantity, allowed-period, in-network-copay,
	// out-network-copay, concurrent-review, appropriate-use-needed, policy-link.
	Code string `yaml:"code" json:"code"`
	// Value is what the detail says, as text, or true/false.
	Value string `yaml:"value" json:"value"`
	// Qualification adds a condition on it.
	Qualification string `yaml:"qualification,omitempty" json:"qualification,omitempty"`
}

type Link struct {
	Label string `yaml:"label" json:"label"`
	URL   string `yaml:"url" json:"url"`
	Type  string `yaml:"type,omitempty" json:"type"`
}

type MemberCheck func(ctx context.Context, coverage, patient map[string]any, now time.Time) (Membership, string, error)

type Membership string

type PAAnswer struct {
	// Decision is "approve", "deny" or "pend".
	Decision string
	// Why is the rule's description, or empty when no rule names the service.
	Why string
	// AllowedQuantity is the rule's allowed-quantity detail, 0 when it has none: an approval asking for more is certified
	// for this many.
	AllowedQuantity float64
	// Questionnaire and Attachments say what a pended request must be supported with: the DTR questionnaire to fill in,
	// and the LOINC attachment codes of the documents to send.
	Questionnaire string
	Attachments   []string
	// AttachmentModifiers are LOINC attachment modifier codes for each attachment asked for.
	AttachmentModifiers []string
	// Alternative is the service approved instead, as a FHIR Coding; nil when there is none.
	Alternative map[string]any
}

type Request struct {
	Hook         string `json:"hook"`
	HookInstance string `json:"hookInstance"`
	FHIRServer   string `json:"fhirServer,omitempty"`
	// FHIRAuthorization is the token for reading the EHR's FHIR server when prefetch does not carry what is needed.
	FHIRAuthorization *struct {
		AccessToken string `json:"access_token"`
	} `json:"fhirAuthorization,omitempty"`
	Context  map[string]json.RawMessage `json:"context"`
	Prefetch map[string]json.RawMessage `json:"prefetch,omitempty"`
	// Extension carries davinci-crd.configuration (the client's choice of options) and davinci-crd.requestedVersion.
	Extension map[string]json.RawMessage `json:"extension,omitempty"`

	// ClientVersion is the Da Vinci release the calling EHR's registration names, set by the server that authenticated it;
	// never read from the request body.
	ClientVersion string `json:"-"`
}

type Response struct {
	Cards         []Card   `json:"cards"`
	SystemActions []Action `json:"systemActions,omitempty"`
}

type Rule struct {
	// Codes are the procedure, device or service codes it applies to: CPT, HCPCS, SNOMED.
	Codes []string `yaml:"codes" json:"codes"`
	// System, when set, limits the match to codings in that system.
	System string `yaml:"system,omitempty" json:"system,omitempty"`
	// Description names the policy, for the card a clinician reads.
	Description string `yaml:"description" json:"description"`
	// Covered is covered, not-covered or conditional.
	Covered string `yaml:"covered" json:"covered"`
	// PA is no-auth, auth-needed, satisfied, performpa or conditional.
	PA string `yaml:"pa,omitempty" json:"pa,omitempty"`
	// Documentation is what must be gathered: clinical, admin, patient, conditional.
	Documentation []string `yaml:"documentation,omitempty" json:"documentation,omitempty"`
	// Questionnaire is the canonical URL of the DTR questionnaire that gathers it.
	Questionnaire string `yaml:"questionnaire,omitempty" json:"questionnaire,omitempty"`
	// Reason is shown to the clinician.
	Reason string `yaml:"reason,omitempty" json:"reason,omitempty"`
	// Links are policy documents.
	Links []Link `yaml:"links,omitempty" json:"links,omitempty"`

	// DocPurpose says what the documentation is for: withclaim, withorder, retain-doc or OTH, and withpa only when the rules
	// file sets allow_withpa: CRD 2.2.1's invariant crd-ci-q4 fails every coverage-information carrying withpa.
	DocPurpose []string `yaml:"doc_purpose,omitempty" json:"docPurpose,omitempty"`
	// BillingCodes are the codes to bill this under, when they differ from the order's.
	BillingCodes []Code `yaml:"billing_codes,omitempty" json:"billingCodes,omitempty"`
	// Details are CRD's name-value details: limits (allowed-quantity, allowed-period), costs (in-network-copay), and so on.
	Details []Detail `yaml:"details,omitempty" json:"details,omitempty"`
	// Contact is who to ask at the payer about this assertion.
	Contact *Contact `yaml:"contact,omitempty" json:"contact,omitempty"`
	// ExpiryDays is how long the assertion holds, from the day it is made.
	ExpiryDays int `yaml:"expiry_days,omitempty" json:"expiryDays,omitempty"`
	// DependsOn are codes of other orders this answer depends on: when one is in the same request, it is named as a
	// dependency, so the EHR knows to ask again if that order changes.
	DependsOn []string `yaml:"depends_on,omitempty" json:"dependsOn,omitempty"`

	// PADecision is what a Da Vinci PAS $submit for this service is answered without a reviewer: approve, deny or pend.
	// Empty derives it from the coverage answer: not-covered is denied, no-auth and satisfied are approved, and anything
	// else is pended for a person to decide. A service no rule names is always pended.
	PADecision string `yaml:"pa_decision,omitempty" json:"paDecision,omitempty"`
	// PAAttachments are the LOINC attachment codes (the valid-hl7-attachment-requests value set) of the documents a pended
	// PAS request for this service must be supported with. The response asks for them.
	PAAttachments []string `yaml:"pa_attachments,omitempty" json:"paAttachments,omitempty"`
	// PAAttachmentModifiers are LOINC attachment modifier codes that narrow what is asked for (a time window, say), sent
	// with each attachment request as written.
	PAAttachmentModifiers []string `yaml:"pa_attachment_modifiers,omitempty" json:"paAttachmentModifiers,omitempty"`
	// PAAlternative is a service the payer approves instead of this one (an X-ray before an MRI): the request is answered
	// modified, with the alternative as an added item.
	PAAlternative *Code `yaml:"pa_alternative,omitempty" json:"paAlternative,omitempty"`
	// contains filtered or unexported fields
}

type Rules struct {
	// Payer names who is answering, on every card.
	Payer string `yaml:"payer" json:"payer"`
	// URL is the payer's site, on every card's source.
	URL   string `yaml:"url,omitempty" json:"url,omitempty"`
	Rules []Rule `yaml:"rules" json:"rules"`
	// Members says where the payer's own member records are, to resolve the coverage an EHR sends: "fhir" is this server's
	// FHIR store, the one $member-match reads. Empty: not checked, and only the Coverage's own status and period are read.
	Members string `yaml:"members,omitempty" json:"members,omitempty"`

	// DaVinciVersion is the CRD release (davinci.V21 or V22) answered when neither the request nor its client's registration
	// says; empty is the newest. Set by the server (-davinci-version), not by the rules file.
	DaVinciVersion string `yaml:"-" json:"-"`
	// AllowWithPA lets doc_purpose name withpa. CRD 2.2.1's invariant crd-ci-q4 is written so that every coverage-information
	// carrying withpa fails it, whatever pa-needed says; the guide's authors agree it is broken and a technical correction is
	// due. Until then the HL7 validator, and Inferno, reject such a response, so this is for a partner who checks against the
	// corrected guide. withpa is still refused beside a pa that says no authorization is needed, which is what crd-ci-q4 means.
	AllowWithPA bool `yaml:"allow_withpa,omitempty" json:"allowWithPA,omitempty"`

	// Check resolves the EHR's Coverage and Patient against the payer's records, when Members names them. Set by the server.
	Check MemberCheck `yaml:"-" json:"-"`
	// Authorized finds a prior authorization already approved for this patient and one of these codes, by its number, from
	// the payer's records. Set by the server with Members: fhir.
	Authorized func(ctx context.Context, coverage, patient map[string]any, codes []string, now time.Time) (string, error) `yaml:"-" json:"-"`
	// Client fetches what the EHR did not prefetch, from its fhirServer. Nil uses a client with a timeout.
	Client *http.Client `yaml:"-" json:"-"`
	// Advise, when set, asks a decision service what a prior authorization request for an order would be told as the
	// record stands (serve -crd-advisor-url): its answer is one more card. ok is false when the service gives no
	// advice, does not decide the service, or fails; the response is then exactly what it is without one.
	Advise func(ctx context.Context, system, code string, record []map[string]any) (advice *Advice, ok bool) `yaml:"-" json:"-"`
	// contains filtered or unexported fields
}