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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" | |
| ] | |
| } | |
| } |