medical-invoice-consolidator-audit

Collect every finding with resultado=fail or conditional. Ignore pass — they do not produce findings for a glosa.

Deduplicate by "root cause".

Two findings are duplicates when:

• They share the same documentary evidence (same file + same section), or
• They point to the same invoice_item (CUPS + quantity + date), or
• Their semantic description is equivalent (LLM check above a similarity threshold).

When merging:

• rule_ids = list of every rule_id that detected the same finding (e.g. ["ADMIN.15", "FIN.20"]).
• severidad = maximum across merged.
• peso = maximum.
• valor_objetado = maximum, not sum (do not double-count money).
• evidencia = formatted concatenation with source attribution.
• auditores_detectaron = list (["admin", "financial"]).

Compute per-finding confidence (0–1).

confidence = 0.4 × evidence_clarity
           + 0.4 × unanimity (auditors that detected it / 3)
           + 0.2 × citation_quality (exact file+page?)

• evidence_clarity: 1 if the evidence contains a literal quote, 0.7 for a specific reference, 0.4 if generic.
• unanimity: if 2+ auditors detected it → very high confidence.
• citation_quality: 1 if file+page, 0.5 if file only, 0 if neither.

Prioritize findings in this order:

• Severity descending: critica > mayor > media > baja.
• Within the same severity: valor_objetado descending.
• Within the same amount: confianza descending.

Assign an Anexo 6 causal to each finding (Res. 3047 Art. 5):

Rules:

• Use the deterministic mapping table first.
• If a finding could map to multiple causales, pick the most severe by this ranking: 4 > 2 > 5 > 1 > 3 > 6 > 7.
• If no mapping applies → mark the finding as needs-human-review (do not force a causal).
• Assign the subcausal if Anexo 6 defines one (e.g. 3.1 clinical documentation, 3.2 administrative documentation).

Compute zone and amounts.

• score = Σ peso of deduplicated findings with resultado=fail.
• zona:
  • Green: score ≤ ZONA_GREEN_MAX (default 5) and no critical rule fails.
  • Yellow: score ≤ ZONA_YELLOW_MAX (default 15) without criticals, or criticals with low confidence.
  • Red: score > ZONA_YELLOW_MAX or at least one critical with confidence ≥ CONFIDENCE_THRESHOLD.
• total_objetado = Σ valor_objetado of failing findings.
• total_a_pagar = invoice_total - total_objetado.
• confianza_global = weighted average by peso.

Publish the consolidated object.

POST {DEST_SOFTWARE_BASE_URL}/cases/{case_id}/consolidated
{
  "consolidated_findings": [
    {
      "finding_id": "fx-001",
      "rule_ids": ["ADMIN.15", "FIN.20"],
      "auditores_detectaron": ["admin", "financial"],
      "severidad": "critica",
      "peso": 3,
      "causal": 6,
      "subcausal": "6.1",
      "valor_objetado": 1200000,
      "confianza": 0.92,
      "evidencia": "autorizacion.pdf: annual cap $5M already consumed; invoice exceeds by $1.2M",
      "justificacion": "Coverage exhaustion per Anexo 6.6.1"
    }
  ],
  "case_summary": {
    "zona": "roja",
    "score": 22,
    "confianza_global": 0.88,
    "total_facturado": 8500000,
    "total_objetado": 3200000,
    "total_a_pagar": 5300000
  }
}

Apply workflow labels.

POST {DEST_SOFTWARE_BASE_URL}/cases/{case_id}/labels

Decision matrix:

Always add: consolidated.

Update the case status.

PATCH {DEST_SOFTWARE_BASE_URL}/cases/{case_id}
{ "status": "consolidated", "zona": "...", "score": ..., "total_objetado": ... }