stellar413/AI_adjudication

1import datetime2from sqlalchemy import Column, String, Integer, Float, Date, DateTime, Boolean, ForeignKey, JSON, Text3from sqlalchemy.orm import relationship4from backend.database.database import Base5 6class Member(Base):7    __tablename__ = "members"8 9    id = Column(String, primary_key=True, index=True) # e.g. EMP00110    name = Column(String, nullable=False)11    policy_number = Column(String, nullable=False, default="PLUM_OPD_2024")12    join_date = Column(Date, nullable=False)13    annual_limit_remaining = Column(Float, nullable=False, default=50000.0)14    status = Column(String, nullable=False, default="ACTIVE") # ACTIVE, INACTIVE15 16    claims = relationship("Claim", back_populates="member")17 18class Claim(Base):19    __tablename__ = "claims"20 21    id = Column(String, primary_key=True, index=True) # e.g. CLM_1234522    member_id = Column(String, ForeignKey("members.id"), nullable=False)23    patient_name = Column(String, nullable=False)24    claim_amount = Column(Float, nullable=False)25    status = Column(String, nullable=False, default="PENDING") # PENDING, PROCESSING, APPROVED, REJECTED, PARTIAL, MANUAL_REVIEW, APPEALED26    hospital_name = Column(String, nullable=True)27    cashless_request = Column(Boolean, nullable=False, default=False)28    treatment_date = Column(Date, nullable=False)29    submitted_at = Column(DateTime, nullable=False, default=datetime.datetime.utcnow)30    updated_at = Column(DateTime, nullable=False, default=datetime.datetime.utcnow, onupdate=datetime.datetime.utcnow)31 32    member = relationship("Member", back_populates="claims")33    documents = relationship("ClaimDocument", back_populates="claim", cascade="all, delete-orphan")34    adjudication_result = relationship("AdjudicationResult", back_populates="claim", uselist=False, cascade="all, delete-orphan")35    audit_logs = relationship("AuditLog", back_populates="claim", cascade="all, delete-orphan")36 37class ClaimDocument(Base):38    __tablename__ = "claim_documents"39 40    id = Column(Integer, primary_key=True, autoincrement=True)41    claim_id = Column(String, ForeignKey("claims.id"), nullable=False)42    document_type = Column(String, nullable=False) # PRESCRIPTION, BILL, LAB_REPORT, OTHER43    file_path = Column(String, nullable=False)44    file_name = Column(String, nullable=False)45    file_size = Column(Integer, nullable=False)46    extracted_data = Column(JSON, nullable=True) # JSON of parsed fields47    raw_llm_response = Column(Text, nullable=True) # raw model output48 49    claim = relationship("Claim", back_populates="documents")50 51class AdjudicationResult(Base):52    __tablename__ = "adjudication_results"53 54    id = Column(Integer, primary_key=True, autoincrement=True)55    claim_id = Column(String, ForeignKey("claims.id"), unique=True, nullable=False)56    decision = Column(String, nullable=False) # APPROVED, REJECTED, PARTIAL, MANUAL_REVIEW57    approved_amount = Column(Float, nullable=False, default=0.0)58    confidence_score = Column(Float, nullable=False, default=0.0)59    reasons = Column(JSON, nullable=False, default=list) # List[str]60    flags = Column(JSON, nullable=False, default=list) # List[str]61    notes = Column(Text, nullable=True)62    next_steps = Column(Text, nullable=True)63    policy_engine_log = Column(JSON, nullable=True) # details of check results64    created_at = Column(DateTime, nullable=False, default=datetime.datetime.utcnow)65 66    claim = relationship("Claim", back_populates="adjudication_result")67 68class AuditLog(Base):69    __tablename__ = "audit_logs"70 71    id = Column(Integer, primary_key=True, autoincrement=True)72    claim_id = Column(String, ForeignKey("claims.id"), nullable=False)73    action = Column(String, nullable=False) # e.g. "CLAIM_SUBMITTED", "OCR_EXTRACTED", "POLICY_VAL_SUCCESS"74    timestamp = Column(DateTime, nullable=False, default=datetime.datetime.utcnow)75    details = Column(Text, nullable=True)76 77    claim = relationship("Claim", back_populates="audit_logs")78