CodeX Insurance Analyst - Hospitalization Claim

CodeX Insurance Analyst

steve_squirrel
policy1234567821
claim21

Policies
	Policy	Insurer	Type	Insuree	Begin	End	Actions

Hospital Cash Claim

Not covered

Claim:
Claimant:
Date:

Hospitalization

Patient: Diagnosis:

Hospital: Physician:

Date Admitted:

Time Admitted:

Date Discharged:

Time Discharged:

Was hospitalization recommended by a practicing physician?

Accident

Activity:
Country:
Date:

Feedback

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% chubb_hospital_cash.hrf
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% recommendations
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

covers(Policy,C) :-
  policy.type(Policy,chubb_hospital_cash) &
  policy.insuree(Policy,I) &
  claim.patient(C,I) &
  policy_in_effect(Policy,C) &
  complete_day(C) &
  evaluate(countofall(E,exclusion(C,E)),0)

covers(Policy,C) :-
  policy.type(Policy,chubb_hospital_cash) &
  policy.insuree(Policy,I) &
  person.parent(P,I) &
  claim.patient(C,P) &
  policy_in_effect(Policy,C) &
  complete_day(C) &
  evaluate(countofall(E,exclusion(C,E)),0)

policy_in_effect(P,C) :-
  policy.startdate(P,PS) &
  policy.enddate(P,PE) &
  claim.startdate(C,CS) &
  claim.enddate(C,CE) &
  overlap(PS,PE,CS,CE)

partial_day(C) :-
  duration(C,DURATION) &
  leq(DURATION,86400000) &
  distinct(DURATION,86400000)

complete_day(C) :-
  duration(C,DURATION) &
  leq(86400000,DURATION)

duration(C,DURATION) :-
  claim.startdate(C,SD) &
  claim.starttime(C,ST) &
  claim.enddate(C,ED) &
  claim.endtime(C,ET) &
  datetimetotimestamp(SD,ST,SS) &
  datetimetotimestamp(ED,ET,ES) &
  evaluate(minus(ES,SS),DURATION)

exclusion(C,4.3m) :-
  hospitalization.patient(Z,P) &
  hospitalization.patient(Y,P) &
  distinct(Y,Z) &
  hospitalization.diagnosis(Z,D) &
  hospitalization.diagnosis(Y,D) &
  hospitalization.startdate(Z,ZS) &
  hospitalization.enddate(Y,YE) &
  evaluate(stringmin(YE,ZS),YE)

exclusion(C,4.3i) :-
  claim.activity(C,skydiving)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% insurance-related definitions
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

person.policy(X,Y) :- policy.insuree(Y,X)
person.policy(X,Y) :- policy.dependent(Y,X)

person.claim(X,Y) :-
  hospitalization.patient(H,X) &
  claim.hospitalization(Y,H)

policy.claim(X,Y) :- claim.policy(Y,X)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% library.hrf
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

policy.insurer(P,C) :- policy.type(P,T) & true(product.insurer(T,C),world)

claim.subject(C,Z) :- claim.hospitalization(C,Z)
claim.subject(C,R) :- claim.repair(C,R)

claim.recommendation(C,pay) :-
  claim.hospitalization(C,Z) &
  covers(P,Z)

claim.recommendation(C,decline) :-
  claim.hospitalization(C,Z) &
  partial_day(Z)

claim.recommendation(C,decline) :-
  claim.hospitalization(C,Z) &
  exclusion(Z,E)

claim.recommendation(C,pay) :- covers(P,C)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

overlap(XS,XE,YS,YE) :-
  evaluate(stringmin(YS,XE),YS) &
  evaluate(stringmin(XS,YE),XS)

datetimetotimestamp(DATE,TIME,STAMP) :-
  evaluate(parsedate(DATE),[Y,M,D]) &
  evaluate(parsetime(TIME),[H,N,S]) &
  evaluate(maketimestamp(Y,M,D,H,N,S),STAMP)

parsedate(DATE) :=
  map(readstring,tail(matches(stringify(DATE),"(....)_(..)_(..)")))

parsetime(TIME) :=
  map(readstring,tail(matches(stringify(TIME),"(..)_(..)_(..)")))

head(X!L) := X
tail(X!L) := L

%%% number relations, e.g. less, greater
%%% string relations, e.g. stringappend
%%% date relations, e.g. dateplus
%%% and so forth...

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Constraints
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

illegal(C) :- countofall(A,claim.activity(C,A),0)
illegal(C) :- claim.repairstart(C,S) & claim.repairend(C,E) & symless(E,S)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Stylesheet Rules
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Initialization
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

load :: user(U) & policy.insuree(P,U) ==> true(active(P),local)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Shortcuts
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

user(U) :- evaluate(parameter(user),U)
claim(C) :- evaluate(parameter(id),C)

insurer(P,C) :- policy.type(P,T) & true(product.insurer(T,C),world)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Policy panel
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(P,true) :- true(active(P),local)
select(P,true) :: true(active(P),local)
select(P,false) :: ~true(active(P),local)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Claim panel
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

innerhtml(disposition,"Covered") :-
  claim(C) & true(active(P),local) & covers(P,C)

innerhtml(disposition,"Not covered") :-
  countofall(R,claim(C) & true(active(P),local) & covers(P,C),0)

attribute(disposition,bgcolor,"#ccffcc") :-
  claim(C) & true(active(P),local) & covers(P,C)

attribute(disposition,bgcolor,"#ff8888") :-
  countofall(R,claim(C) & true(active(P),local) & covers(P,C),0)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(claim,C) :- claim(C)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(claimdate,D) :- claim(C) & claim.date(C,D)
date(claimdate,D) :- claim(C) & claim.date(C,D)
select(claimdate,D) :: claim(C) ==> claim.date(C,D)
select(claimdate,D) :: claim(C) & claim.date(C,OD) ==> ~claim.date(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Hospitalization panel
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(patient,P) :- claim(C) & claim.patient(C,P)
options(patient,L) :- setofall(X,type(X,person),L)
select(patient,P) :: claim(C) & distinct(D,blank) ==> claim.patient(C,P)
select(patient,P) :: claim(C) & claim.patient(C,OP) ==> ~claim.patient(C,OP)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(hospital,H) :- claim(C) & claim.hospital(C,H)
select(hospital,H) :: claim(C) & distinct(H,blank) ==> claim.hospital(C,H)
select(hospital,H) :: claim(C) & claim.hospital(C,OH) ==> ~claim.hospital(C,OH)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(diagnosis,D) :- claim(C) & claim.diagnosis(C,D)
options(diagnosis,L) :- setofall(X,true(type(X,diagnosis),world),L)
select(diagnosis,D) :: claim(C) & distinct(D,blank) ==> claim.diagnosis(C,D)
select(diagnosis,D) :: claim(C) & claim.diagnosis(C,OD) ==> ~claim.diagnosis(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(physician,D) :- claim(C) & claim.physician(C,D)
select(physician,D) :: claim(C) & distinct(D,blank) ==> claim.physician(C,D)
select(physician,D) :: claim(C) & claim.physician(C,OD) ==> ~claim.physician(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(startdate,D) :- claim(C) & claim.startdate(C,D)
date(startdate,D) :- claim(C) & claim.startdate(C,D)
select(startdate,D) :: claim(C) & distinct(D,blank) ==> claim.startdate(C,D)
select(startdate,D) :: claim(C) & claim.startdate(C,OD) ==> ~claim.startdate(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(leavedate,D) :- claim(C) & claim.enddate(C,D)
date(leavedate,D) :- claim(C) & claim.enddate(C,D)
select(leavedate,D) :: claim(C) & distinct(D,blank) ==> claim.enddate(C,D)
select(leavedate,D) :: claim(C) & claim.enddate(C,OD) ==> ~claim.enddate(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(starttime,T) :- claim(C) & claim.starttime(C,T)
select(starttime,T) :: claim(C) & distinct(T,blank) ==> claim.starttime(C,T)
select(starttime,T) :: claim(C) & claim.starttime(C,OT) ==> ~claim.starttime(C,OT)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(leavetime,T) :- claim(C) & claim.endtime(C,T)
select(leavetime,T) :: claim(C) & distinct(T,blank) ==> claim.endtime(C,T)
select(leavetime,T) :: claim(C) & claim.endtime(C,OT) ==> ~claim.endtime(C,OT)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(physicianref,B) :- claim(C) & claim.physicianref(C,B)
select(physicianref,B) :: claim(C) & distinct(B,blank) ==> claim.physicianref(C,B)
select(physicianref,B) :: claim(C) & claim.physicianref(C,OB) ==> ~claim.physicianref(C,OB)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% Accident panel
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(accidentactivity,A) :- claim(C) & claim.activity(C,A)
select(accidentactivity,A) :: claim(C) ==> claim.activity(C,A)
select(accidentactivity,A) :: claim(C) & claim.activity(C,OA)==> ~claim.activity(C,OA)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(accidentcountry,W) :- claim(C) & claim.country(C,W)
options(accidentcountry,L) :- setofall(D,true(type(D,country),world),L)
select(accidentcountry,W) :: claim(C) & distinct(W,blank) ==> claim.country(C,W)
select(accidentcountry,W) :: claim(C) & claim.country(C,OW)==> ~claim.country(C,OW)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

value(accidentdate,D) :- claim(C) & claim.accidentdate(C,D)
date(accidentdate,D) :- claim(C) & claim.accidentdate(C,D)
select(accidentdate,D) :: claim(C) ==> claim.accidentdate(C,D)
select(accidentdate,D) :: claim(C) & claim.accidentdate(C,OD) ==> ~claim.accidentdate(C,OD)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% policies
%%% endorsements forthcoming
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

type(policy1234567821,policy)
policy.type(policy1234567821,chubb_hospital_cash)
policy.insuree(policy1234567821,steve_squirrel)
policy.dependent(policy1234567821,sally_squirrel)
policy.dependent(policy1234567821,susan_squirrel)
policy.startdate(policy1234567821,2023_01_01)
policy.enddate(policy1234567821,2023_12_31)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% claims
%%% claimlines forthcoming
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

type(claim21,hospitalizationclaim)
claim.claimant(claim21,steve_squirrel)
claim.date(claim21,2023_11_30)

claim.patient(claim21,sally_squirrel)
claim.hospital(claim21,johns_hopkins)
claim.physician(claim21,kildare)
claim.physicianref(claim21,yes)
claim.diagnosis(claim21,sprained_ankle)
claim.startdate(claim21,2023_08_23)
claim.starttime(claim21,22_00_00)
claim.enddate(claim21,2023_08_24)
claim.endtime(claim21,10_00_00)

claim.activity(claim21,dancing)
claim.country(claim21,usa)
claim.accidentdate(claim21,2023_08_23)

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%% people
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

type(sally_squirrel,person)
person.firstname(sally_squirrel,"Sally")
person.lastname(sally_squirrel,"Squirrel")
person.gender(sally_squirrel,female)
person.dob(sally_squirrel,2002_10_15)
person.parent(sally_squirrel,steve_squirrel)
person.parent(sally_squirrel,susan_squirrel)
person.nationality(sally_squirrel,usa)
person.occupation(sally_squirrel,student)
person.mobile(sally_squirrel,"555-4327")
person.email(sally_squirrel,"sally@squirrels.com")

type(sibyl_squirrel,person)
person.firstname(sibyl_squirrel,"Sibyl")
person.lastname(sibyl_squirrel,"Squirrel")
person.gender(sibyl_squirrel,female)
person.dob(sibyl_squirrel,2004_10_15)
person.parent(sibyl_squirrel,steve_squirrel)
person.parent(sibyl_squirrel,susan_squirrel)
person.nationality(sibyl_squirrel,usa)
person.occupation(sibyl_squirrel,student)
person.mobile(sibyl_squirrel,"555-4327")
person.email(sibyl_squirrel,"sibyl@squirrels.com")

type(steve_squirrel,person)
person.firstname(steve_squirrel,"Steve")
person.lastname(steve_squirrel,"Squirrel")
person.gender(steve_squirrel,male)
person.dob(steve_squirrel,1976_10_15)
person.spouse(steve_squirrel,susan_squirrel)
person.nationality(steve_squirrel,usa)
person.occupation(steve_squirrel,exterminator)
person.mobile(steve_squirrel,"555-4327")
person.email(steve_squirrel,"steve@squirrels.com")
person.focus(steve_squirrel,steve_squirrel)
person.focus(steve_squirrel,susan_squirrel)
person.focus(steve_squirrel,sally_squirrel)
person.focus(steve_squirrel,sibyl_squirrel)

type(susan_squirrel,person)
person.firstname(susan_squirrel,"Susan")
person.lastname(susan_squirrel,"Squirrel")
person.gender(susan_squirrel,female)
person.dob(susan_squirrel,1984_10_15)
person.spouse(susan_squirrel,steve_squirrel)
person.nationality(susan_squirrel,usa)
person.occupation(susan_squirrel,housewife)
person.mobile(susan_squirrel,"555-4327")
person.email(susan_squirrel,"susan@squirrels.com")