BFD-4550: Condensing fields used to populate providers

apps/bfd-model-idr/StructureDefinitions/Source/Provider.json

@@ -91,6 +91,18 @@
                     }
                 ]
             },
+            {
+                "id": "Provider.PRVDR_LAST_OR_LGL_NAME",
+                "path": "Provider.PRVDR_LAST_OR_LGL_NAME",
+                "label": "Provider Last or Legal Name",
+                "min": 0,
+                "max": "1",
+                "type": [
+                    {
+                        "code": "string"
+                    }
+                ]
+            },
             {
                 "id": "Provider.PRVDR_MDL_NAME",
                 "path": "Provider.PRVDR_MDL_NAME",
@@ -189,8 +201,8 @@
                 ]
             },
             {
-                "id": "Provider.prvdr_zip",
-                "path": "Provider.prvdr_zip",
+                "id": "Provider.CLM_BLG_PRVDR_ZIP5_CD",
+                "path": "Provider.CLM_BLG_PRVDR_ZIP5_CD",
                 "label": "Billing Provider Zip 5",
                 "min": 0,
                 "max": "1",
@@ -199,6 +211,18 @@
                         "code": "string"
                     }
                 ]
+            },
+            {
+                "id": "Provider.PRVDR_TAX_NUM",
+                "path": "Provider.PRVDR_TAX_NUM",
+                "label": "Provider Tax Number",
+                "min": 0,
+                "max": "1",
+                "type": [
+                    {
+                        "code": "string"
+                    }
+                ]
             }
         ]
     }

apps/bfd-model-idr/augment_sample_resources.py

@@ -8,7 +8,6 @@
 
 prvdr_info_file = "sample-data/PRVDR_HSTRY_POC.csv"
 df = pd.read_csv(prvdr_info_file, dtype={"PRVDR_SK": str})
-df.head()
 
 cur_sample = sys.argv[1]
 cur_sample_data = {}
@@ -35,7 +34,7 @@
     "CLM_LINE_PMD_UNIQ_TRKNG_NUM",
     "CLM_LINE_PA_UNIQ_TRKNG_NUM",
 ]
-npis_used = []
+# npis_used = []
 cur_sample_data["providerList"] = []
 cur_careteam_sequence = 1
 # we only use PRVDR_SRVC_PRVDR_NPI_NUM for part D events.
@@ -44,11 +43,9 @@
 
 populate_fields_except_na = [
     "PRVDR_LGL_NAME",
-    "PRVDR_OSCAR_NUM",
+    # "PRVDR_OSCAR_NUM", No longer pulling this from PRVDR, rather based upon submission.
     "PRVDR_LAST_NAME",
     "PRVDR_1ST_NAME",
-    "PRVDR_MDL_NAME",
-    "PRVDR_TYPE_CD",
 ]
 provider_list = []
 
@@ -75,10 +72,11 @@ def convert_to_decimal(val: str | None) -> Decimal:
         continue
     provider_object = {}
     provider_object["PRVDR_SK"] = cur_sample_data.get(column)
-    if provider_object.get("PRVDR_SK") in npis_used:
-        provider_object["isDuplicate"] = True
-    else:
-        npis_used.append(provider_object.get("PRVDR_SK"))
+    # Removing since we are not going to populate more than header-level providers using contained resources.
+    # if provider_object.get("PRVDR_SK") in npis_used:
+    #    provider_object["isDuplicate"] = True
+    # else:
+    #    npis_used.append(provider_object.get("PRVDR_SK"))
 
     prvdr_hstry_for_npi = json.loads(
         df[df["PRVDR_SK"] == str(provider_object.get("PRVDR_SK"))].iloc[0].to_json()
@@ -94,13 +92,14 @@ def convert_to_decimal(val: str | None) -> Decimal:
             if prvdr_hstry_for_npi.get(fld)
         }
     )
-
+    """ we'll remove this...
     if prvdr_hstry_for_npi.get("PRVDR_TXNMY_CMPST_CD"):
         taxonomy_val = prvdr_hstry_for_npi.get("PRVDR_TXNMY_CMPST_CD")
         taxonomy_codes = [
             taxonomy_val[i : i + 10] for i in range(len(taxonomy_val), 10)
         ]
         provider_object["taxonomyCodes"] = taxonomy_codes
+    """
 
     # assign care team type + sequence for header-level info
     if len(header_columns.get(column)) > 0:
@@ -126,11 +125,18 @@ def convert_to_decimal(val: str | None) -> Decimal:
 
     # We may want to remove this in the future, depending on requirements
     # regarding address info.
-    if (
-        column == "PRVDR_BLG_PRVDR_NPI_NUM"
-        and "CLM_BLG_PRVDR_ZIP5_CD" in cur_sample_data
-    ):
-        provider_object["prvdr_zip"] = cur_sample_data.get("CLM_BLG_PRVDR_ZIP5_CD")
+    if column in ("PRVDR_BLG_PRVDR_NPI_NUM", "PRVDR_SRVC_PRVDR_NPI_NUM"):
+        if "CLM_BLG_PRVDR_ZIP5_CD" in cur_sample_data:
+            provider_object["CLM_BLG_PRVDR_ZIP5_CD"] = cur_sample_data.get("CLM_BLG_PRVDR_ZIP5_CD")
+        if provider_object.get("NPI_TYPE") == 2:
+            provider_object["PRVDR_LAST_OR_LGL_NAME"] = provider_object.get("PRVDR_LGL_NAME")
+        else:
+            provider_object["PRVDR_LAST_OR_LGL_NAME"] = provider_object.get("PRVDR_LAST_NAME")
+            # don't worry about first name since we already pull it in above.
+        if "CLM_BLG_PRVDR_OSCAR_NUM" in cur_sample_data:
+            provider_object["PRVDR_OSCAR_NUM"] = cur_sample_data.get("CLM_BLG_PRVDR_OSCAR_NUM")
+        if "CLM_BLG_PRVDR_TAX_NUM" in cur_sample_data:
+            provider_object["PRVDR_TAX_NUM"] = cur_sample_data.get("CLM_BLG_PRVDR_TAX_NUM")
 
     provider_list.append(provider_object)
 
@@ -150,7 +156,7 @@ def convert_to_decimal(val: str | None) -> Decimal:
         if item.get(line_supporting_info_col):
             item["SEQUENCE_INFO"] = supporting_info_seq
             supporting_info_seq += 1
-
+    """
     for line_col in line_columns:
         if line_col in item and item.get(line_col) not in npis_used:
             npi = item.get(line_col)
@@ -206,7 +212,7 @@ def convert_to_decimal(val: str | None) -> Decimal:
             ]
             careTeamSequence = matching_providers[0]
             item["careTeamSequence"] = [careTeamSequence]
-
+    """
     # for part D claims, sum CLM_LINE_INGRDNT_CST_AMT, CLM_LINE_SRVC_CST_AMT, CLM_LINE_SLS_TAX_AMT,
     # CLM_LINE_VCCN_ADMIN_FEE_AMT to set TOT_RX_CST_AMT
     tot_rx_amt = sum(

apps/bfd-model-idr/dictionary-support-files/ExplanationOfBenefit.yaml

@@ -2282,6 +2282,7 @@
     - CCLF4.PRVDR_OSCAR_NUM
     - CCLF4.CLM_BLG_PRVDR_OSCAR_NUM
   fhirPath: ExplanationOfBenefit.contained.where(id = %root.provider.reference.substring(1)).identifier.where(system='http://terminology.hl7.org/NamingSystem/CCN').value
+  notes: This will sometimes be populated on Practitioners, even though individuals cannot be assigned an OSCAR number.
 - inputPath: ExplanationOfBenefit-Institutional-Base.CLM_MDCR_INSTNL_BENE_PD_AMT
   appliesTo:
     - Outpatient

apps/bfd-model-idr/maps/ExplanationOfBenefit-Base.map

@@ -94,7 +94,6 @@ group createEOBBase(source src: ExplanationOfBenefitBase, target tgt: BFDEOB){
         src.providerList as provider where provider.isDuplicate.exists().not() and provider.careTeamType.exists().not() and provider.NPI_TYPE = 1 -> tgt.contained = create('Practitioner') as tgtPract then createPractitioner(provider, tgtPract) "Add Practitioner";
         src.providerList as provider where provider.isDuplicate.exists().not() and provider.careTeamType.exists().not() and provider.NPI_TYPE = 2 -> tgt.contained = create('Organization') as tgtOrg then createOrg(provider, tgtOrg) "Add Organization";
     } "Add billing provider";
-
 
     //Partial for PAC data, complete for adjudicated. Of note, we do this by source. So even if final action on PAC source, still "partial"
     src.CLM_SRC_ID as sourceSk where sourceSk = '20000' -> tgt.outcome = "complete" "Set NCH outcome to complete.";
@@ -592,13 +591,20 @@ group createOrg(source src: Provider, target tgt: Organization){
     src -> tgtId.system = "http://hl7.org/fhir/sid/us-npi" "set NPI system url";
     npi -> tgtId.value = npi "set NPI";
   } "Create NPI identifier";
-  src.PRVDR_LGL_NAME as orgName -> tgt.name = orgName;
+
+  src.PRVDR_LAST_OR_LGL_NAME as orgName -> tgt.name = orgName;
   src.PRVDR_OSCAR_NUM as ccn -> tgt.identifier = create('Identifier') as tgtId then{
     src -> tgtId.system = "http://terminology.hl7.org/NamingSystem/CCN" "set ccn system url";
     src -> tgtId.value = ccn "set ccn";
   } "Add OSCAR/CCN num";
 
-  src.prvdr_zip as zip5 -> tgt.address = create('Address') as tgtAddress then{
+  src.PRVDR_TAX_NUM as taxId -> tgt.identifier = create('Identifier') as tgtId then{
+    src -> tgtId.type = cc("http://terminology.hl7.org/CodeSystem/v2-0203","TAX") "set type";
+    src -> tgtId.system = "urn:oid:2.16.840.1.113883.4.4" "add system";
+    taxId -> tgtId.value = taxId "set tax Id";
+  } "Add tax Id";
+
+  src.CLM_BLG_PRVDR_ZIP5_CD as zip5 -> tgt.address = create('Address') as tgtAddress then{
     zip5-> tgtAddress.postalCode = zip5 "add zip code";
   } "Add zip code";
 }
@@ -616,17 +622,23 @@ group createPractitioner(source src: Provider, target tgt: Practitioner){
     src.PRVDR_SK as npi -> tgtId.value = npi "set NPI";
   } "Create NPI identifier";
 
-  src.PRVDR_LAST_NAME as familyName -> tgt.name = create('HumanName') as tgtName then {
+  src.PRVDR_OSCAR_NUM as ccn -> tgt.identifier = create('Identifier') as tgtId then{
+    src -> tgtId.system = "http://terminology.hl7.org/NamingSystem/CCN" "set ccn system url";
+    src -> tgtId.value = ccn "set ccn";
+  } "Add OSCAR/CCN num";
+
+  src.PRVDR_TAX_NUM as taxId -> tgt.identifier = create('Identifier') as tgtId then{
+    src -> tgtId.type = cc("http://terminology.hl7.org/CodeSystem/v2-0203","TAX") "set type";
+    src -> tgtId.system = "urn:oid:2.16.840.1.113883.4.4" "add system";
+    taxId -> tgtId.value = taxId "set tax Id";
+  } "Add tax Id";
+
+  src.PRVDR_LAST_OR_LGL_NAME as familyName -> tgt.name = create('HumanName') as tgtName then {
     familyName -> tgtName.family = familyName "set family name";
     src.PRVDR_1ST_NAME as firstName -> tgtName.given = firstName "set first name";
-    src.PRVDR_MDL_NAME as middleName -> tgtName.given = middleName "set middle name";
   } "Add name";
 
-  src.taxonomyCodes as taxonomyCodes -> tgt.qualification = create('BackboneElement') as tgtBBElement then{
-    taxonomyCodes as taxCode -> tgtBBElement.code = cc("http://nucc.org/provider-taxonomy", taxCode) "Add qualification";
-  } "Add taxonomy info to Practitioner resource.";
-
-  src.prvdr_zip as zip5 -> tgt.address = create('Address') as tgtAddress then{
+  src.CLM_BLG_PRVDR_ZIP5_CD as zip5 -> tgt.address = create('Address') as tgtAddress then{
     zip5-> tgtAddress.postalCode = zip5 "add zip code";
   } "Add zip code";
 }

apps/bfd-model-idr/maps/ExplanationOfBenefit-Helper.map

@@ -8,6 +8,66 @@ conceptmap "FinalActionIndicator" {
   s:N == t:"cancelled"
 }
 
+conceptmap "FED_PRVDR_SPCLTY_TO_TAXONOMY" {
+  prefix s = "https://hl7.org/fhir/string"
+  prefix t = "http://nucc.org/provider-taxonomy"
+
+  s:"1" == t:"208D00000X"
+  s:"2" == t:"208600000X"
+  s:"3" == t:"207K00000X"
+  s:"4" == t:"207Y00000X"
+  s:"5" == t:"207L00000X"
+  s:"6" == t:"207RC0000X"
+  s:"7" == t:"207N00000X"
+  s:"8" == t:"207Q00000X"
+  s:"9" == t:"208VP0014X"
+  s:"10" == t:"207RG0100X"
+  s:"11" == t:"207R00000X"
+  s:"12" == t:"204D00000X"
+  s:"13" == t:"2084N0400X"
+  s:"14" == t:"207T00000X"
+  s:"63" == t:"335V00000X"
+  s:"64" == t:"231H00000X"
+  s:"65" == t:"225100000X"
+  s:"66" == t:"207RR0500X"
+  s:"67" == t:"225X00000X"
+  s:"68" == t:"103TC0700X"
+  s:"69" == t:"291U00000X"
+  s:"70" == t:"193200000X"
+  s:"71" == t:"133V00000X"
+  s:"72" == t:"208VP0000X"
+  s:"74" == t:"261QX0203X"
+  s:"76" == t:"2086S0129X"
+  s:"77" == t:"2086S0129X"
+  s:"78" == t:"2086S0129X"
+  s:"79" == t:"207RA0401X"
+  s:"80" == t:"1041C0700X"
+  s:"81" == t:"207RC0200X"
+  s:"82" == t:"207RH0000X"
+  s:"83" == t:"207RH0003X"
+  s:"84" == t:"2083P0901X"
+  s:"85" == t:"204E00000X"
+  s:"86" == t:"2084N0600X"
+  s:"89" == t:"364S00000X"
+  s:"90" == t:"207RX0202X"
+  s:"91" == t:"2086X0206X"
+  s:"92" == t:"2085R0001X"
+  s:"93" == t:"207P00000X"
+  s:"94" == t:"2085R0204X"
+  s:"96" == t:"156FX1800X"
+  s:"97" == t:"363A00000X"
+  s:"98" == t:"207VX0201X"
+  s:"A0" == t:"282N00000X"
+  s:"A1" == t:"314000000X"
+  s:"A2" == t:"313M00000X"
+  s:"A3" == t:"313M00000X"
+  s:"A4" == t:"251E00000X"
+  s:"A5" == t:"333600000X"
+  s:"A6" == t:"332B00000X"
+  s:"A7" == t:"332B00000X"
+  s:"A8" == t:"332B00000X"
+}
+
 conceptmap "CLM_LTST_CLM_IND" {
   prefix s = "https://hl7.org/fhir/string"
   prefix t = "http://hl7.org/fhir/explanationofbenefit-status"

apps/bfd-model-idr/maps/ExplanationOfBenefit-Pharmacy.map

@@ -84,6 +84,9 @@ group createEOBPharmacy(source src: ExplanationOfBenefitPharmacy, target tgt: BF
         src.providerList as provider where provider.isDuplicate.exists().not() and provider.careTeamType.exists().not() and provider.NPI_TYPE = 2 -> tgt.contained = create('Organization') as tgtOrg then createOrg(provider, tgtOrg) "Add Organization";
     } "Add billing provider";
 
+    //QLFYR_TYPE_CD logic goes here pending CMS decision.
+
+
     src.providerList as pList where pList.careTeamType.exists() -> tgt then {
       pList where pList.NPI_TYPE = 1 and pList.isDuplicate.exists().not() -> tgt.contained = create('Practitioner') as tgtPract then createPractitioner(pList, tgtPract) "Add Practitioner";
       pList where pList.NPI_TYPE = 2 and pList.isDuplicate.exists().not() -> tgt.contained = create('Organization') as tgtOrg then createOrg(pList, tgtOrg) "Add Organization";

apps/bfd-model-idr/sample-data/EOB-Base-Sample.json

@@ -128,6 +128,7 @@
     "CLM_MDCR_COINSRNC_AMT":"9.82",
     "CLM_NCVRD_CHRG_AMT":"11.50",
     "CLM_BLOOD_LBLTY_AMT":"121.10",
+    "CLM_BLG_PRVDR_TAX_NUM": "765432",
     "institutionalComponents":{"CLM_HIPPS_MODEL_BNDLD_PYMT_AMT":"44.11","CLM_MDCR_HHA_TOT_VISIT_CNT":"2","CLM_MDCR_HOSPC_PRD_CNT":"1","CLM_MDCR_INSTNL_PRMRY_PYR_AMT":"50.50","CLM_MDCR_IP_LRD_USE_CNT":"7","CLM_INSTNL_PER_DIEM_AMT":"5.00","CLM_INSTNL_CVRD_DAY_CNT":"30","CLM_HIPPS_UNCOMPD_CARE_AMT":"15.00","CLM_MDCR_IP_PPS_DSPRPRTNT_AMT":"15.11","CLM_MDCR_IP_PPS_DRG_WT_NUM":"1.08","CLM_INSTNL_MDCR_COINS_DAY_CNT":"3","CLM_INSTNL_NCVRD_DAY_CNT":"4","CLM_MDCR_IP_PPS_EXCPTN_AMT":"11.50","CLM_MDCR_IP_PPS_CPTL_FSP_AMT":"11.81","CLM_MDCR_IP_PPS_CPTL_IME_AMT":"14.11","CLM_MDCR_IP_PPS_OUTLIER_AMT":"40.11","CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT":"13.31","CLM_MDCR_IP_PPS_CPTL_TOT_AMT":"11.11","CLM_INSTNL_DRG_OUTLIER_AMT":"15.89","CLM_MDCR_IP_BENE_DDCTBL_AMT":"19.11","CLM_INSTNL_PRFNL_AMT":"93.22","CLM_FINL_STDZD_PYMT_AMT":"10.00","CLM_HAC_RDCTN_PYMT_AMT":"10.01","CLM_HIPPS_MODEL_BNDLD_PMT_AMT":"10.02","CLM_HIPPS_READMSN_RDCTN_AMT":"10.03","CLM_HIPPS_VBP_AMT":"10.04","CLM_INSTNL_LOW_VOL_PMT_AMT":"10.05","CLM_MDCR_IP_1ST_YR_RATE_AMT":"10.06","CLM_MDCR_IP_SCND_YR_RATE_AMT":"10.07","CLM_PPS_MD_WVR_STDZD_VAL_AMT":"10.08","CLM_SITE_NTRL_CST_BSD_PYMT_AMT":"10.09","CLM_SITE_NTRL_IP_PPS_PYMT_AMT":"10.10","CLM_SS_OUTLIER_STD_PYMT_AMT":"10.11"},
     "PRVDR_ATNDG_PRVDR_NPI_NUM":"1942945159",
     "PRVDR_OPRTG_PRVDR_NPI_NUM":"1942945159",