stellar413/AI_adjudication

1{2  "test_cases": [3    {4      "case_id": "TC001",5      "case_name": "Simple Consultation - Approved",6      "description": "Regular doctor consultation for fever, all documents valid",7      "input_data": {8        "member_id": "EMP001",9        "member_name": "Rajesh Kumar",10        "treatment_date": "2024-11-01",11        "claim_amount": 1500,12        "documents": {13          "prescription": {14            "doctor_name": "Dr. Sharma",15            "doctor_reg": "KA/45678/2015",16            "diagnosis": "Viral fever",17            "medicines_prescribed": ["Paracetamol 650mg", "Vitamin C"]18          },19          "bill": {20            "consultation_fee": 1000,21            "diagnostic_tests": 500,22            "test_names": ["CBC", "Dengue test"]23          }24        }25      },26      "expected_output": {27        "decision": "APPROVED",28        "approved_amount": 1350,29        "deductions": {30          "copay": 15031        },32        "confidence_score": 0.9533      }34    },35    {36      "case_id": "TC002",37      "case_name": "Dental Treatment - Partial Approval",38      "description": "Root canal treatment with cosmetic whitening",39      "input_data": {40        "member_id": "EMP002",41        "member_name": "Priya Singh",42        "treatment_date": "2024-10-15",43        "claim_amount": 12000,44        "documents": {45          "prescription": {46            "doctor_name": "Dr. Patel",47            "doctor_reg": "MH/23456/2018",48            "diagnosis": "Tooth decay requiring root canal",49            "procedures": ["Root canal treatment", "Teeth whitening"]50          },51          "bill": {52            "root_canal": 8000,53            "teeth_whitening": 400054          }55        }56      },57      "expected_output": {58        "decision": "PARTIAL",59        "approved_amount": 8000,60        "rejected_items": ["Teeth whitening - cosmetic procedure"],61        "confidence_score": 0.9262      }63    },64    {65      "case_id": "TC003",66      "case_name": "Limit Exceeded - Rejected",67      "description": "Claim exceeds per-claim limit",68      "input_data": {69        "member_id": "EMP003",70        "member_name": "Amit Verma",71        "treatment_date": "2024-10-20",72        "claim_amount": 7500,73        "documents": {74          "prescription": {75            "doctor_name": "Dr. Gupta",76            "doctor_reg": "DL/34567/2016",77            "diagnosis": "Gastroenteritis",78            "medicines_prescribed": ["Antibiotics", "Probiotics"]79          },80          "bill": {81            "consultation_fee": 2000,82            "medicines": 550083          }84        }85      },86      "expected_output": {87        "decision": "REJECTED",88        "rejection_reasons": ["PER_CLAIM_EXCEEDED"],89        "notes": "Claim amount exceeds per-claim limit of ₹5000",90        "confidence_score": 0.9891      }92    },93    {94      "case_id": "TC004",95      "case_name": "Missing Documents - Rejected",96      "description": "Prescription missing from claim submission",97      "input_data": {98        "member_id": "EMP004",99        "member_name": "Sneha Reddy",100        "treatment_date": "2024-10-25",101        "claim_amount": 2000,102        "documents": {103          "bill": {104            "consultation_fee": 1500,105            "medicines": 500106          }107        }108      },109      "expected_output": {110        "decision": "REJECTED",111        "rejection_reasons": ["MISSING_DOCUMENTS"],112        "notes": "Prescription from registered doctor is required",113        "confidence_score": 1.0114      }115    },116    {117      "case_id": "TC005",118      "case_name": "Pre-existing Condition - Waiting Period",119      "description": "Diabetes treatment within waiting period",120      "input_data": {121        "member_id": "EMP005",122        "member_name": "Vikram Joshi",123        "member_join_date": "2024-09-01",124        "treatment_date": "2024-10-15",125        "claim_amount": 3000,126        "documents": {127          "prescription": {128            "doctor_name": "Dr. Mehta",129            "doctor_reg": "GJ/56789/2014",130            "diagnosis": "Type 2 Diabetes",131            "medicines_prescribed": ["Metformin", "Glimepiride"]132          },133          "bill": {134            "consultation_fee": 1000,135            "medicines": 2000136          }137        }138      },139      "expected_output": {140        "decision": "REJECTED",141        "rejection_reasons": ["WAITING_PERIOD"],142        "notes": "Diabetes has 90-day waiting period. Eligible from 2024-11-30",143        "confidence_score": 0.96144      }145    },146    {147      "case_id": "TC006",148      "case_name": "Alternative Medicine - Approved",149      "description": "Ayurvedic treatment within limits",150      "input_data": {151        "member_id": "EMP006",152        "member_name": "Kavita Nair",153        "treatment_date": "2024-10-28",154        "claim_amount": 4000,155        "documents": {156          "prescription": {157            "doctor_name": "Vaidya Krishnan",158            "doctor_reg": "AYUR/KL/2345/2019",159            "diagnosis": "Chronic joint pain",160            "treatment": "Panchakarma therapy"161          },162          "bill": {163            "consultation_fee": 1000,164            "therapy_charges": 3000165          }166        }167      },168      "expected_output": {169        "decision": "APPROVED",170        "approved_amount": 4000,171        "notes": "Alternative medicine covered under policy",172        "confidence_score": 0.89173      }174    },175    {176      "case_id": "TC007",177      "case_name": "Diagnostic Tests - Pre-auth Required",178      "description": "MRI scan without pre-authorization",179      "input_data": {180        "member_id": "EMP007",181        "member_name": "Suresh Patil",182        "treatment_date": "2024-11-02",183        "claim_amount": 15000,184        "documents": {185          "prescription": {186            "doctor_name": "Dr. Rao",187            "doctor_reg": "AP/67890/2017",188            "diagnosis": "Suspected lumbar disc herniation",189            "tests_prescribed": ["MRI Lumbar Spine"]190          },191          "bill": {192            "mri_scan": 15000193          }194        }195      },196      "expected_output": {197        "decision": "REJECTED",198        "rejection_reasons": ["PRE_AUTH_MISSING"],199        "notes": "MRI requires pre-authorization for claims above ₹10000",200        "confidence_score": 0.94201      }202    },203    {204      "case_id": "TC008",205      "case_name": "Fraud Detection - Manual Review",206      "description": "Multiple high-value claims same day",207      "input_data": {208        "member_id": "EMP008",209        "member_name": "Ravi Menon",210        "treatment_date": "2024-10-30",211        "claim_amount": 4800,212        "previous_claims_same_day": 3,213        "documents": {214          "prescription": {215            "doctor_name": "Dr. Khan",216            "doctor_reg": "UP/45678/2016",217            "diagnosis": "Migraine",218            "medicines_prescribed": ["Sumatriptan", "Propranolol"]219          },220          "bill": {221            "consultation_fee": 2000,222            "medicines": 2800223          }224        }225      },226      "expected_output": {227        "decision": "MANUAL_REVIEW",228        "flags": ["Multiple claims same day", "Unusual pattern detected"],229        "confidence_score": 0.65230      }231    },232    {233      "case_id": "TC009",234      "case_name": "Excluded Treatment - Rejected",235      "description": "Weight loss treatment not covered",236      "input_data": {237        "member_id": "EMP009",238        "member_name": "Anita Desai",239        "treatment_date": "2024-10-18",240        "claim_amount": 8000,241        "documents": {242          "prescription": {243            "doctor_name": "Dr. Banerjee",244            "doctor_reg": "WB/34567/2015",245            "diagnosis": "Obesity - BMI 35",246            "treatment": "Bariatric consultation and diet plan"247          },248          "bill": {249            "consultation_fee": 3000,250            "diet_plan": 5000251          }252        }253      },254      "expected_output": {255        "decision": "REJECTED",256        "rejection_reasons": ["SERVICE_NOT_COVERED"],257        "notes": "Weight loss treatments are excluded from coverage",258        "confidence_score": 0.97259      }260    },261    {262      "case_id": "TC010",263      "case_name": "Network Hospital - Cashless Approved",264      "description": "Treatment at network hospital with instant approval",265      "input_data": {266        "member_id": "EMP010",267        "member_name": "Deepak Shah",268        "treatment_date": "2024-11-03",269        "claim_amount": 4500,270        "hospital": "Apollo Hospitals",271        "cashless_request": true,272        "documents": {273          "prescription": {274            "doctor_name": "Dr. Iyer",275            "doctor_reg": "TN/56789/2013",276            "diagnosis": "Acute bronchitis",277            "medicines_prescribed": ["Antibiotics", "Bronchodilators"]278          },279          "bill": {280            "consultation_fee": 1500,281            "medicines": 3000282          }283        }284      },285      "expected_output": {286        "decision": "APPROVED",287        "approved_amount": 3600,288        "cashless_approved": true,289        "network_discount": 900,290        "confidence_score": 0.93291      }292    }293  ],294  "validation_notes": {295    "scoring_guidelines": [296      "Each test case should complete within 5 seconds",297      "Confidence scores should be provided for all decisions",298      "System should handle edge cases gracefully",299      "Clear reasoning should be provided for rejections"300    ],301    "bonus_test_scenarios": [302      "Handle illegible/blurry document images",303      "Process handwritten prescriptions",304      "Detect forged/modified documents",305      "Handle claims in regional languages",306      "Process multiple receipts in single claim"307    ]308  }309}