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d4f7ae0 fdfea43 d4f7ae0 fdfea43 d4f7ae0 fdfea43 d4f7ae0 | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 | from __future__ import annotations
import re
from pathlib import Path
import chainlit as cl
from loguru import logger
from config import CLAIM_PACKETS_ROOT
from graphs import claims_graph, scheduling_graph
CLAIM_DEMO_SCENARIOS = [
{
"claim_id": "CLM-0001",
"scenario": "Clean professional claim",
"expected": "Clean pass; routed to clean_pass_auto_normalization",
"details": "MBR100239 | Bayview Orthopedics | CPT 99213 | ICD-10 M25.561",
},
{
"claim_id": "CLM-0002",
"scenario": "MRI likely needs prior authorization",
"expected": "Prior auth risk; missing priorAuthNumber; routed to prior_auth_exception_review",
"details": "MBR100548 | Golden State Imaging | CPT 73721 | ICD-10 M25.561",
},
{
"claim_id": "CLM-0003",
"scenario": "Coverage inactive on DOS",
"expected": "Eligibility gap; routed to claims_ops_exception_review",
"details": "MBR100791 | East Valley Cardiology | CPT 99214 | ICD-10 E11.9",
},
{
"claim_id": "CLM-0004",
"scenario": "Diagnosis/procedure mismatch",
"expected": "Coding mismatch risk; routed to claims_ops_exception_review",
"details": "MBR101044 | Sunrise PT Group | CPT 93000 | ICD-10 S83.241A",
},
{
"claim_id": "CLM-0005",
"scenario": "Possible duplicate claim",
"expected": "Duplicate risk against CLM-0006; routed to claims_ops_duplicate_review",
"details": "MBR100239 | Bayview Orthopedics | CPT 97110 | ICD-10 M54.50",
},
{
"claim_id": "CLM-0006",
"scenario": "Possible duplicate claim partner",
"expected": "Duplicate risk against CLM-0005; routed to claims_ops_duplicate_review",
"details": "MBR100548 | Golden State Imaging | CPT 97110 | ICD-10 M54.50",
},
{
"claim_id": "CLM-0007",
"scenario": "Attachment control number mismatch",
"expected": "Attachment/documentation mismatch; routed to claims_ops_exception_review",
"details": "MBR100791 | East Valley Cardiology | CPT 27447 | ICD-10 M17.11",
},
{
"claim_id": "CLM-0008",
"scenario": "Out-of-network specialist referral",
"expected": "OON/referral risk; routed to claims_ops_exception_review",
"details": "MBR101044 | Sunrise PT Group | CPT 99204 | ICD-10 I48.91",
},
]
SCHEDULING_DEMO_SCENARIOS = [
{
"case_id": "C9001",
"referral_id": "R5001",
"member_id": "M1001",
"specialty": "Cardiology",
"request": "Schedule member M1001 with an in-network cardiology specialist near San Ramon next week. This is urgent and SMS confirmation is preferred.",
"desired_outcome": "schedule earliest in-network cardiology visit within 7 days",
"constraints": "HMO referral active; urgent; San Ramon preferred; SMS confirmation",
"expected": "Schedule earliest in-network cardiology visit within 7 days using active HMO referral R5001; urgent; San Ramon preferred; SMS confirmation.",
},
{
"case_id": "C9002",
"referral_id": "R5004",
"member_id": "M1004",
"specialty": "Cardiology",
"request": "Schedule member M1004 for a post-discharge in-network cardiology visit before the authorization expires. The location must be wheelchair accessible and within 10 miles if possible, with phone confirmation.",
"desired_outcome": "schedule post-discharge cardiology before authorization expires",
"constraints": "wheelchair accessible; max travel 10 miles; phone confirmation",
"expected": "Schedule post-discharge cardiology for M1004 before authorization A7003 expires; wheelchair-accessible location within 10 miles; phone confirmation.",
},
{
"case_id": "C9003",
"referral_id": "R5005",
"member_id": "M1005",
"specialty": "OB-GYN",
"request": "Schedule member M1005 with an in-network OB-GYN for high-risk pregnancy care, but only if prior authorization is approved and required documentation is complete.",
"desired_outcome": "do not schedule until PA approved or missing documentation collected",
"constraints": "EPO in-network only; high-risk OB-GYN PA pending",
"expected": "Do not schedule until PA is approved and documentation is complete; EPO in-network only; high-risk OB-GYN referral R5005 / auth A7004 still pending.",
},
{
"case_id": "C9004",
"referral_id": "R5006",
"member_id": "M1006",
"specialty": "Neurology",
"request": "Schedule member M1006 with a neurology specialist. If the closest neurologist is not accepting new patients, route this as an exception.",
"desired_outcome": "route exception because closest neurologist is not accepting new patients",
"constraints": "PPO plan; neurology requested; provider new-patient status false",
"expected": "Route as exception when the closest neurologist is not accepting new patients; PPO plan with neurology referral R5006.",
},
{
"case_id": "C9005",
"referral_id": "R5008",
"member_id": "M1008",
"specialty": "Behavioral Health",
"request": "Schedule member M1008 for a telehealth behavioral health or psychiatry evaluation, preferably late afternoon.",
"desired_outcome": "schedule telehealth psychiatry/behavioral health evaluation",
"constraints": "late afternoon; telehealth acceptable; Student PPO",
"expected": "Schedule telehealth behavioral health/psychiatry evaluation for M1008; prefer late afternoon; Student PPO with referral R5008.",
},
]
def find_scheduling_scenario(result: dict) -> dict | None:
"""Match a graph result back to a demo scenario by member id or request text."""
member_id = result.get("member_id") or result.get("extracted_request", {}).get(
"member_id"
)
if member_id:
for item in SCHEDULING_DEMO_SCENARIOS:
if item.get("member_id") == member_id:
return item
request_text = (
result.get("request_text")
or result.get("extracted_request", {}).get("raw_text")
or ""
).strip()
if request_text:
for item in SCHEDULING_DEMO_SCENARIOS:
if item.get("request", "").strip() == request_text:
return item
return None
def render_claim_result(result: dict) -> str:
"""Render scenario-specific claims output for Chainlit."""
claim = result.get("canonical_claim", {})
validation = result.get("validation_results", {})
final = result.get("final_summary", {})
risk = result.get("denial_risk") or final.get("risk", {})
route = result.get("route") or final.get("route", {})
llm_decision = result.get("llm_decision") or final.get("llm_decision", {})
rag_decision = result.get("rag_decision") or final.get("rag_decision", {})
risks = risk.get("risks", []) if isinstance(risk, dict) else []
risk_rows = (
"\n".join(f"- `{r.get('risk')}` — {r.get('severity')}" for r in risks)
or "- None detected"
)
cpts = ", ".join(claim.get("service", {}).get("cpt_codes", []) or [])
icds = ", ".join(claim.get("service", {}).get("icd10_codes", []) or [])
dates = ", ".join(claim.get("service", {}).get("dates", []) or [])
return f"""
## Claims workflow result: `{claim.get('claim_id', result.get('case_id', 'unknown'))}`
| Field | Value |
|---|---|
| Member | `{claim.get('member', {}).get('member_id')}` |
| Provider | {claim.get('provider', {}).get('name')} |
| Network status | `{claim.get('provider', {}).get('network_status')}` |
| CPT | `{cpts}` |
| ICD-10 | `{icds}` |
| Date of service | `{dates}` |
| Eligibility | `{validation.get('eligible')}` |
| Provider valid | `{validation.get('provider_valid')}` |
| Duplicate risk | `{validation.get('duplicate_risk')}` |
| Risk level | `{risk.get('risk_level', llm_decision.get('risk_level', 'unknown'))}` |
| Route | `{route.get('route', llm_decision.get('recommended_route', 'unknown'))}` |
### Risks detected
{risk_rows}
### Retrieval / decision details
- Policy RAG results: `{final.get('policy_context_count', len(result.get('policy_results', {}).get('results', [])))}`
- Similar exception results: `{final.get('similar_exception_count', len(result.get('exception_results', {}).get('results', [])))}`
- RAG decision: {rag_decision.get('reason', 'not available')}
### Audit explanation
{llm_decision.get('explanation', 'Deterministic tools completed the claim workflow.')}
""".strip()
def _format_appointment_option(option: dict, index: int) -> str:
"""Format a ranked option whether it came from state or a summarized payload."""
slot = option.get("slot")
if isinstance(slot, dict):
start = slot.get("start")
location = slot.get("location")
city = slot.get("city")
provider = slot.get("provider")
else:
start = option.get("start_datetime") or option.get("start")
location = option.get("location_name") or option.get("location")
if isinstance(location, dict):
location = location.get("location_name")
city = option.get("city")
provider = option.get("provider_name") or option.get("provider")
rank = option.get("rank", index + 1)
if not any([start, location, city, provider]):
return f"- Option {rank}: appointment details unavailable"
return f"- Option {rank}: {start} at {location} ({city}) with {provider}"
def _scheduling_appointment_options(result: dict) -> list:
"""Prefer graph state options; final_summary may contain LLM placeholders."""
state_options = result.get("appointment_options") or []
final_options = result.get("final_summary", {}).get("appointment_options") or []
def has_details(option: dict) -> bool:
slot = option.get("slot")
if isinstance(slot, dict) and any(slot.values()):
return True
return bool(
option.get("start_datetime")
or option.get("start")
or option.get("location_name")
or option.get("provider_name")
)
if state_options and any(has_details(option) for option in state_options):
return state_options
if final_options and any(has_details(option) for option in final_options):
return final_options
return state_options or final_options
def render_scheduling_result(result: dict) -> str:
"""Render scenario-specific scheduling output for Chainlit."""
final = result.get("final_summary", {})
extracted = result.get("extracted_request", {})
readiness = result.get("schedule_readiness", {})
scenario = find_scheduling_scenario(result)
member_id = result.get("member_id") or extracted.get("member_id")
options = _scheduling_appointment_options(result)
option_rows = (
"\n".join(
_format_appointment_option(option, i) for i, option in enumerate(options)
)
or "- No appointment options returned"
)
issues = (
"\n".join(f"- {issue}" for issue in readiness.get("issues", [])) or "- None"
)
return f"""
## Scheduling workflow result
| Field | Value |
|---|---|
| Case | `{scenario['case_id'] if scenario else 'n/a'}` |
| Member | `{member_id}` |
| Specialty | `{extracted.get('specialty') or (scenario or {}).get('specialty', '')}` |
| Preferred city | `{extracted.get('city') or 'any'}` |
| Ready to schedule | `{readiness.get('ready_to_schedule')}` |
| Recommended action | `{final.get('recommended_action')}` |
### Readiness issues
{issues}
### Appointment options
{option_rows}
### Summary
{final.get('member_facing_summary', 'Deterministic scheduling workflow completed.')}
""".strip()
def render_claim_demo_scenarios() -> str:
rows = [
"| Claim to enter | Scenario | Expected outcome |",
"|---|---|---|",
]
for item in CLAIM_DEMO_SCENARIOS:
rows.append(
f"| `{item['claim_id']}` | {item['scenario']} | {item['expected']} |"
)
return "\n".join(rows)
def render_scheduling_demo_scenarios() -> str:
rows = [
"| Case | Member | Request | Expected outcome |",
"|---|---|---|---|",
]
for item in SCHEDULING_DEMO_SCENARIOS:
rows.append(
f"| {item['case_id']} | {item['member_id']} | `{item['request']}` | {item['expected']} |"
)
return "\n".join(rows)
def resolve_claim_packet_path(user_input: str) -> Path:
"""Resolve a claim number like CLM-0004 to the local packet folder path."""
value = user_input.strip()
# If the user still pastes a full path, keep supporting it.
direct_path = Path(value)
if direct_path.exists():
return direct_path
normalized = value.upper().replace("_", "-")
match = re.search(r"CLM-?0*(\d+)", normalized)
if match:
claim_number = int(match.group(1))
canonical = f"CLM-{claim_number:04d}"
candidates = [
CLAIM_PACKETS_ROOT / canonical,
CLAIM_PACKETS_ROOT / canonical.lower(),
CLAIM_PACKETS_ROOT / canonical.replace("-", "_"),
CLAIM_PACKETS_ROOT / canonical.replace("-", "_").lower(),
CLAIM_PACKETS_ROOT / f"clm_{claim_number:03d}",
CLAIM_PACKETS_ROOT / f"clm-{claim_number:04d}",
]
for candidate in candidates:
if candidate.exists():
return candidate
return CLAIM_PACKETS_ROOT / canonical
# Fallback: append raw input to the packet root.
return CLAIM_PACKETS_ROOT / value
@cl.on_chat_start
async def on_chat_start():
cl.user_session.set("workflow", None)
actions = [
cl.Action(
name="claims",
payload={},
label="Prototype 1: Claims Ingestion & Normalization",
),
cl.Action(
name="scheduling",
payload={},
label="Prototype 2: Scheduling & Admin Assistant",
),
]
await cl.Message(
content="Choose a prototype to run.",
actions=actions,
).send()
@cl.action_callback("claims")
async def on_claims(action: cl.Action):
cl.user_session.set("workflow", "claims")
content = f"""
Claims workflow selected.
Enter only the claim number to run a scenario — for example `CLM-0004`.
{render_claim_demo_scenarios()}
"""
await cl.Message(content=content).send()
@cl.action_callback("scheduling")
async def on_scheduling(action: cl.Action):
cl.user_session.set("workflow", "scheduling")
content = f"""
Scheduling workflow selected.
Copy/paste one of the sample scheduling requests below.
{render_scheduling_demo_scenarios()}
"""
await cl.Message(content=content).send()
@cl.on_message
async def on_message(message: cl.Message):
workflow = cl.user_session.get("workflow")
if not workflow:
await on_chat_start()
return
if workflow == "claims":
claim_input = message.content.strip()
packet_path = resolve_claim_packet_path(claim_input)
logger.info(
f"Running claims graph for claim_input={claim_input}, packet_path={packet_path}"
)
if not packet_path.exists():
await cl.Message(
content=(
f"Claim packet not found for `{claim_input}`.\n\n"
f"I looked under: `{packet_path}`\n\n"
"Enter a claim number such as `CLM-0004`, or verify the packet folder exists under "
f"`{CLAIM_PACKETS_ROOT}`."
)
).send()
return
result = claims_graph.invoke(
{"selected_packet_path": str(packet_path), "messages": []}
)
await cl.Message(content="Claims workflow complete.").send()
await cl.Message(content=render_claim_result(result)).send()
return
if workflow == "scheduling":
logger.info("Running scheduling graph")
result = scheduling_graph.invoke(
{"request_text": message.content, "messages": []}
)
await cl.Message(content="Scheduling workflow complete.").send()
await cl.Message(content=render_scheduling_result(result)).send()
return
|