|
| 1 | +import json |
| 2 | +import sys |
| 3 | +from pathlib import Path |
| 4 | +from typing import Any |
| 5 | + |
| 6 | +import click |
| 7 | +import pandas as pd |
| 8 | + |
| 9 | + |
| 10 | +@click.command |
| 11 | +@click.option( |
| 12 | + '--clm-uniq-id', |
| 13 | + type=str, |
| 14 | + required=True, |
| 15 | + help='Pass the claim unique ID.' |
| 16 | +) |
| 17 | +def main(clm_uniq_id:str): |
| 18 | + """Generate EOB sample JSON from SYNTHETIC_EOB.csv based on claim unique ID.""" |
| 19 | + claim_row = read_clm(clm_uniq_id) |
| 20 | + claim_type = int(claim_row.get("CLM_TYPE_CD")) |
| 21 | + |
| 22 | + match claim_type: |
| 23 | + case 1 | 2 | 3 | 4: |
| 24 | + result = create_pharmacy(clm_uniq_id,claim_row) |
| 25 | + case _: |
| 26 | + print("Unknown Type") |
| 27 | + sys.exit(1) |
| 28 | + |
| 29 | + with Path(result.output_file).open(mode="w", encoding="utf-8") as f: |
| 30 | + json.dump(result.result_json, f, indent=2) |
| 31 | + |
| 32 | + print(f"Successfully generated sample JSON: {result.output_file}") |
| 33 | + |
| 34 | +class Result: |
| 35 | + result_json: dict[str, Any] |
| 36 | + output_file: str |
| 37 | + |
| 38 | + |
| 39 | +def create_pharmacy(clm_uniq_id: Any,claim_row: Any) -> Result: |
| 40 | + |
| 41 | + provider_npi = str(claim_row.get("PRVDR_PRSCRBNG_PRVDR_NPI_NUM", "")).strip() |
| 42 | + |
| 43 | + prov_row = read_provider(provider_npi) |
| 44 | + |
| 45 | + clm_sig_row = read_sig_line(str(claim_row.get("CLM_DT_SGNTR_SK", "")).strip()) |
| 46 | + |
| 47 | + clm_sbmtr_cntrct_num = str(claim_row.get("CLM_SBMTR_CNTRCT_NUM", "")).strip() |
| 48 | + clm_sbmtr_cntrct_pbp_num = str(claim_row.get("CLM_SBMTR_CNTRCT_PBP_NUM", "")).strip() |
| 49 | + |
| 50 | + ctr_pmp_row = read_pmp(clm_sbmtr_cntrct_num,clm_sbmtr_cntrct_pbp_num) |
| 51 | + |
| 52 | + clm_lines = read_line(claim_row) |
| 53 | + |
| 54 | + clm_line = {} if clm_lines.empty else clm_lines.iloc[0] |
| 55 | + |
| 56 | + rx_line = read_rx_line(claim_row) |
| 57 | + |
| 58 | + output_json = { |
| 59 | + "resourceType": "ExplanationOfBenefit-Pharmacy", |
| 60 | + "id": str(clm_uniq_id.replace('-', '')).strip(), |
| 61 | + "lastUpdated": extract_col_str(claim_row,"IDR_UPDT_TS"), |
| 62 | + "CLM_FINL_ACTN_IND": extract_col_str(claim_row,"CLM_FINL_ACTN_IND"), |
| 63 | + "CLM_SRC_ID": extract_col_str(claim_row,"CLM_SRC_ID"), |
| 64 | + "BENE_SK": extract_col_str(claim_row,"BENE_SK"), |
| 65 | + "CLM_TYPE_CD": int(extract_col_str(claim_row,"CLM_TYPE_CD")), |
| 66 | + "CLM_UNIQ_ID": extract_col_str(claim_row,"CLM_UNIQ_ID"), |
| 67 | + "CLM_CNTL_NUM": extract_col_str(claim_row,"CLM_CNTL_NUM"), |
| 68 | + "CLM_ORIG_CNTL_NUM": extract_col_str(claim_row,"CLM_ORIG_CNTL_NUM"), |
| 69 | + "CLM_FROM_DT": extract_col_str(claim_row,"CLM_FROM_DT"), |
| 70 | + "CLM_THRU_DT": extract_col_str(claim_row,"CLM_THRU_DT"), |
| 71 | + "CLM_EFCTV_DT": extract_col_str(claim_row,"CLM_EFCTV_DT"), |
| 72 | + "CLM_SRVC_PRVDR_GNRC_ID_NUM": extract_col_str(claim_row,"CLM_SRVC_PRVDR_GNRC_ID_NUM"), |
| 73 | + "CLM_PD_DT": extract_col_str(claim_row,"CLM_PD_DT"), |
| 74 | + "PRVDR_PRSCRBNG_PRVDR_NPI_NUM": provider_npi, |
| 75 | + "CLM_PRSBNG_PRVDR_GNRC_ID_NUM": extract_col_str(claim_row,"CLM_PRSBNG_PRVDR_GNRC_ID_NUM"), |
| 76 | + "PRVDR_PRSBNG_ID_QLFYR_CD": extract_col_str(claim_row,"PRVDR_PRSBNG_ID_QLFYR_CD"), |
| 77 | + "PRVDR_LAST_NAME": extract_col_str(prov_row,"PRVDR_LAST_NAME"), |
| 78 | + "CNTRCT_PBP_NAME": extract_col_str(ctr_pmp_row,"CNTRCT_PBP_NAME"), |
| 79 | + "CLM_BENE_PMT_AMT": extract_col_str(claim_row,"CLM_BENE_PMT_AMT"), |
| 80 | + "CLM_OTHR_TP_PD_AMT": extract_col_str(claim_row,"CLM_OTHR_TP_PD_AMT"), |
| 81 | + "META_SRC_SK": extract_col_str(claim_row,"META_SRC_SK"), |
| 82 | + "PRVDR_SRVC_ID_QLFYR_CD": extract_col_str(claim_row,"PRVDR_SRVC_ID_QLFYR_CD"), |
| 83 | + "supportingInfoComponents": [], |
| 84 | + "lineItemComponents": [ |
| 85 | + { |
| 86 | + "CLM_LINE_NUM": extract_col_str(clm_line,"CLM_LINE_NUM"), |
| 87 | + "CLM_LINE_FROM_DT": extract_col_str(clm_line,"CLM_LINE_FROM_DT"), |
| 88 | + "CLM_LINE_NDC_CD": extract_col_str(clm_line,"CLM_LINE_NDC_CD"), |
| 89 | + "CLM_LINE_NDC_QTY": extract_col_str(clm_line,"CLM_LINE_NDC_QTY"), |
| 90 | + "CLM_LINE_NDC_QTY_QLFYR_CD": extract_col_str( |
| 91 | + clm_line,"CLM_LINE_NDC_QTY_QLFYR_CD"), |
| 92 | + "CLM_LINE_CVRD_PD_AMT": extract_col_str(clm_line,"CLM_LINE_CVRD_PD_AMT"), |
| 93 | + "CLM_LINE_GRS_ABOVE_THRSHLD_AMT": extract_col_str(rx_line, |
| 94 | + "CLM_LINE_GRS_ABOVE_THRSHLD_AMT"), |
| 95 | + "CLM_LINE_GRS_BLW_THRSHLD_AMT": extract_col_str( |
| 96 | + rx_line,"CLM_LINE_GRS_BLW_THRSHLD_AMT"), |
| 97 | + "CLM_LINE_LIS_AMT": extract_col_str(rx_line,"CLM_LINE_LIS_AMT"), |
| 98 | + "CLM_LINE_TROOP_TOT_AMT": extract_col_str(rx_line,"CLM_LINE_TROOP_TOT_AMT"), |
| 99 | + "CLM_LINE_PLRO_AMT": extract_col_str(rx_line,"CLM_LINE_PLRO_AMT"), |
| 100 | + "CLM_RPTD_MFTR_DSCNT_AMT": extract_col_str(rx_line,"CLM_RPTD_MFTR_DSCNT_AMT"), |
| 101 | + "CLM_LINE_INGRDNT_CST_AMT": extract_col_str(rx_line,"CLM_LINE_INGRDNT_CST_AMT"), |
| 102 | + "CLM_LINE_SRVC_CST_AMT": extract_col_str(rx_line,"CLM_LINE_SRVC_CST_AMT"), |
| 103 | + "CLM_LINE_SLS_TAX_AMT": extract_col_str(rx_line,"CLM_LINE_SLS_TAX_AMT"), |
| 104 | + "CLM_LINE_VCCN_ADMIN_FEE_AMT": extract_col_str(rx_line,"CLM_LINE_VCCN_ADMIN_FEE_AMT"), |
| 105 | + "CLM_PRCNG_EXCPTN_CD": extract_col_str(rx_line,"CLM_PRCNG_EXCPTN_CD"), |
| 106 | + "CLM_LINE_BENE_PMT_AMT": extract_col_str(clm_line,"CLM_LINE_BENE_PMT_AMT"), |
| 107 | + "CLM_CMS_CALCD_MFTR_DSCNT_AMT": extract_col_str(rx_line, |
| 108 | + "CLM_CMS_CALCD_MFTR_DSCNT_AMT"), |
| 109 | + "CLM_LINE_GRS_CVRD_CST_TOT_AMT": extract_col_str(rx_line, |
| 110 | + "CLM_LINE_GRS_CVRD_CST_TOT_AMT"), |
| 111 | + "CLM_LINE_REBT_PASSTHRU_POS_AMT": extract_col_str(rx_line, |
| 112 | + "CLM_LINE_REBT_PASSTHRU_POS_AMT"), |
| 113 | + "CLM_PHRMCY_PRICE_DSCNT_AT_POS_AMT": extract_col_str(rx_line, |
| 114 | + "CLM_PHRMCY_PRICE_DSCNT_AT_POS_AMT"), |
| 115 | + "CLM_LINE_OTHR_TP_PD_AMT": extract_col_str(clm_line, |
| 116 | + "CLM_LINE_OTHR_TP_PD_AMT"), |
| 117 | + "CLM_LINE_NCVRD_PD_AMT": extract_col_str(clm_line, |
| 118 | + "CLM_LINE_NCVRD_PD_AMT"), |
| 119 | + "isCompound": str(extract_col_str(rx_line,"CLM_CMPND_CD") == "2").lower(), |
| 120 | + "CLM_LINE_RPTD_GAP_DSCNT_AMT": extract_col_str(rx_line, |
| 121 | + "CLM_LINE_RPTD_GAP_DSCNT_AMT"), |
| 122 | + "CLM_LINE_AUTHRZD_FILL_NUM": extract_col_str(rx_line, |
| 123 | + "CLM_LINE_AUTHRZD_FILL_NUM"), |
| 124 | + "CLM_PHRMCY_SRVC_TYPE_CD": extract_col_str(rx_line, |
| 125 | + "CLM_PHRMCY_SRVC_TYPE_CD"), |
| 126 | + "CLM_LINE_RX_ORGN_CD": extract_col_str(rx_line, |
| 127 | + "CLM_LINE_RX_ORGN_CD"), |
| 128 | + "CLM_BRND_GNRC_CD": extract_col_str(rx_line, |
| 129 | + "CLM_BRND_GNRC_CD"), |
| 130 | + "CLM_PTNT_RSDNC_CD": extract_col_str(rx_line, |
| 131 | + "CLM_PTNT_RSDNC_CD"), |
| 132 | + "CLM_LTC_DSPNSNG_MTHD_CD": extract_col_str(rx_line, |
| 133 | + "CLM_LTC_DSPNSNG_MTHD_CD"), |
| 134 | + "CLM_CMPND_CD": extract_col_str(rx_line,"CLM_CMPND_CD"), |
| 135 | + "CLM_LINE_DAYS_SUPLY_QTY": extract_col_str(rx_line,"CLM_LINE_DAYS_SUPLY_QTY"), |
| 136 | + "CLM_LINE_RX_FILL_NUM": extract_col_str(rx_line,"CLM_LINE_RX_FILL_NUM"), |
| 137 | + "CLM_DAW_PROD_SLCTN_CD": extract_col_str(rx_line,"CLM_DAW_PROD_SLCTN_CD"), |
| 138 | + "CLM_DRUG_CVRG_STUS_CD": extract_col_str(rx_line,"CLM_DRUG_CVRG_STUS_CD"), |
| 139 | + "CLM_CTSTRPHC_CVRG_IND_CD": extract_col_str(rx_line,"CLM_CTSTRPHC_CVRG_IND_CD"), |
| 140 | + "CLM_LINE_RX_NUM": extract_col_str(clm_line,"CLM_LINE_RX_NUM"), |
| 141 | + "CLM_DSPNSNG_STUS_CD": extract_col_str(rx_line,"CLM_DSPNSNG_STUS_CD"), |
| 142 | + } |
| 143 | + ], |
| 144 | + "CLM_CMS_PROC_DT": extract_col_str(clm_sig_row,"CLM_CMS_PROC_DT"), |
| 145 | + "CLM_IDR_LD_DT ": extract_col_str(claim_row,"CLM_IDR_LD_DT"), |
| 146 | + "CLM_ADJSTMT_TYPE_CD": extract_col_str(claim_row,"CLM_ADJSTMT_TYPE_CD"), |
| 147 | + "CLM_SBMT_FRMT_CD": extract_col_str(claim_row,"CLM_SBMT_FRMT_CD"), |
| 148 | + "CLM_SBMTR_CNTRCT_NUM": extract_col_str(claim_row,"CLM_SBMTR_CNTRCT_NUM"), |
| 149 | + "CLM_SBMTR_CNTRCT_PBP_NUM": extract_col_str(claim_row,"CLM_SBMTR_CNTRCT_PBP_NUM"), |
| 150 | + "CLM_DT_SGNTR_SK": extract_col_str(clm_sig_row,"CLM_DT_SGNTR_SK"), |
| 151 | + } |
| 152 | + |
| 153 | + result = Result() |
| 154 | + result.result_json = output_json |
| 155 | + result.output_file = "sample-data/EOB-Pharmacy-Sample.json" |
| 156 | + return result |
| 157 | + |
| 158 | + |
| 159 | +def read_clm(clm_uniq_id: Any) -> Any: |
| 160 | + eob_path = "out/SYNTHETIC_CLM.csv" |
| 161 | + if not Path(eob_path).exists(): |
| 162 | + print("EOB file not found. Run the generator or this will not go well.") |
| 163 | + sys.exit(1) |
| 164 | + |
| 165 | + claims_found = pd.read_csv(eob_path, dtype=str, keep_default_na=False) |
| 166 | + |
| 167 | + clm_matches = claims_found[claims_found["CLM_UNIQ_ID"] == clm_uniq_id] |
| 168 | + |
| 169 | + if clm_matches.empty: |
| 170 | + print(f"No claims found for claim unique ID: {clm_uniq_id}") |
| 171 | + sys.exit(1) |
| 172 | + |
| 173 | + return clm_matches.iloc[0] |
| 174 | + |
| 175 | +def read_provider(provider_npi: Any) -> Any: |
| 176 | + provider_path = "out/SYNTHETIC_PRVDR_HSTRY.csv" |
| 177 | + |
| 178 | + if not Path(provider_path).exists(): |
| 179 | + print("Provider file not found. Run the generator or this will not go well.") |
| 180 | + sys.exit(1) |
| 181 | + |
| 182 | + provs_found = pd.read_csv(provider_path, dtype=str, keep_default_na=False) |
| 183 | + |
| 184 | + prov_matches = provs_found[provs_found["PRVDR_NPI_NUM"] == provider_npi] |
| 185 | + |
| 186 | + return {} if prov_matches.empty else prov_matches.iloc[0] |
| 187 | + |
| 188 | +def read_sig_line(clm_dt_sgntr_sk: Any) -> Any: |
| 189 | + clm_sig_path = "out/SYNTHETIC_CLM_DT_SGNTR.csv" |
| 190 | + |
| 191 | + if not Path(clm_sig_path).exists(): |
| 192 | + print("Claim signature file not found. Run the generator or this will not go well.") |
| 193 | + sys.exit(1) |
| 194 | + |
| 195 | + clm_sig_found = pd.read_csv(clm_sig_path, dtype=str, keep_default_na=False) |
| 196 | + |
| 197 | + clm_sig_matches = clm_sig_found[clm_sig_found["CLM_DT_SGNTR_SK"] == clm_dt_sgntr_sk] |
| 198 | + |
| 199 | + return {} if clm_sig_matches.empty else clm_sig_matches.iloc[0] |
| 200 | + |
| 201 | +def read_pmp(clm_sbmtr_cntrct_num:Any,clm_sbmtr_cntrct_pbp_num:Any) -> Any: |
| 202 | + ctr_pmp_path = "out/SYNTHETIC_CNTRCT_PBP_NUM.csv" |
| 203 | + |
| 204 | + if not Path(ctr_pmp_path).exists(): |
| 205 | + print("Provider file not found. Run the generator or this will not go well.") |
| 206 | + sys.exit(1) |
| 207 | + |
| 208 | + ctr_pmp_found = pd.read_csv(ctr_pmp_path, dtype=str, keep_default_na=False) |
| 209 | + |
| 210 | + ctr_pmp_matches = ctr_pmp_found[ |
| 211 | + (ctr_pmp_found["CNTRCT_NUM"] == clm_sbmtr_cntrct_num) |
| 212 | + & (ctr_pmp_found["CNTRCT_PBP_NUM"] == clm_sbmtr_cntrct_pbp_num) |
| 213 | + ] |
| 214 | + |
| 215 | + return {} if ctr_pmp_matches.empty else ctr_pmp_matches.iloc[0] |
| 216 | + |
| 217 | +def read_line(clm_line:Any) -> Any: |
| 218 | + line_path = "out/SYNTHETIC_CLM_LINE.csv" |
| 219 | + |
| 220 | + if not Path(line_path).exists(): |
| 221 | + print("Claim Line file not found. Run the generator or this will not go well.") |
| 222 | + sys.exit(1) |
| 223 | + |
| 224 | + line_found = pd.read_csv(line_path, dtype=str, keep_default_na=False) |
| 225 | + |
| 226 | + return line_found[ |
| 227 | + (line_found["GEO_BENE_SK"] == clm_line["GEO_BENE_SK"]) |
| 228 | + & (line_found["CLM_DT_SGNTR_SK"] == clm_line["CLM_DT_SGNTR_SK"]) |
| 229 | + & (line_found["CLM_TYPE_CD"] == clm_line["CLM_TYPE_CD"]) |
| 230 | + & (line_found["CLM_NUM_SK"] == clm_line["CLM_NUM_SK"]) |
| 231 | + ] |
| 232 | + |
| 233 | +def read_rx_line(clm_line:Any) -> Any: |
| 234 | + line_rx_path = "out/SYNTHETIC_CLM_LINE_RX.csv" |
| 235 | + |
| 236 | + if not Path(line_rx_path).exists(): |
| 237 | + print("Claim RX Line file not found. Run the generator or this will not go well.") |
| 238 | + sys.exit(1) |
| 239 | + |
| 240 | + line_rx_found = pd.read_csv(line_rx_path, dtype=str, keep_default_na=False) |
| 241 | + |
| 242 | + line_rx_matches = line_rx_found[ |
| 243 | + (line_rx_found["GEO_BENE_SK"] == clm_line["GEO_BENE_SK"]) |
| 244 | + & (line_rx_found["CLM_DT_SGNTR_SK"] == clm_line["CLM_DT_SGNTR_SK"]) |
| 245 | + & (line_rx_found["CLM_TYPE_CD"] == clm_line["CLM_TYPE_CD"]) |
| 246 | + & (line_rx_found["CLM_NUM_SK"] == clm_line["CLM_NUM_SK"]) |
| 247 | + ] |
| 248 | + |
| 249 | + return {} if line_rx_matches.empty else line_rx_matches.iloc[0] |
| 250 | + |
| 251 | + |
| 252 | +def extract_col_str(row: Any,name: str) -> str: |
| 253 | + return str(row.get(name, "")).strip() |
| 254 | + |
| 255 | + |
| 256 | +if __name__ == "__main__": |
| 257 | + main() |
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