zen/test-data/graphs/insurance-prior-authorization.json

{
  "tests": [
    {
      "input": {
        "patientInfo": {
          "insuranceType": "Commercial"
        },
        "diagnosisCodes": [
          "M54.5",
          "M51.26"
        ],
        "serviceType": "Imaging",
        "serviceDetails": {
          "code": "70551",
          "cost": 1200,
          "isEmergency": false
        }
      },
      "output": {
        "reason": "Advanced imaging requires prior authorization",
        "requiresAuthorization": true,
        "timestamp": 1755622502
      }
    }
  ],
  "nodes": [
    {
      "type": "inputNode",
      "content": {
        "schema": "{\n  \"type\": \"object\",\n  \"properties\": {\n    \"patientInfo\": {\n      \"type\": \"object\",\n      \"properties\": {\n        \"insuranceType\": {\n          \"type\": \"string\",\n          \"enum\": [\"Medicaid\", \"Medicare\", \"Commercial\"]\n        }\n      }\n    },\n    \"diagnosisCodes\": {\n      \"type\": \"array\",\n      \"items\": {\n        \"type\": \"string\"\n      }\n    },\n    \"serviceType\": {\n      \"type\": \"string\",\n      \"enum\": [\"Medication\", \"Procedure\", \"Equipment\", \"Imaging\"]\n    },\n    \"serviceDetails\": {\n      \"type\": \"object\",\n      \"properties\": {\n        \"code\": {\n          \"type\": \"string\"\n        },\n        \"cost\": {\n          \"type\": \"number\"\n        },\n        \"isEmergency\": {\n          \"type\": \"boolean\"\n        }\n      }\n    }\n  }\n}"
      },
      "id": "inputNode",
      "name": "request",
      "position": {
        "x": 110,
        "y": 161.5
      }
    },
    {
      "type": "switchNode",
      "content": {
        "hitPolicy": "first",
        "statements": [
          {
            "id": "s1",
            "condition": "patientInfo.insuranceType == 'Medicaid'",
            "isDefault": false
          },
          {
            "id": "s2",
            "condition": "patientInfo.insuranceType == 'Medicare'",
            "isDefault": false
          },
          {
            "id": "s3",
            "condition": "patientInfo.insuranceType == 'Commercial'",
            "isDefault": false
          },
          {
            "id": "s4",
            "condition": "",
            "isDefault": true
          }
        ]
      },
      "id": "insuranceTypeCheck",
      "name": "Insurance Type Check",
      "position": {
        "x": 430,
        "y": 161.5
      }
    },
    {
      "type": "decisionTableNode",
      "content": {
        "hitPolicy": "first",
        "rules": [
          {
            "_id": "r1",
            "i1": "'Medication'",
            "i2": "> 200",
            "o1": "true",
            "o2": "'High-cost medication requires prior authorization'"
          },
          {
            "_id": "r2",
            "i1": "'Procedure'",
            "i2": "> 500",
            "o1": "true",
            "o2": "'High-cost procedure requires prior authorization'"
          },
          {
            "_id": "r3",
            "i1": "'Imaging'",
            "i2": "",
            "o1": "true",
            "o2": "'All imaging services require prior authorization'"
          },
          {
            "_id": "r4",
            "i1": "'Equipment'",
            "i2": "> 300",
            "o1": "true",
            "o2": "'DME over threshold requires prior authorization'"
          },
          {
            "_id": "r5",
            "i1": "",
            "i2": "",
            "o1": "false",
            "o2": "'Standard service does not require prior authorization'"
          }
        ],
        "inputs": [
          {
            "id": "i1",
            "name": "Service Type",
            "field": "serviceType"
          },
          {
            "id": "i2",
            "name": "Cost",
            "field": "serviceDetails.cost"
          }
        ],
        "outputs": [
          {
            "id": "o1",
            "name": "Requires Authorization",
            "field": "requiresAuthorization"
          },
          {
            "id": "o2",
            "name": "Reason",
            "field": "authorizationReason"
          }
        ],
        "passThrough": true,
        "inputField": null,
        "outputPath": null,
        "executionMode": "single"
      },
      "id": "medicaidRules",
      "name": "Medicaid Rules",
      "position": {
        "x": 750,
        "y": 63.5
      }
    },
    {
      "type": "decisionTableNode",
      "content": {
        "hitPolicy": "first",
        "rules": [
          {
            "_id": "r1",
            "i1": "'Medication'",
            "i2": "contains($, 'J')",
            "o1": "true",
            "o2": "'Part B medication requires prior authorization'"
          },
          {
            "_id": "r2",
            "i1": "'Procedure'",
            "i2": "number($) > 1000",
            "o1": "true",
            "o2": "'High-cost procedure requires prior authorization'"
          },
          {
            "_id": "r3",
            "i1": "'Imaging'",
            "i2": "startsWith($, 'CT') or startsWith($, 'MRI')",
            "o1": "true",
            "o2": "'Advanced imaging requires prior authorization'"
          },
          {
            "_id": "r4",
            "i1": "'Equipment'",
            "i2": "number($) > 500",
            "o1": "true",
            "o2": "'DME over threshold requires prior authorization'"
          },
          {
            "_id": "r5",
            "i1": "",
            "i2": "",
            "o1": "false",
            "o2": "'Standard Medicare service does not require prior authorization'"
          }
        ],
        "inputs": [
          {
            "id": "i1",
            "name": "Service Type",
            "field": "serviceType"
          },
          {
            "id": "i2",
            "name": "Code",
            "field": "serviceDetails.code"
          }
        ],
        "outputs": [
          {
            "id": "o1",
            "name": "Requires Authorization",
            "field": "requiresAuthorization"
          },
          {
            "id": "o2",
            "name": "Reason",
            "field": "authorizationReason"
          }
        ],
        "passThrough": true,
        "inputField": null,
        "outputPath": null,
        "executionMode": "single",
        "passThorough": false
      },
      "id": "medicareRules",
      "name": "Medicare Rules",
      "position": {
        "x": 750,
        "y": 161.5
      }
    },
    {
      "type": "decisionTableNode",
      "content": {
        "hitPolicy": "first",
        "rules": [
          {
            "_id": "r1",
            "i1": "'Medication'",
            "i2": "contains(serviceDetails.code, 'SPE')",
            "o1": "true",
            "o2": "'Specialty medication requires prior authorization'"
          },
          {
            "_id": "r2",
            "i1": "'Procedure'",
            "i2": "serviceDetails.code in ['33361', '33362', '33363', '33364']",
            "o1": "true",
            "o2": "'Specific procedures require prior authorization'"
          },
          {
            "_id": "r3",
            "i1": "'Imaging'",
            "i2": "serviceDetails.code in ['70450', '70460', '70470', '70551', '70552', '70553']",
            "o1": "true",
            "o2": "'Advanced imaging requires prior authorization'"
          },
          {
            "_id": "r4",
            "i1": "'Equipment'",
            "i2": "serviceDetails.cost > 1000",
            "o1": "true",
            "o2": "'High-cost equipment requires prior authorization'"
          },
          {
            "_id": "r5",
            "i1": "",
            "i2": "serviceDetails.isEmergency == true",
            "o1": "false",
            "o2": "'Emergency services do not require prior authorization'"
          },
          {
            "_id": "r6",
            "i1": "",
            "i2": "",
            "o1": "false",
            "o2": "'Standard commercial service does not require prior authorization'"
          }
        ],
        "inputs": [
          {
            "id": "i1",
            "name": "Service Type",
            "field": "serviceType"
          },
          {
            "id": "i2",
            "name": "Additional Check"
          }
        ],
        "outputs": [
          {
            "id": "o1",
            "name": "Requires Authorization",
            "field": "requiresAuthorization"
          },
          {
            "id": "o2",
            "name": "Reason",
            "field": "authorizationReason"
          }
        ],
        "passThrough": true,
        "inputField": null,
        "outputPath": null,
        "executionMode": "single"
      },
      "id": "commercialRules",
      "name": "Commercial Rules",
      "position": {
        "x": 750,
        "y": 259.5
      }
    },
    {
      "type": "decisionTableNode",
      "content": {
        "hitPolicy": "first",
        "rules": [
          {
            "_id": "r1",
            "i1": "some($, startsWith(#, 'Z51'))",
            "i2": "requiresAuthorization == true",
            "o1": "false",
            "o2": "'Encounter for chemotherapy exempt from prior authorization'"
          },
          {
            "_id": "r2",
            "i1": "some($, # in ['O09.511', 'O09.512', 'O09.513', 'O09.519'])",
            "i2": "requiresAuthorization == true",
            "o1": "false",
            "o2": "'Pregnancy-related services exempt from prior authorization'"
          },
          {
            "_id": "r3",
            "i1": "some($, # in ['U07.1'])",
            "i2": "requiresAuthorization == true and serviceType == 'Imaging'",
            "o1": "false",
            "o2": "'COVID-19 related imaging exempt from prior authorization'"
          },
          {
            "_id": "r4",
            "i1": "",
            "i2": "",
            "o1": "requiresAuthorization",
            "o2": "authorizationReason"
          }
        ],
        "inputs": [
          {
            "id": "i1",
            "name": "Diagnosis Codes",
            "field": "diagnosisCodes"
          },
          {
            "id": "i2",
            "name": "Current Authorization Status"
          }
        ],
        "outputs": [
          {
            "id": "o1",
            "name": "Final Authorization Required",
            "field": "requiresAuthorization"
          },
          {
            "id": "o2",
            "name": "Final Reason",
            "field": "authorizationReason"
          }
        ],
        "passThrough": true,
        "inputField": null,
        "outputPath": null,
        "executionMode": "single",
        "passThorough": false
      },
      "id": "diagnosisCheck",
      "name": "Diagnosis Code Exclusions",
      "position": {
        "x": 1070,
        "y": 161.5
      }
    },
    {
      "type": "expressionNode",
      "content": {
        "expressions": [
          {
            "id": "e1",
            "key": "requiresAuthorization",
            "value": "requiresAuthorization"
          },
          {
            "id": "e2",
            "key": "reason",
            "value": "authorizationReason"
          },
          {
            "id": "e3",
            "key": "timestamp",
            "value": "date('now')"
          }
        ],
        "passThrough": false,
        "inputField": null,
        "outputPath": null,
        "executionMode": "single"
      },
      "id": "finalDetermination",
      "name": "Final Determination",
      "position": {
        "x": 1390,
        "y": 161.5
      }
    }
  ],
  "edges": [
    {
      "id": "edge1",
      "sourceId": "inputNode",
      "targetId": "insuranceTypeCheck",
      "type": "edge"
    },
    {
      "id": "edge2",
      "sourceId": "insuranceTypeCheck",
      "targetId": "medicaidRules",
      "sourceHandle": "s1",
      "type": "edge"
    },
    {
      "id": "edge3",
      "sourceId": "insuranceTypeCheck",
      "targetId": "medicareRules",
      "sourceHandle": "s2",
      "type": "edge"
    },
    {
      "id": "edge4",
      "sourceId": "insuranceTypeCheck",
      "targetId": "commercialRules",
      "sourceHandle": "s3",
      "type": "edge"
    },
    {
      "id": "edge5",
      "sourceId": "medicaidRules",
      "targetId": "diagnosisCheck",
      "type": "edge"
    },
    {
      "id": "edge6",
      "sourceId": "medicareRules",
      "targetId": "diagnosisCheck",
      "type": "edge"
    },
    {
      "id": "edge7",
      "sourceId": "commercialRules",
      "targetId": "diagnosisCheck",
      "type": "edge"
    },
    {
      "id": "edge8",
      "sourceId": "diagnosisCheck",
      "targetId": "finalDetermination",
      "type": "edge"
    }
  ]
}