Chris Bull
54a62944aa
QCQA Integration * Merged in bugfix/npi_hotfix (pull request #305) double filter for duplicates * double filter for duplicates Approved-by: Katon Minhas * Merged in chore/npi (pull request #309) npi hotfix into main * npi hotfix into main * npi hotfix into main Approved-by: Alex Galarce * Merged in chore/irs (pull request #310) irs hotfix into main * irs hotfix into main * pass top sheet to irs hotfix func * docstring updates Approved-by: Alex Galarce * slight fix to methodology short fix * Merged in bugfix/all_cnc_hotfixes (pull request #302) DRAFT: Bugfix/all cnc hotfixes * Pipeline fix - health plan state * Update for prompt vs non-prompt fixes * Revert utils.find_regex_matches() * Remove prints * Non-prompt run * Health Plan State, IRS, NPI, LOB, Lesser, Prov 2, Default, Rate Standard, Contract Effective Date, Term Group * Merged in bugfix/agreement_name (pull request #294) contract title fixed * contract title fixed * Merged bugfix/all_cnc_hotfixes into bugfix/agreement_name Approved-by: Katon Minhas * All hotfixes added * Fixed utils * fix for clean_contract_effective_date * Merged in default-fix (pull request #296) moved default funcs to the top, dropped intermediate columns * moved default funcs to the top, dropped intermediate columns Approved-by: Katon Minhas * quick fix to dropping extra columns * Merged in bugfix/effective_date_meridian (pull request #297) fixed effective date for meridian contracts * fixed effective date for meridian contracts Approved-by: Kat… * Merged in hotfix/irs_tweak (pull request #303) returning None instead on str(N/A) * returning None instead on str(N/A) Approved-by: Katon Minhas * Merged in bugfix/npi_hotfix (pull request #305) double filter for duplicates * double filter for duplicates Approved-by: Katon Minhas * Merged in bugfix/all_cnc_hotfixes (pull request #302) DRAFT: Bugfix/all cnc hotfixes * Pipeline fix - health plan state * Update for prompt vs non-prompt fixes * Revert utils.find_regex_matches() * Remove prints * Non-prompt run * Health Plan State, IRS, NPI, LOB, Lesser, Prov 2, Default, Rate Standard, Contract Effective Date, Term Group * Merged in bugfix/agreement_name (pull request #294) contract title fixed * contract title fixed * Merged bugfix/all_cnc_hotfixes into bugfix/agreement_name Approved-by: Katon Minhas * All hotfixes added * Fixed utils * fix for clean_contract_effective_date * Merged in default-fix (pull request #296) moved default funcs to the top, dropped intermediate columns * moved default funcs to the top, dropped intermediate columns Approved-by: Katon Minhas * quick fix to dropping extra columns * Merged in bugfix/effective_date_meridian (pull request #297) fixed effective date for meridian contracts * fixed effective date for meridian contracts Approved-by: Kat… * Merged in hotfix/irs_tweak (pull request #303) returning None instead on str(N/A) * returning None instead on str(N/A) Approved-by: Katon Minhas * Merged in bugfix/npi_hotfix (pull request #305) double filter for duplicates * double filter for duplicates Approved-by: Katon Minhas * Merged in chore/npi (pull request #309) npi hotfix into main * npi hotfix into main * npi hotfix into main Approved-by: Alex Galarce * Merged in chore/irs (pull request #310) irs hotfix into main * irs hotfix into main * pass top sheet to irs hotfix func * docstring updates Approved-by: Alex Galarce * Merged in bugfix/clean_short_methodology (pull request #312) changed regex pattern in get_short_methodology * changed regex pattern in Approved-by: Katon Minhas * Merged in hotfix/filename_fix (pull request #314) filename corrected * filename corrected * Merged main into hotfix/filename_fix Approved-by: Katon Minhas * Merge remote-tracking branch 'remotes/origin/main' into HEAD * rearranged qcqa scripts/funcs and prep for merge w main, moved lots of stuff to postprocess * slight change to icm_number_fix * transitioned some qcqa funcs to postprocessing, added fields to qcqa report * Merged main into QCQA_Integration * reorganization of qa qc helpers, consolidate_output, qa_qc from Katon's feedback * adhoc and at scale qcqa ran successfully * fix to consolidate_output * Merge remote-tracking branch 'remotes/origin/main' into QCQA_Integration * Merged main into QCQA_Integration * small changes to npi_check, changed name of config.CONTRACT_FILE_NAME to config.FILE_NAME_COLUMN Approved-by: Katon Minhas
822 lines
30 KiB
Python
822 lines
30 KiB
Python
import config
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import pandas as pd
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VALID_LOBS = [
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"MEDICARE",
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"MEDICARE ADVANTAGE",
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"MEDICAID",
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"NON-MEDICAID",
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"MARKETPLACE",
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"COMMERCIAL",
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"COMMERCIAL-EXCHANGE",
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"MEDICAID-MEDICARE",
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]
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## PROGRAMS ##
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state_list = config.STATE.split("-")
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VALID_PROGRAMS = []
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for state in state_list:
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if state == "TX":
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VALID_PROGRAMS += [
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"CHIP",
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"CHIP-P",
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"CHIP-PERINATE",
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"STAR",
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"STAR+PLUS",
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"DUAL SPECIAL NEEDS PLAN",
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"DSNP",
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"D-SNP",
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"FOSTER CARE",
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"MA Plan",
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"MA-PD",
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"MMP",
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"HMO",
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"PPO",
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"EPO",
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]
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elif state == "IL":
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VALID_PROGRAMS += [
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"Meridian Medicaid Plan",
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"YouthCare HealthChoice Illinois",
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"Wellcare",
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"Ambetter",
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"Meridican Medicare-Medicaid Plan",
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"Meridian Managed Long Term Services and Support Plan",
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]
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elif state == "FL":
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VALID_PROGRAMS += [
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"Sunshine Health",
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"Wellcare",
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"Ambetter by Sunshine Health",
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"Childrens Medical Services Health Plan",
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]
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elif state == "KY":
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VALID_PROGRAMS += [
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"Wellcare",
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"Wellcare of Kentucky",
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"Ambetter for Wellcare of Kentucky",
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]
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elif state == "OH":
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VALID_PROGRAMS += [
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"Buckeye Health Plan",
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"MyCare Ohio",
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"Wellcare",
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"Ambetter from Buckeye Health Plan",
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]
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elif state == "MI":
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VALID_PROGRAMS += [
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"Meridian",
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"Meridian Complete",
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"Wellcare",
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"Ambetter from Meridian",
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]
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elif state == "LA":
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VALID_PROGRAMS += [
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"Louisiana Healthcare Connections",
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"Wellcare",
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"Ambetter from Louisiana Healthcare Connections",
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]
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elif state == "OK":
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VALID_PROGRAMS += [
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"Oklahoma Complete Health",
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"Wellcare",
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"Ambetter of Oklahoma",
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]
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elif state == "NY":
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VALID_PROGRAMS += ["Fidelis Care", "Wellcare", "Ambetter from Fidelis Care"]
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VALID_PROGRAMS = list(set(VALID_PROGRAMS))
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if VALID_PROGRAMS:
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VALID_PROGRAMS = f"One or more programs may be valid. ONLY from the following values: {VALID_PROGRAMS}. If there language such as 'MA PLAN/MA-PD PLAN/DSNP PLAN' and also 'Medicare -HMO' present, then ensure you extract HMO as well with the other plans"
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else:
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VALID_PROGRAMS = f"A program is defined as a plan or product offering from an insurance company. Look for the brand name of a health plan."
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VALID_PROV_TYPES = ["Facility", "Professional", "Ancillary"]
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# VALID_NETWORKS = ['HMO', 'PPO', 'EPO']
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VALID_MSR = [
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"Multiple Procedures",
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"Multiple Outpatient",
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"Multiple Surgical",
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"Multiple Surgeries",
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]
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VALID_DEFAULT = [
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"codes not found in",
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"all other services",
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"services not listed",
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"except for those listed below",
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"codes not covered",
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"services not defined",
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"no established payment",
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"no established fee amount",
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"procedures not listed",
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"default",
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]
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INVALID_DEFAULT = ["Except as otherwise provided"]
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NULL_ANSWER_TERMS = [
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"do not have",
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"do not see",
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"does not specify",
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"does not explicitly",
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"don't know",
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"Not specified",
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"don't see",
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"don't have",
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"Nothing found",
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"does not contain",
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"unable to find",
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]
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EXCLUSION_TERMS = [
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"Exclusions",
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"Excluded",
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"Exclude",
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"Not including",
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"Not to include",
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]
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VALID_MEDICALLY_NECESSARY = ["Medically Necessary", "Medical Necessity"]
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INVALID_MEDICALLY_NECESSARY = [
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"nan",
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"N/A",
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"Defined",
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"Records",
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"Payments",
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"Definition",
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"mean",
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"Those medical services which:",
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"twenty-four",
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"seven",
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"24",
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"7",
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]
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INVALID_HCBS = [
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"nan",
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"N/A",
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"Defined",
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"Definition",
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"mean",
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] # TODO add postprocessing for HCBS
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# Provider Type Level 2
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VALID_PROF = [
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"Physician",
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"Primary Care Provider",
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"Dual Capacity Physician",
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"Mid-Level Practicioner",
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"Specialist",
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"OB/GYN",
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"Behavioral Health",
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"Therapist",
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"Surgery",
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"Independent RHC",
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"Ambulance Services",
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"Home Health",
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]
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VALID_ANC = [
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"DME",
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"Durable Medical Equipment",
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"Radiology",
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"Lab",
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"Home Health",
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"Hospice",
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"Dialysis",
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"PT/OT/ST",
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"Urgent Care",
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"Home Infusion",
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"Ambulatory Surgery Center",
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"ASC",
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"Ambulance Services",
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"Home Health",
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]
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VALID_FAC = [
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"Skilled Nursing Facility",
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"Ambulatory Surgery Center",
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"ASC",
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"Hospital",
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"Clinic",
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"Rural Health Clinic",
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"FQHC",
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"Long Term Care",
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"Community Mental Health Center",
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]
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def select_valid_prov_2(provider_type):
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if isinstance(provider_type, pd.Series):
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# If it's a Series, use str.contains() method
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if provider_type.str.contains("PROFESSIONAL", case=False, na=False).any():
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valid_list = VALID_PROF
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elif provider_type.str.contains("ANCILLARY", case=False, na=False).any():
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valid_list = VALID_ANC
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elif provider_type.str.contains("FACILITY", case=False, na=False).any():
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valid_list = VALID_FAC
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else:
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valid_list = VALID_PROF + VALID_ANC + VALID_FAC
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else:
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# If it's a single string, use the original logic
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if "PROFESSIONAL" in provider_type.upper():
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valid_list = VALID_PROF
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elif "ANCILLARY" in provider_type.upper():
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valid_list = VALID_ANC
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elif "FACILITY" in provider_type.upper():
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valid_list = VALID_FAC
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else:
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valid_list = VALID_PROF + VALID_ANC + VALID_FAC
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return valid_list
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RATE_REPLACEMENTS = {
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"Medicare": "MCR",
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"Medicaid": "MCD",
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"Allowable Charges": "AC",
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"Allowed Amount": "AA",
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"Billed Charges": "BC",
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"Average Sales Price": "ASP",
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"Average Wholesale Price": "AWP",
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"Amount Payable by Medicare": "MCR",
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"Amount Payable by Medicaid": "MCD",
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}
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# List of fields that will have derived indicators
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DERIVED_INDICATOR_FIELDS = [
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"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE",
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"INVOICE_PRICING_LANGUAGE",
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"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE",
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"CLAIMS_EDITING_LANGUAGE",
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"DISPARAGEMENT_PROHIBITION_LANGUAGE",
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"NONSTANDARD_APPEALS_PROCESS_LANGUAGE",
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"RELATIONSHIP_OF_PARTIES_LANGUAGE",
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"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE",
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"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE",
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"NETWORK_ACCESS_FEES_LANGUAGE",
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"MEMBER_CONFINEMENT_DAYS_LANGUAGE",
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"INDEPENDENT_REVIEW_LANGUAGE",
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"EXCLUSIVITY_REQUIREMENT_LANGUAGE",
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"LATE_PAID_CLAIMS_LANGUAGE",
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"COST_SETTLEMENT_LANGUAGE",
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"DELEGATED_TERMS",
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"SEQUESTRATION_LANGUAGE",
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]
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B_MAPPING = {
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"Filename": "Contract Name",
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"Parent Agreement Code": "Parent Agreement Code",
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"Pages": "Pages",
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"page_num": "Page_Num",
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"EXHIBIT": "Attachment/Exhibit",
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"CONTRACT_LOB": "Line of Business",
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"PROV_TYPE": "Provider Type",
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"PROV_TYPE_LEVEL_2": "Provider Type - Level 2",
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"IP_OP": "IP/OP",
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"FULL_SERVICE": "Service Type",
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"CONTRACT_PROGRAM": "Plan Type",
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"LESSER": "Lesser of Logic language, included (Y/N)",
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"LESSER_RATE": "Lesser of Rate",
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"FULL_METHODOLOGY": "Reimb. Methodology",
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"SHORT_METHODOLOGY": "Reimb. Methodology_Short",
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"RATE_STANDARD": "If rate is % of Payor or MCR [STANDARD]",
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"RATE_SHORT": "If rate is % of Payor or MCR [STANDARD]_Short",
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"FLAT_FEE_STANDARD": "FLAT FEE",
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"DEFAULT_TERM": "Default Term",
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"DEFAULT_RATE": "Default Rate",
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"MEDICAL_NECESSITY_LANGUAGE": "Medical Necessity Language (Language)",
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"MEDICAL_NECESSITY_LANGUAGE_IND": "Medical Necessity Language (Y/N)",
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'Inclusion of essential RBRVS "Fee Source" Language (Y/N)': 'Inclusion of essential RBRVS "Fee Source" Language (Y/N)',
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"CDM_IND": "CDM Neutralization Language, included (Y/N)",
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"CHARGEMASTER": "CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE",
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"ADD_ON_REIMBURSEMENT_LANGUAGE": "Add On Reimbursement (Language)",
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"ADD_ON_REIMBURSEMENT_IND": "Add On Reimbursement (Y/N)",
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"SINGLE_CODE_MULTIPLE_RATES_LANGUAGE": "Single Code Multiple Rates (Language)",
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"SINGLE_CODE_MULTIPLE_RATES_IND": "Single Code Multiple Rates (Y/N)",
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"IP - DSH/IME/UC, included (Y/N)": "IP - DSH/IME/UC, included (Y/N)",
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"IP - Stoploss Catastrophic Threshold": "IP - Stoploss Catastrophic Threshold",
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"EXCLUSIONS": "Exclusions",
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"NOT_TO_EXCEED": "Not to Exceed",
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"RATE_ESCALATOR_IND": "Escalator or COLA (Y/N)",
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"RATE_ESCALATOR_DT": "Escalator I, Eff. Date",
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}
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AC_MAPPING = {
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"Filename": "Contract Name",
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"Pages": "Pages",
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"Parent Agreement Code": "Parent Agreement Code",
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"CONTRACT_TITLE": "Agreement_Name (Contract Title)",
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"PAYER_NAME": "PAYER NAME",
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"AFFILIATION_CLAUSE_IND": "Affiliate (Y/N)",
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"TERM_CLAUSE": "Term Clause",
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"CONTRACT_AUTO_RENEWAL_IND": "Contract Auto-Renewal Indicator",
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"CONTRACT_TERMINATION_DT": "Termination Date",
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"TERMINATION_UPON_NOTICE": "Termination Upon Notice - Days",
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"TERMINATION_UPON_CAUSE": "Termination With Cause - Days",
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"AMEND_CONTRACT_NOTICE_IND": "Amend Contract Upon notice Flag (Y/N)",
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"TIME_TO_OBJECT": "Timeframe to Object - Days",
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"ASSIGNMENTS_CLAUSE_IND": "Assignments Clause (Y/N)",
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"CONTRACT_EFFECTIVE_DT": "Contract Effective Date",
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"PROV_GROUP_TIN": "IRS #",
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"PROV_GROUP_NAME": "IRS_Name",
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"PROV_GROUP_NPI": "NPI (10-digits)",
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"PROV_GROUP_TIN_SIGNATORY": "PROV_GROUP_TIN_SIGNATORY",
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"PROV_TIN_OTHER": "PROV_TIN_OTHER",
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"PROV_NPI_OTHER": "PROV_NPI_OTHER",
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"NOTICE_PROVIDER_NAME": "Notice to Provider Name",
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"NOTICE_PROVIDER_ADDRESS": "Notice to Provider Address",
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"HEALTH_PLAN_STATE": "Health Plan State",
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"CREDENTIALING_APP_IND": "Credentialing Application Indicator",
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"SEQUESTRATION_LANGUAGE": "Sequestration Language",
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"SEQUESTRATION_LANGUAGE_IND": "Sequestration Reductions (Y/N)",
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"NPI_NAME": "NPI Name",
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"DELEGATED_TERMS_IND": "Delegated Function Indicator",
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"DELEGATED_TERMS": "Delegated Terms",
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"ECM": "ECM",
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"NATIONAL_AGREEMENT_IND": "National Agreement Indicator",
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"COST_SETTLEMENT_LANGUAGE_IND": "Cost Settlement (Y/N)",
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"COST_SETTLEMENT_LANGUAGE": "Cost Settlement (Language)",
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"LATE_PAID_CLAIMS_LANGUAGE_IND": "Late Paid Claims (Y/N)",
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"LATE_PAID_CLAIMS_LANGUAGE": "Late Paid Claims (Language)",
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"DEEMER_AMENDMENT": "Deemer Amendment",
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"REGULATORY_REQUIREMENTS": "Regulatory Requirements",
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"RECOVERY_RIGHTS": "Recovery Rights",
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"ARBITRATION_AND_DISPUTES": "Arbitration and Disputes",
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"EXCLUSIVITY_REQUIREMENT_LANGUAGE_IND": "Exclusivity Requirement (Y/N)",
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"EXCLUSIVITY_REQUIREMENT_LANGUAGE": "Exclusivity Requirement (Language)",
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"PAYOR": "Payor",
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"PARTICIPATION_IN_PRODUCTS": "Participation in Products",
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"CLEAN_CLAIM": "Clean Claim",
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"INDEPENDENT_REVIEW_LANGUAGE_IND": "Independent Review (Y/N)",
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"INDEPENDENT_REVIEW_LANGUAGE": "Independent Review (Language)",
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"INDEMNIFICATION": "Indemnification",
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"ACCESS_TO_MEDICAL_RECORDS": "Access to Medical Records",
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"MEMBER_CONFINEMENT_DAYS_LANGUAGE_IND": "Member Confinement Days Language (Y/N)",
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"MEMBER_CONFINEMENT_DAYS_LANGUAGE": "Member Confinement Days Language (Language)",
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"NETWORK_ACCESS_FEES_LANGUAGE_IND": "Network Access Fees (Y/N)",
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"NETWORK_ACCESS_FEES_LANGUAGE": "Network Access Fees (Language)",
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"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE_IND": "Payment in Advance of Claims Submission Language (Y/N)",
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"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE": "Payment in Advance of Claims Submission Language",
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"ELIGIBILITY_VERIFICATION": "Eligibility Verification",
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"PREAUTHORIZATION": "Preauthorization",
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"POLICIES_AND_PROCEDURES": "Policies and Procedures",
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"INSURANCE_REQUIREMENT": "Insurance Requirement",
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"CARVEOUT_VENDORS": "Carve-Out Vendors",
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"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE_IND": "Conflicts Between Certain Documents (Y/N)",
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"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE": "Conflicts Between Certain Documents (Language)",
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"RELATIONSHIP_OF_PARTIES_LANGUAGE_IND": "Relationship of Parties (Y/N)",
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"RELATIONSHIP_OF_PARTIES_LANGUAGE": "Relationship of Parties (Language)",
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"NONSTANDARD_APPEALS_PROCESS_LANGUAGE_IND": "Nonstandard Appeals Process (Y/N)",
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"NONSTANDARD_APPEALS_PROCESS_LANGUAGE": "Nonstandard Appeals Process (Language)",
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"PRODUCT_REMOVAL": "Product Removal",
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"DISPARAGEMENT_PROHIBITION_LANGUAGE_IND": "Disparagement Prohibition (Y/N)",
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"DISPARAGEMENT_PROHIBITION_LANGUAGE": "Disparagement Prohibition (Language)",
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"CLAIMS_EDITING_LANGUAGE_IND": "Claims Editing Language (Y/N)",
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"CLAIMS_EDITING_LANGUAGE": "Claims Editing Language (Language)",
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"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE_IND": "Guarantee of Provider Yield (Y/N)",
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"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE": "Guarantee of Provider Yield (Language)",
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"HCBS_SERVICES": "HCBS Services",
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"ADD_ON_REIMBURSEMENT_IND": "Add On Reimbursement (Y/N)",
|
|
"ADD_ON_REIMBURSEMENT_LANGUAGE": "Add On Reimbursement (Language)",
|
|
"PMPM": "PMPM",
|
|
"SINGLE_CODE_MULTIPLE_RATES_IND": "Single Code Multiple Rates (Y/N)",
|
|
"SINGLE_CODE_MULTIPLE_RATES_LANGUAGE": "Single Code Multiple Rates (Language)",
|
|
"INVOICE_PRICING_LANGUAGE_IND": "Invoice Pricing (Y/N)",
|
|
"INVOICE_PRICING_LANGUAGE": "Invoice Pricing (Language)",
|
|
"TEMPLATE": "Template",
|
|
"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE_IND": "Provider-based Billing Exclusion (Y/N)",
|
|
"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE": "Provider-based Billing Exclusion (Language)",
|
|
"NON_RENEWAL_LANGUAGE": "Non-Renewal Language",
|
|
"NON_RENEWAL_DAYS": "Non-Renewal - Days",
|
|
"TIMELY_FILING": "Timely Filing",
|
|
}
|
|
|
|
|
|
ABC_COLUMNS = [
|
|
"Contract Name",
|
|
"Agreement_Name (Contract Title)",
|
|
"PAYER NAME",
|
|
"Health Plan State",
|
|
"Affiliate (Y/N)",
|
|
"Credentialing Application Indicator",
|
|
"Term Clause",
|
|
"Contract Auto-Renewal Indicator",
|
|
"Termination Date",
|
|
"Termination Upon Notice - Days",
|
|
"Termination With Cause - Days",
|
|
"Non-Renewal Language",
|
|
"Non-Renewal - Days",
|
|
"Amend Contract Upon notice Flag (Y/N)",
|
|
"Timeframe to Object - Days",
|
|
"Assignments Clause (Y/N)",
|
|
"Contract Effective Date",
|
|
"IRS #",
|
|
"IRS_Name",
|
|
"NPI (10-digits)",
|
|
"NPI Name",
|
|
"PROV_GROUP_TIN_SIGNATORY",
|
|
"PROV_TIN_OTHER",
|
|
"PROV_NPI_OTHER",
|
|
"Notice to Provider Name",
|
|
"Notice to Provider Address",
|
|
"Sequestration Language",
|
|
"Sequestration Reductions (Y/N)",
|
|
"Parent Agreement Code",
|
|
"Pages",
|
|
"Page_Num",
|
|
"Attachment/Exhibit",
|
|
"Line of Business",
|
|
"Provider Type",
|
|
"Provider Type - Level 2",
|
|
"IP/OP",
|
|
"Service Type",
|
|
"Plan Type",
|
|
"Lesser of Logic language, included (Y/N)",
|
|
"Lesser of Rate",
|
|
"Reimb. Methodology",
|
|
"Reimb. Methodology_Short",
|
|
"If rate is % of Payor or MCR [STANDARD]",
|
|
"If rate is % of Payor or MCR [STANDARD]_Short",
|
|
"FLAT FEE",
|
|
"Default Term",
|
|
"Default Rate",
|
|
'Inclusion of essential RBRVS "Fee Source" Language (Y/N)',
|
|
"CDM Neutralization Language, included (Y/N)",
|
|
"CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE",
|
|
"IP - DSH/IME/UC, included (Y/N)",
|
|
"IP - Stoploss Catastrophic Threshold",
|
|
"Exclusions",
|
|
"Not to Exceed",
|
|
"Escalator or COLA (Y/N)",
|
|
"Escalator I, Eff. Date",
|
|
"Delegated Function Indicator",
|
|
"Delegated Terms",
|
|
"ECM",
|
|
"National Agreement Indicator",
|
|
"Cost Settlement (Y/N)",
|
|
"Cost Settlement (Language)",
|
|
"Late Paid Claims (Y/N)",
|
|
"Late Paid Claims (Language)",
|
|
"Deemer Amendment",
|
|
"Regulatory Requirements",
|
|
"Recovery Rights",
|
|
"Arbitration and Disputes",
|
|
"Exclusivity Requirement (Y/N)",
|
|
"Exclusivity Requirement (Language)",
|
|
"Payor",
|
|
"Participation in Products",
|
|
"Clean Claim",
|
|
"Independent Review (Y/N)",
|
|
"Independent Review (Language)",
|
|
"Indemnification",
|
|
"Access to Medical Records",
|
|
"Member Confinement Days Language (Y/N)",
|
|
"Member Confinement Days Language (Language)",
|
|
"Network Access Fees (Y/N)",
|
|
"Network Access Fees (Language)",
|
|
"Payment in Advance of Claims Submission Language (Y/N)",
|
|
"Payment in Advance of Claims Submission Language",
|
|
"Eligibility Verification",
|
|
"Preauthorization",
|
|
"Policies and Procedures",
|
|
"Insurance Requirement",
|
|
"Carve-Out Vendors",
|
|
"Conflicts Between Certain Documents (Y/N)",
|
|
"Conflicts Between Certain Documents (Language)",
|
|
"Relationship of Parties (Y/N)",
|
|
"Relationship of Parties (Language)",
|
|
"Nonstandard Appeals Process (Y/N)",
|
|
"Nonstandard Appeals Process (Language)",
|
|
"Product Removal",
|
|
"Disparagement Prohibition (Y/N)",
|
|
"Disparagement Prohibition (Language)",
|
|
"Claims Editing Language (Y/N)",
|
|
"Claims Editing Language (Language)",
|
|
"Guarantee of Provider Yield (Y/N)",
|
|
"Guarantee of Provider Yield (Language)",
|
|
"HCBS Services",
|
|
"Add On Reimbursement (Y/N)",
|
|
"Add On Reimbursement (Language)",
|
|
"PMPM",
|
|
"Single Code Multiple Rates (Y/N)",
|
|
"Single Code Multiple Rates (Language)",
|
|
"Invoice Pricing (Y/N)",
|
|
"Invoice Pricing (Language)",
|
|
"Medical Necessity Language (Y/N)",
|
|
"Medical Necessity Language (Language)",
|
|
"Template",
|
|
"Provider-based Billing Exclusion (Y/N)",
|
|
"Provider-based Billing Exclusion (Language)",
|
|
]
|
|
|
|
|
|
BASE_COLUMNS = [
|
|
"Lesser of Logic Language, included (Y/N)",
|
|
"Lesser of Rate",
|
|
"Reimb. methodology",
|
|
"Reimb. methodology_short",
|
|
"If rate is % of Payer or MCR [STANDARD]",
|
|
"If rate is % of Payer or MCR [STANDARD]_Short",
|
|
"If rate is Flat Fee [STANDARD]",
|
|
"Default Term",
|
|
"Default Rate",
|
|
"Exclusions",
|
|
"Not to Exceed",
|
|
"Escalator or COLA (Y/N)",
|
|
"Escalator I, Eff. Date",
|
|
]
|
|
|
|
SERVICE_FILTER = [
|
|
"LIABILITY",
|
|
"RISK",
|
|
"LOBBYING",
|
|
"DAMAGES",
|
|
"CONFIDENTIALITY",
|
|
"ARBITRATION",
|
|
"FALSE CLAIMS ACT",
|
|
"UNSPECIFIED",
|
|
"AUDIT",
|
|
"INTEREST",
|
|
"N/A",
|
|
"BUSINESS",
|
|
"COMPLIANCE",
|
|
"Medical Assistance Program",
|
|
"MATERIAL SUBCONTRACT",
|
|
"GIFTS",
|
|
"GRATUITIES",
|
|
"Insurance",
|
|
"Clean Claim",
|
|
"Employment verification",
|
|
"Suspension",
|
|
"thing of value",
|
|
"laws",
|
|
"safe drinking water act",
|
|
"immigration reform",
|
|
"social security",
|
|
"Lease",
|
|
"related entity",
|
|
"Negative balance",
|
|
"medicaid payments",
|
|
"federal water pollution control act",
|
|
"microbacteriology",
|
|
"epsdt",
|
|
"appeal",
|
|
"prompt pay",
|
|
"capitation",
|
|
"harmless",
|
|
"30 days",
|
|
"fee source",
|
|
"Rent-to-Purchase",
|
|
"chargemaster",
|
|
"stop-loss",
|
|
"mobile crisis",
|
|
"quality incentive program",
|
|
]
|
|
|
|
METHODOLOGY_FILTER = [
|
|
"interest",
|
|
"clean claim",
|
|
"timely",
|
|
"adjudicate",
|
|
"appeal",
|
|
"30 days",
|
|
"https",
|
|
"prior authorization",
|
|
"compliance",
|
|
"provider-based billing",
|
|
"not less than the level and amount of payment",
|
|
"Fee Change Effective Date",
|
|
"management fees",
|
|
"PMPM",
|
|
"quality incentive program",
|
|
"if there is no established payment",
|
|
]
|
|
|
|
STATE_MAP = {
|
|
"AL": "Alabama",
|
|
"AK": "Alaska",
|
|
"AZ": "Arizona",
|
|
"AR": "Arkansas",
|
|
"AS": "American Samoa",
|
|
"CA": "California",
|
|
"CO": "Colorado",
|
|
"CT": "Connecticut",
|
|
"DE": "Delaware",
|
|
"DC": "District of Columbia",
|
|
"FL": "Florida",
|
|
"GA": "Georgia",
|
|
"GU": "Guam",
|
|
"HI": "Hawaii",
|
|
"ID": "Idaho",
|
|
"IL": "Illinois",
|
|
"IN": "Indiana",
|
|
"IA": "Iowa",
|
|
"KS": "Kansas",
|
|
"KY": "Kentucky",
|
|
"LA": "Louisiana",
|
|
"ME": "Maine",
|
|
"MD": "Maryland",
|
|
"MA": "Massachusetts",
|
|
"MI": "Michigan",
|
|
"MN": "Minnesota",
|
|
"MS": "Mississippi",
|
|
"MO": "Missouri",
|
|
"MT": "Montana",
|
|
"NE": "Nebraska",
|
|
"NV": "Nevada",
|
|
"NH": "New Hampshire",
|
|
"NJ": "New Jersey",
|
|
"NM": "New Mexico",
|
|
"NY": "New York",
|
|
"NC": "North Carolina",
|
|
"ND": "North Dakota",
|
|
"MP": "Northern Mariana Islands",
|
|
"OH": "Ohio",
|
|
"OK": "Oklahoma",
|
|
"OR": "Oregon",
|
|
"PA": "Pennsylvania",
|
|
"PR": "Puerto Rico",
|
|
"RI": "Rhode Island",
|
|
"SC": "South Carolina",
|
|
"SD": "South Dakota",
|
|
"TN": "Tennessee",
|
|
"TX": "Texas",
|
|
"TT": "Trust Territories",
|
|
"UT": "Utah",
|
|
"VT": "Vermont",
|
|
"VA": "Virginia",
|
|
"VI": "Virgin Islands",
|
|
"WA": "Washington",
|
|
"WV": "West Virginia",
|
|
"WI": "Wisconsin",
|
|
"WY": "Wyoming",
|
|
}
|
|
|
|
HOTFIX_MAPPING = {
|
|
"Filename": "Contract Name",
|
|
"Parent Agreement Code": "Parent Agreement Code",
|
|
"Pages": "Pages",
|
|
"page_num": "Page_Num",
|
|
"Page Num" : "Page_Num",
|
|
"EXHIBIT": "Attachment/Exhibit",
|
|
"CONTRACT_LOB": "Line of Business",
|
|
"PROV_TYPE": "Provider Type",
|
|
"PROV_TYPE_LEVEL_2": "Provider Type - Level 2",
|
|
"IP_OP": "IP/OP",
|
|
"FULL_SERVICE": "Service Type",
|
|
"CONTRACT_PROGRAM": "Plan Type",
|
|
'Lesser of Logic Language, Included (Y/N)' : "Lesser of Logic language, included (Y/N)",
|
|
"LESSER": "Lesser of Logic language, included (Y/N)",
|
|
"LESSER_RATE": "Lesser of Rate",
|
|
"FULL_METHODOLOGY": "Reimb. Methodology",
|
|
"SHORT_METHODOLOGY": "Reimb. Methodology_Short",
|
|
'Reimb. Methodology Short' : 'Reimb. Methodology_Short',
|
|
'If rate is % of Payor or MCR [Standard]' : 'If rate is % of Payor or MCR [STANDARD]',
|
|
'If Rate is % of Payor or MCR [Standard]' : "If rate is % of Payor or MCR [STANDARD]",
|
|
'If rate is % of Payor or MCR [STANDARD]' : "If rate is % of Payor or MCR [STANDARD]",
|
|
"RATE_STANDARD": "If rate is % of Payor or MCR [STANDARD]",
|
|
'If rate is % of Payor or MCR [Standard] Short' : 'If rate is % of Payor or MCR [STANDARD]_Short',
|
|
"RATE_SHORT": "If rate is % of Payor or MCR [STANDARD]_Short",
|
|
"FLAT_FEE_STANDARD": "FLAT FEE",
|
|
'Flat Fee' : 'FLAT FEE',
|
|
"DEFAULT_TERM": "Default Term",
|
|
"DEFAULT_RATE": "Default Rate",
|
|
"MEDICAL_NECESSITY_LANGUAGE": "Medical Necessity Language (Language)",
|
|
"MEDICAL_NECESSITY_LANGUAGE_IND": "Medical Necessity Language (Y/N)",
|
|
'Inclusion of essential RBRVS "Fee Source" Language (Y/N)': 'Inclusion of essential RBRVS "Fee Source" Language (Y/N)',
|
|
"CDM_IND": "CDM Neutralization Language, included (Y/N)",
|
|
"CHARGEMASTER": "CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE",
|
|
'Contract Chargemaster Protection Language' : "CONTRACT_CHARGEMASTER_PROTECTION_LANGUAGE",
|
|
"ADD_ON_REIMBURSEMENT_LANGUAGE": "Add On Reimbursement (Language)",
|
|
"ADD_ON_REIMBURSEMENT_IND": "Add On Reimbursement (Y/N)",
|
|
"SINGLE_CODE_MULTIPLE_RATES_LANGUAGE": "Single Code Multiple Rates (Language)",
|
|
"SINGLE_CODE_MULTIPLE_RATES_IND": "Single Code Multiple Rates (Y/N)",
|
|
"IP - DSH/IME/UC, included (Y/N)": "IP - DSH/IME/UC, included (Y/N)",
|
|
"IP - Stoploss Catastrophic Threshold": "IP - Stoploss Catastrophic Threshold",
|
|
"EXCLUSIONS": "Exclusions",
|
|
"NOT_TO_EXCEED": "Not to Exceed",
|
|
"RATE_ESCALATOR_IND": "Escalator or COLA (Y/N)",
|
|
"RATE_ESCALATOR_DT": "Escalator I, Eff. Date",
|
|
"CONTRACT_TITLE": "Agreement_Name (Contract Title)",
|
|
'Agreement Name (Contract Title)': "Agreement_Name (Contract Title)",
|
|
"PAYER_NAME": "PAYER NAME",
|
|
"Payer Name" : "PAYER NAME",
|
|
"AFFILIATION_CLAUSE_IND": "Affiliate (Y/N)",
|
|
"TERM_CLAUSE": "Term Clause",
|
|
"CONTRACT_AUTO_RENEWAL_IND": "Contract Auto-Renewal Indicator",
|
|
"CONTRACT_TERMINATION_DT": "Termination Date",
|
|
"TERMINATION_UPON_NOTICE": "Termination Upon Notice - Days",
|
|
"TERMINATION_UPON_CAUSE": "Termination With Cause - Days",
|
|
"AMEND_CONTRACT_NOTICE_IND": "Amend Contract Upon notice Flag (Y/N)",
|
|
"TIME_TO_OBJECT": "Timeframe to Object - Days",
|
|
"ASSIGNMENTS_CLAUSE_IND": "Assignments Clause (Y/N)",
|
|
"CONTRACT_EFFECTIVE_DT": "Contract Effective Date",
|
|
"PROV_GROUP_TIN": "IRS #",
|
|
"PROV_GROUP_NAME": "IRS_Name",
|
|
"PROV_GROUP_NPI": "NPI (10-digits)",
|
|
"PROV_GROUP_TIN_SIGNATORY": "PROV_GROUP_TIN_SIGNATORY",
|
|
'Prov Group TIN Signatory' : "PROV_GROUP_TIN_SIGNATORY",
|
|
"PROV_TIN_OTHER": "PROV_TIN_OTHER",
|
|
"Prov TIN Other" : "PROV_TIN_OTHER",
|
|
"PROV_NPI_OTHER": "PROV_NPI_OTHER",
|
|
'Prov NPI Other' : "PROV_NPI_OTHER",
|
|
"NOTICE_PROVIDER_NAME": "Notice to Provider Name",
|
|
"NOTICE_PROVIDER_ADDRESS": "Notice to Provider Address",
|
|
"HEALTH_PLAN_STATE": "Health Plan State",
|
|
"CREDENTIALING_APP_IND": "Credentialing Application Indicator",
|
|
"SEQUESTRATION_LANGUAGE": "Sequestration Language",
|
|
"SEQUESTRATION_LANGUAGE_IND": "Sequestration Reductions (Y/N)",
|
|
"NPI_NAME": "NPI Name",
|
|
"DELEGATED_TERMS_IND": "Delegated Function Indicator",
|
|
"DELEGATED_TERMS": "Delegated Terms",
|
|
"ECM": "ECM",
|
|
"NATIONAL_AGREEMENT_IND": "National Agreement Indicator",
|
|
"COST_SETTLEMENT_LANGUAGE_IND": "Cost Settlement (Y/N)",
|
|
"COST_SETTLEMENT_LANGUAGE": "Cost Settlement (Language)",
|
|
"LATE_PAID_CLAIMS_LANGUAGE_IND": "Late Paid Claims (Y/N)",
|
|
"LATE_PAID_CLAIMS_LANGUAGE": "Late Paid Claims (Language)",
|
|
"DEEMER_AMENDMENT": "Deemer Amendment",
|
|
"REGULATORY_REQUIREMENTS": "Regulatory Requirements",
|
|
"RECOVERY_RIGHTS": "Recovery Rights",
|
|
"ARBITRATION_AND_DISPUTES": "Arbitration and Disputes",
|
|
"EXCLUSIVITY_REQUIREMENT_LANGUAGE_IND": "Exclusivity Requirement (Y/N)",
|
|
"EXCLUSIVITY_REQUIREMENT_LANGUAGE": "Exclusivity Requirement (Language)",
|
|
"PAYOR": "Payor",
|
|
"PARTICIPATION_IN_PRODUCTS": "Participation in Products",
|
|
"CLEAN_CLAIM": "Clean Claim",
|
|
"INDEPENDENT_REVIEW_LANGUAGE_IND": "Independent Review (Y/N)",
|
|
"INDEPENDENT_REVIEW_LANGUAGE": "Independent Review (Language)",
|
|
"INDEMNIFICATION": "Indemnification",
|
|
"ACCESS_TO_MEDICAL_RECORDS": "Access to Medical Records",
|
|
"MEMBER_CONFINEMENT_DAYS_LANGUAGE_IND": "Member Confinement Days Language (Y/N)",
|
|
"MEMBER_CONFINEMENT_DAYS_LANGUAGE": "Member Confinement Days Language (Language)",
|
|
"NETWORK_ACCESS_FEES_LANGUAGE_IND": "Network Access Fees (Y/N)",
|
|
"NETWORK_ACCESS_FEES_LANGUAGE": "Network Access Fees (Language)",
|
|
"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE_IND": "Payment in Advance of Claims Submission Language (Y/N)",
|
|
"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE": "Payment in Advance of Claims Submission Language",
|
|
"ELIGIBILITY_VERIFICATION": "Eligibility Verification",
|
|
"PREAUTHORIZATION": "Preauthorization",
|
|
"POLICIES_AND_PROCEDURES": "Policies and Procedures",
|
|
"INSURANCE_REQUIREMENT": "Insurance Requirement",
|
|
"CARVEOUT_VENDORS": "Carve-Out Vendors",
|
|
"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE_IND": "Conflicts Between Certain Documents (Y/N)",
|
|
"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE": "Conflicts Between Certain Documents (Language)",
|
|
"RELATIONSHIP_OF_PARTIES_LANGUAGE_IND": "Relationship of Parties (Y/N)",
|
|
"RELATIONSHIP_OF_PARTIES_LANGUAGE": "Relationship of Parties (Language)",
|
|
"NONSTANDARD_APPEALS_PROCESS_LANGUAGE_IND": "Nonstandard Appeals Process (Y/N)",
|
|
"NONSTANDARD_APPEALS_PROCESS_LANGUAGE": "Nonstandard Appeals Process (Language)",
|
|
"PRODUCT_REMOVAL": "Product Removal",
|
|
"DISPARAGEMENT_PROHIBITION_LANGUAGE_IND": "Disparagement Prohibition (Y/N)",
|
|
"DISPARAGEMENT_PROHIBITION_LANGUAGE": "Disparagement Prohibition (Language)",
|
|
"CLAIMS_EDITING_LANGUAGE_IND": "Claims Editing Language (Y/N)",
|
|
"CLAIMS_EDITING_LANGUAGE": "Claims Editing Language (Language)",
|
|
"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE_IND": "Guarantee of Provider Yield (Y/N)",
|
|
"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE": "Guarantee of Provider Yield (Language)",
|
|
"HCBS_SERVICES": "HCBS Services",
|
|
"ADD_ON_REIMBURSEMENT_IND": "Add On Reimbursement (Y/N)",
|
|
"ADD_ON_REIMBURSEMENT_LANGUAGE": "Add On Reimbursement (Language)",
|
|
"PMPM": "PMPM",
|
|
"SINGLE_CODE_MULTIPLE_RATES_IND": "Single Code Multiple Rates (Y/N)",
|
|
"SINGLE_CODE_MULTIPLE_RATES_LANGUAGE": "Single Code Multiple Rates (Language)",
|
|
"INVOICE_PRICING_LANGUAGE_IND": "Invoice Pricing (Y/N)",
|
|
"INVOICE_PRICING_LANGUAGE": "Invoice Pricing (Language)",
|
|
"TEMPLATE": "Template",
|
|
"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE_IND": "Provider-based Billing Exclusion (Y/N)",
|
|
"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE": "Provider-based Billing Exclusion (Language)",
|
|
"NON_RENEWAL_LANGUAGE": "Non-Renewal Language",
|
|
"NON_RENEWAL_DAYS": "Non-Renewal - Days",
|
|
"TIMELY_FILING": "Timely Filing",
|
|
}
|
|
|
|
B_IND_LANG_COLS = {
|
|
"LESSER" : "LESSER_RATE",
|
|
"MEDICAL_NECESSITY_LANGUAGE" : "MEDICAL_NECESSITY_LANGUAGE_IND",
|
|
"ADD_ON_REIMBURSEMENT_LANGUAGE" : "ADD_ON_REIMBURSEMENT_IND",
|
|
"SINGLE_CODE_MULTIPLE_RATES_IND" : "SINGLE_CODE_MULTIPLE_RATES_LANGUAGE",
|
|
"RATE_ESCALATOR_IND" : "RATE_ESCALATOR_DT"
|
|
}
|
|
|
|
AC_IND_LANG_COLS = {
|
|
"SEQUESTRATION_LANGUAGE_IND" : "SEQUESTRATION_LANGUAGE",
|
|
"COST_SETTLEMENT_LANGUAGE_IND" : "COST_SETTLEMENT_LANGUAGE",
|
|
"LATE_PAID_CLAIMS_LANGUAGE_IND" : "LATE_PAID_CLAIMS_LANGUAGE",
|
|
"EXCLUSIVITY_REQUIREMENT_LANGUAGE_IND": "EXCLUSIVITY_REQUIREMENT_LANGUAGE",
|
|
"INDEPENDENT_REVIEW_LANGUAGE_IND" : "INDEPENDENT_REVIEW_LANGUAGE",
|
|
"MEMBER_CONFINEMENT_DAYS_LANGUAGE_IND" : "MEMBER_CONFINEMENT_DAYS_LANGUAGE",
|
|
"NETWORK_ACCESS_FEES_LANGUAGE_IND" : "NETWORK_ACCESS_FEES_LANGUAGE",
|
|
"PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE_IND" : "PAYMENT_IN_ADVANCE_OF_CLAIMS_SUBMISSION_LANGUAGE",
|
|
"CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE_IND" : "CONFLICTS_BETWEEN_CERTAIN_DOCUMENTS_LANGUAGE",
|
|
"RELATIONSHIP_OF_PARTIES_LANGUAGE_IND" : "RELATIONSHIP_OF_PARTIES_LANGUAGE",
|
|
"NONSTANDARD_APPEALS_PROCESS_LANGUAGE_IND" : "NONSTANDARD_APPEALS_PROCESS_LANGUAGE",
|
|
"DISPARAGEMENT_PROHIBITION_LANGUAGE_IND" : "DISPARAGEMENT_PROHIBITION_LANGUAGE",
|
|
"CLAIMS_EDITING_LANGUAGE_IND" : "CLAIMS_EDITING_LANGUAGE",
|
|
"GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE_IND" : "GUARANTEE_OF_PROVIDER_YIELD_LANGUAGE",
|
|
"ADD_ON_REIMBURSEMENT_IND" : "ADD_ON_REIMBURSEMENT_LANGUAGE",
|
|
"SINGLE_CODE_MULTIPLE_RATES_IND" : "SINGLE_CODE_MULTIPLE_RATES_LANGUAGE",
|
|
"INVOICE_PRICING_LANGUAGE_IND" : "INVOICE_PRICING_LANGUAGE",
|
|
"PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE_IND" : "PROVIDER_BASED_BILLING_EXCLUSION_LANGUAGE"
|
|
}
|