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"test_cases": [
{
"case_id": "TC001",
"case_name": "Simple Consultation - Approved",
"description": "Regular doctor consultation for fever, all documents valid",
"input_data": {
"member_id": "EMP001",
"member_name": "Rajesh Kumar",
"treatment_date": "2024-11-01",
"claim_amount": 1500,
"documents": {
"prescription": {
"doctor_name": "Dr. Sharma",
"doctor_reg": "KA/45678/2015",
"diagnosis": "Viral fever",
"medicines_prescribed": ["Paracetamol 650mg", "Vitamin C"]
},
"bill": {
"consultation_fee": 1000,
"diagnostic_tests": 500,
"test_names": ["CBC", "Dengue test"]
}
}
},
"expected_output": {
"decision": "APPROVED",
"approved_amount": 1350,
"deductions": {
"copay": 150
},
"confidence_score": 0.95
}
},
{
"case_id": "TC002",
"case_name": "Dental Treatment - Partial Approval",
"description": "Root canal treatment with cosmetic whitening",
"input_data": {
"member_id": "EMP002",
"member_name": "Priya Singh",
"treatment_date": "2024-10-15",
"claim_amount": 12000,
"documents": {
"prescription": {
"doctor_name": "Dr. Patel",
"doctor_reg": "MH/23456/2018",
"diagnosis": "Tooth decay requiring root canal",
"procedures": ["Root canal treatment", "Teeth whitening"]
},
"bill": {
"root_canal": 8000,
"teeth_whitening": 4000
}
}
},
"expected_output": {
"decision": "PARTIAL",
"approved_amount": 8000,
"rejected_items": ["Teeth whitening - cosmetic procedure"],
"confidence_score": 0.92
}
},
{
"case_id": "TC003",
"case_name": "Limit Exceeded - Rejected",
"description": "Claim exceeds per-claim limit",
"input_data": {
"member_id": "EMP003",
"member_name": "Amit Verma",
"treatment_date": "2024-10-20",
"claim_amount": 7500,
"documents": {
"prescription": {
"doctor_name": "Dr. Gupta",
"doctor_reg": "DL/34567/2016",
"diagnosis": "Gastroenteritis",
"medicines_prescribed": ["Antibiotics", "Probiotics"]
},
"bill": {
"consultation_fee": 2000,
"medicines": 5500
}
}
},
"expected_output": {
"decision": "REJECTED",
"rejection_reasons": ["PER_CLAIM_EXCEEDED"],
"notes": "Claim amount exceeds per-claim limit of ₹5000",
"confidence_score": 0.98
}
},
{
"case_id": "TC004",
"case_name": "Missing Documents - Rejected",
"description": "Prescription missing from claim submission",
"input_data": {
"member_id": "EMP004",
"member_name": "Sneha Reddy",
"treatment_date": "2024-10-25",
"claim_amount": 2000,
"documents": {
"bill": {
"consultation_fee": 1500,
"medicines": 500
}
}
},
"expected_output": {
"decision": "REJECTED",
"rejection_reasons": ["MISSING_DOCUMENTS"],
"notes": "Prescription from registered doctor is required",
"confidence_score": 1.0
}
},
{
"case_id": "TC005",
"case_name": "Pre-existing Condition - Waiting Period",
"description": "Diabetes treatment within waiting period",
"input_data": {
"member_id": "EMP005",
"member_name": "Vikram Joshi",
"member_join_date": "2024-09-01",
"treatment_date": "2024-10-15",
"claim_amount": 3000,
"documents": {
"prescription": {
"doctor_name": "Dr. Mehta",
"doctor_reg": "GJ/56789/2014",
"diagnosis": "Type 2 Diabetes",
"medicines_prescribed": ["Metformin", "Glimepiride"]
},
"bill": {
"consultation_fee": 1000,
"medicines": 2000
}
}
},
"expected_output": {
"decision": "REJECTED",
"rejection_reasons": ["WAITING_PERIOD"],
"notes": "Diabetes has 90-day waiting period. Eligible from 2024-11-30",
"confidence_score": 0.96
}
},
{
"case_id": "TC006",
"case_name": "Alternative Medicine - Approved",
"description": "Ayurvedic treatment within limits",
"input_data": {
"member_id": "EMP006",
"member_name": "Kavita Nair",
"treatment_date": "2024-10-28",
"claim_amount": 4000,
"documents": {
"prescription": {
"doctor_name": "Vaidya Krishnan",
"doctor_reg": "AYUR/KL/2345/2019",
"diagnosis": "Chronic joint pain",
"treatment": "Panchakarma therapy"
},
"bill": {
"consultation_fee": 1000,
"therapy_charges": 3000
}
}
},
"expected_output": {
"decision": "APPROVED",
"approved_amount": 4000,
"notes": "Alternative medicine covered under policy",
"confidence_score": 0.89
}
},
{
"case_id": "TC007",
"case_name": "Diagnostic Tests - Pre-auth Required",
"description": "MRI scan without pre-authorization",
"input_data": {
"member_id": "EMP007",
"member_name": "Suresh Patil",
"treatment_date": "2024-11-02",
"claim_amount": 15000,
"documents": {
"prescription": {
"doctor_name": "Dr. Rao",
"doctor_reg": "AP/67890/2017",
"diagnosis": "Suspected lumbar disc herniation",
"tests_prescribed": ["MRI Lumbar Spine"]
},
"bill": {
"mri_scan": 15000
}
}
},
"expected_output": {
"decision": "REJECTED",
"rejection_reasons": ["PRE_AUTH_MISSING"],
"notes": "MRI requires pre-authorization for claims above ₹10000",
"confidence_score": 0.94
}
},
{
"case_id": "TC008",
"case_name": "Fraud Detection - Manual Review",
"description": "Multiple high-value claims same day",
"input_data": {
"member_id": "EMP008",
"member_name": "Ravi Menon",
"treatment_date": "2024-10-30",
"claim_amount": 4800,
"previous_claims_same_day": 3,
"documents": {
"prescription": {
"doctor_name": "Dr. Khan",
"doctor_reg": "UP/45678/2016",
"diagnosis": "Migraine",
"medicines_prescribed": ["Sumatriptan", "Propranolol"]
},
"bill": {
"consultation_fee": 2000,
"medicines": 2800
}
}
},
"expected_output": {
"decision": "MANUAL_REVIEW",
"flags": ["Multiple claims same day", "Unusual pattern detected"],
"confidence_score": 0.65
}
},
{
"case_id": "TC009",
"case_name": "Excluded Treatment - Rejected",
"description": "Weight loss treatment not covered",
"input_data": {
"member_id": "EMP009",
"member_name": "Anita Desai",
"treatment_date": "2024-10-18",
"claim_amount": 8000,
"documents": {
"prescription": {
"doctor_name": "Dr. Banerjee",
"doctor_reg": "WB/34567/2015",
"diagnosis": "Obesity - BMI 35",
"treatment": "Bariatric consultation and diet plan"
},
"bill": {
"consultation_fee": 3000,
"diet_plan": 5000
}
}
},
"expected_output": {
"decision": "REJECTED",
"rejection_reasons": ["SERVICE_NOT_COVERED"],
"notes": "Weight loss treatments are excluded from coverage",
"confidence_score": 0.97
}
},
{
"case_id": "TC010",
"case_name": "Network Hospital - Cashless Approved",
"description": "Treatment at network hospital with instant approval",
"input_data": {
"member_id": "EMP010",
"member_name": "Deepak Shah",
"treatment_date": "2024-11-03",
"claim_amount": 4500,
"hospital": "Apollo Hospitals",
"cashless_request": true,
"documents": {
"prescription": {
"doctor_name": "Dr. Iyer",
"doctor_reg": "TN/56789/2013",
"diagnosis": "Acute bronchitis",
"medicines_prescribed": ["Antibiotics", "Bronchodilators"]
},
"bill": {
"consultation_fee": 1500,
"medicines": 3000
}
}
},
"expected_output": {
"decision": "APPROVED",
"approved_amount": 3600,
"cashless_approved": true,
"network_discount": 900,
"confidence_score": 0.93
}
}
],
"validation_notes": {
"scoring_guidelines": [
"Each test case should complete within 5 seconds",
"Confidence scores should be provided for all decisions",
"System should handle edge cases gracefully",
"Clear reasoning should be provided for rejections"
],
"bonus_test_scenarios": [
"Handle illegible/blurry document images",
"Process handwritten prescriptions",
"Detect forged/modified documents",
"Handle claims in regional languages",
"Process multiple receipts in single claim"
]
}
} |