ManikandanandClaude Opus 5.5
ba15a574ab
Snapshot of the working project as of 2026-10-23 (local 2d4d4fc), one commit with no earlier history: the tracked files were de-identified first (synthetic claim ids and patient data only; see Context.md section 7). Credentials, run logs, screenshots, claim reports and client workbooks are gitignored and not included. Co-Authored-By: Claude Opus 5.5 <noreply@anthropic.com>
82 lines
3.5 KiB
Python
82 lines
3.5 KiB
Python
"""
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Payer -> Group Name lookup for the categorization step.
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Exact-string match against a small hand-edited table (`payer_groups.json`,
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next to this package) — no fuzzy or substring matching. eCW's own PAYER
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values already differ by case and spacing for what is really the same
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carrier (see `tests/test_payer_groups.py`'s docstring), so "close enough"
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matching has no safe way to pick which known string a new one is closest to.
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An unrecognized payer must come back as None and get a human's attention —
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never a guess, on billing data.
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Since 2026-10-06 the table is the team's own template: the Payer Name ->
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Payer Group Name pairs of their Claim Status Dashboard, imported with
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`tools/import_payer_groups.py` (re-run it when the dashboard changes). Adding
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a payer by hand is still a one-line edit to `payer_groups.json`.
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"""
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import json
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from pathlib import Path
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_CONFIG_PATH = Path(__file__).resolve().parent.parent / "payer_groups.json"
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def load_mapping(path=None) -> dict:
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"""The payer -> group table. `path` defaults to the shipped config."""
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p = Path(path) if path else _CONFIG_PATH
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if not p.exists():
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raise FileNotFoundError(
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f"{p} not found — the payer group table is missing")
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data = json.loads(p.read_text(encoding="utf-8"))
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if not isinstance(data, dict):
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raise ValueError(
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f"{p} does not contain a JSON object (payer -> group name) — "
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f"got {type(data).__name__}")
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return data
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def classify(payer: str, mapping: dict) -> str:
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"""The Group Name for this exact PAYER string, or None if unmapped."""
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return mapping.get((payer or "").strip())
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# ── Group names the CONDITIONS decide on ─────────────────────────────────────
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# Since 2026-10-06 `payer_groups.json` is the team's own template — the
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# "Payer Name" -> "Payer Group Name" pairs of their Claim Status Dashboard
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# (tools/import_payer_groups.py) — so its group names are the dashboard's
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# ("Commercial Ins", "RAE (Behavioral Health)", "Dental - CHP+/DentaQuest"...)
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# and that is what the Group Name columns show. The condition modules were
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# written against the earlier, shorter names, which stay the vocabulary of
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# their rules; this table translates. A name not listed (including every
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# earlier short name) passes through unchanged.
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RULE_GROUP = {
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"Commercial Ins": "Commercial",
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"RAE (Behavioral Health)": "RAE payer",
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"Regional Accountable Entity-RAE (Reporting Group)": "RAE payer",
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"Dental - CHP+/DentaQuest": "Dentaquest",
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"Self Pay": "Program", # the clinic's programs (Outreach, slides…)
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"Payer Not In Group": None, # the dashboard's own "unclassified"
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}
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# A payer whose condition rule differs from its dashboard group. Empty since
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# 2026-10-21: the Medicare Advantage plans (AARP Medicare Advantage, Aetna
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# Medicare ADV) were kept on Medicare here until the operator ruled; the
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# ruling is "follow the dashboard", so they are Commercial for every
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# condition (#21 95/93 not #22 G2025; no #14, #19, #27-#29; #18 / #20 add).
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RULE_OVERRIDES = {}
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def rule_group(payer: str, mapping: dict) -> str:
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"""
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The group a condition's rule should use for this PAYER, or None if
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unmapped: the payer's own override if it has one, else its Group Name
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translated through RULE_GROUP.
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"""
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key = (payer or "").strip()
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if key in RULE_OVERRIDES:
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return RULE_OVERRIDES[key]
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group = classify(key, mapping)
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if group is None:
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return None
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return RULE_GROUP.get(group, group)
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