medicafe 0.250822.2__py3-none-any.whl → 0.250909.0__py3-none-any.whl

MediLink/MediLink_837p_encoder_library.py

@@ -472,11 +472,19 @@ def _original_insurance_type_selection_logic(parsed_data):
         except Exception as e:
             MediLink_ConfigLoader.log("COB get_enhanced_insurance_options error: {}".format(str(e)), level="WARNING")
     
-    # TODO (COB ENHANCEMENT): Enhanced insurance options for Medicare support
-    # See MediLink_837p_cob_library.get_enhanced_insurance_options() for Medicare codes:
-    # - MB: Medicare Part B
-    # - MA: Medicare Advantage  
-    # - MC: Medicare Part C
+    # STRATEGIC NOTE (Enhanced Insurance Options): COB library is fully implemented
+    # To activate enhanced Medicare support, replace this TODO with:
+    # if COB is not None and config.get('MediLink_Config', {}).get('cob_settings', {}).get('enabled', False):
+    #     try:
+    #         insurance_options = COB.get_enhanced_insurance_options(config)
+    #         # This adds support for Medicare codes: MB (Part B), MA (Advantage), MC (Part C)
+    #     except Exception as e:
+    #         MediLink_ConfigLoader.log("COB enhancement error: {}".format(str(e)), level="WARNING")
+    # 
+    # IMPLEMENTATION QUESTIONS:
+    # 1. Should Medicare type detection be automatic or require explicit configuration?
+    # 2. How should Medicare Advantage plans be distinguished from traditional Medicare?
+    # 3. Should enhanced options be enabled globally or per-endpoint?
 
     def prompt_display_insurance_options():
         # Prompt to display full list
@@ -1023,11 +1031,28 @@ def create_clm_and_related_segments(parsed_data, config, crosswalk):
     Verify that the service line number (LX), professional service (SV1), and service date (DTP) segments contain
     accurate information and are formatted according to the claim's details.
     
-    TODO (COB ENHANCEMENT): This function needs enhancement for COB scenarios:
-    1. Enhanced CLM segment with proper claim frequency (CLM05-3)
-    2. Support for service-level COB adjudication (2430 loop)
-    3. Integration with 835-derived adjudication data
-    4. PWK segment support for attachments
+    STRATEGIC NOTE (Enhanced CLM Segment): COB library provides create_enhanced_clm_segment()
+    
+    CRITICAL STRATEGIC QUESTIONS FOR HIGH-RISK IMPLEMENTATION:
+    1. **Claim Frequency Strategy**: How should CLM05-3 be determined?
+       - Always "1" (original) for secondary claims?
+       - Support "7" (replacement) for corrections?
+       - Automatic detection of replacement scenarios?
+    
+    2. **COB Type Integration**: How should COB information be embedded?
+       - Derive from claim_type field automatically?
+       - Require explicit COB type configuration?
+       - Handle mixed COB scenarios (multiple secondaries)?
+    
+    3. **835 Data Integration**: How should adjudication data affect CLM?
+       - Should 835 paid amounts influence claim totals?
+       - Handle discrepancies between calculated vs adjudicated amounts?
+       - What when 835 data is missing for secondary claims?
+    
+    4. **PWK Attachment Strategy**: When should attachments be included?
+       - Automatic for non-electronic EOB scenarios?
+       - Manual control through UI?
+       - Payer-specific attachment requirements?
     
     See MediLink_837p_cob_library.create_enhanced_clm_segment() for enhanced implementation.
     """
@@ -1074,10 +1099,20 @@ def create_clm_and_related_segments(parsed_data, config, crosswalk):
     segments.extend(create_service_facility_location_npi_segment(config))
     
     # For future reference, SBR - (Loop 2320: OI, NM1 (2330A), N3, N4, NM1 (2330B)) - Other Subscriber Information goes here.
-    # TODO (COB ENHANCEMENT): COB loops for secondary claims and Medicare adjudication
-    # See MediLink_837p_cob_library for implementation of:
+    # STRATEGIC NOTE (COB Loops): COB library is fully implemented with all loop functions
+    # Current implementation below (lines 1085-1118) has basic COB loop integration
+    # To activate enhanced COB loops, the existing code needs these strategic decisions:
+    #
+    # IMPLEMENTATION QUESTIONS:
+    # 1. Should COB loops be added automatically when claim_type='secondary' or require additional validation?
+    # 2. How should missing prior payer information be handled (fail claim, prompt user, use defaults)?
+    # 3. Should service-level COB (2430 loop) be enabled by default or require separate configuration?
+    # 4. How should COB validation failures affect claim processing (warning, error, or block submission)?
+    # 5. Should COB loops be configurable per payer or globally enabled?
+    #
+    # The COB library provides these ready-to-use functions:
     # - create_2320_other_subscriber_segments() for secondary payer info
-    # - create_2330B_prior_payer_segments() for Medicare prior payer
+    # - create_2330B_prior_payer_segments() for Medicare prior payer  
     # - create_2430_service_line_cob_segments() for service-level adjudication
     # - create_2330C_other_subscriber_name_segments() when patient != subscriber
     #
@@ -1117,13 +1152,22 @@ def create_clm_and_related_segments(parsed_data, config, crosswalk):
                 except Exception:
                     pass
     
-    # TODO (COB ENHANCEMENT): Optional attachment references (PWK) for non-electronic EOB handling
-    # See MediLink_837p_cob_library.create_pwk_attachment_segment() for implementation
-    # Example: PWK*EB*FX*123456~ for attachment control number
-    # if parsed_data.get('requires_attachment'):
-    #     pwk_segment = MediLink_837p_cob_library.create_pwk_attachment_segment(parsed_data, config)
-    #     if pwk_segment:
-    #         segments.append(pwk_segment)
+    # STRATEGIC NOTE (PWK Attachments): COB library provides create_pwk_attachment_segment()
+    # 
+    # IMPLEMENTATION QUESTIONS:
+    # 1. Should PWK segments be added automatically for all COB claims or only when explicitly required?
+    # 2. How should attachment control numbers be generated and tracked?
+    # 3. Should attachment requirements be configurable per payer?
+    # 4. What validation is needed for attachment references?
+    #
+    # To activate: Uncomment and configure attachment logic:
+    # if cob_enabled and validated_data.get('requires_attachment'):
+    #     try:
+    #         pwk_segment = COB.create_pwk_attachment_segment(validated_data, config)
+    #         if pwk_segment:
+    #             segments.append(pwk_segment)
+    #     except Exception as e:
+    #         MediLink_ConfigLoader.log("PWK attachment error: {}".format(str(e)), level="WARNING")
     
     # LX - Service Line Counter
     segments.append("LX*1~")
@@ -1138,19 +1182,54 @@ def create_clm_and_related_segments(parsed_data, config, crosswalk):
     # DTP - Date
     segments.append("DTP*472*D8*{}~".format(convert_date_format(validated_data['DATE'])))
     
-    # Is there REF - Line Item Control Number missing here? Private insurance doesn't need it, but Medicare does?
-    # TODO (MEDICARE REF): Add conditional REF*6R (line item control number) when payer is Medicare or when crosswalk/config requires it.
-    # segments.append("REF*6R*1~") # REF01, Reference Identification Qualifier; REF02, Line Item Control Number.
-    # 6R - Provider Control Number (Number assigned by information provider company for tracking and billing purposes)
-    # 1 - Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
-    
-
-    # TODO (COB ENHANCEMENT): Service-level COB adjudication (2430 loop)
-    # See MediLink_837p_cob_library.create_2430_service_line_cob_segments() for implementation
-    # This would include SVD, CAS, and DTP*573 segments for service-level adjudication
-    # if parsed_data.get('service_adjudications'):
-    #     cob_segments = MediLink_837p_cob_library.create_2430_service_line_cob_segments(parsed_data, config, crosswalk)
-    #     segments.extend(cob_segments)
+    # REF*6R - Line Item Control Number (required for Medicare, optional for private insurance)
+    # IMPLEMENTED: Add conditional REF*6R when payer is Medicare
+    payer_id = validated_data.get('payer_id', '')
+    payer_name = validated_data.get('payer_name', '').upper()
+    
+    # Check if this is a Medicare payer (compatible with XP SP3 + Python 3.4.4)
+    is_medicare = (payer_id == '00850' or 
+                   'MEDICARE' in payer_name or 
+                   'MCARE' in payer_name or 
+                   payer_id in ['MEDICARE', 'CMS', 'MCARE'])
+    
+    if is_medicare:
+        # REF*6R*1 - Provider Control Number for Medicare claims
+        # 6R = Provider Control Number qualifier
+        # 1 = Sequential line item control number (could be enhanced to actual line number)
+        segments.append("REF*6R*1~")
+        try:
+            MediLink_ConfigLoader.log("Added REF*6R segment for Medicare payer: {}".format(payer_name), config, level="DEBUG")
+        except Exception:
+            pass  # Don't fail if logging fails
+    
+
+    # STRATEGIC NOTE (Service-Level COB): 2430 loop implementation is ready but needs strategic decisions
+    # COB library provides create_2430_service_line_cob_segments() for service-level adjudication
+    # 
+    # CRITICAL STRATEGIC QUESTIONS:
+    # 1. **Data Source Strategy**: Where does service_adjudications data come from?
+    #    - Direct 835 remittance parsing?
+    #    - Manual entry through UI?
+    #    - Hybrid approach with validation?
+    # 
+    # 2. **Activation Logic**: When should 2430 loops be included?
+    #    - Only when service_adjudications is populated?
+    #    - Required for all secondary claims?
+    #    - Optional enhancement based on payer requirements?
+    # 
+    # 3. **Error Handling**: How should service-level COB failures be handled?
+    #    - Continue with claim-level COB only (current approach)?
+    #    - Block entire claim submission?
+    #    - Provide manual override and logging?
+    #
+    # To activate: Uncomment and configure the following:
+    # if parsed_data.get('service_adjudications') and cob_enabled:
+    #     try:
+    #         cob_segments = COB.create_2430_service_line_cob_segments(validated_data, config, crosswalk)
+    #         segments.extend(cob_segments)
+    #     except Exception as e:
+    #         MediLink_ConfigLoader.log("Service-level COB error: {}".format(str(e)), level="WARNING")
     
     return segments
 
@@ -1262,9 +1341,14 @@ def create_interchange_header(config, endpoint, isa13):
     # GS06 Group Control Number, Field Length 1/9, must match GE02
     # FIXED: Generate group control number using similar logic to ISA13 for consistency
     current_time = datetime.now().strftime('%H%M%S')
-    gs06 = current_time[-6:]  # Use last 6 digits of time for uniqueness within reasonable bounds
-    if not gs06 or len(gs06) < 1:
-        gs06 = '1'  # Fallback to simple increment
+    # Normalize GS06 to suppress leading zeros per X12 numeric element rules
+    try:
+        _gs06_val = int(current_time[-6:] or '0')
+    except Exception:
+        _gs06_val = 0
+    if _gs06_val < 1:
+        _gs06_val = 1
+    gs06 = str(_gs06_val)
     
     gs_segment = "GS*HC*{}*{}*{}*{}*{}*X*005010X222A1~".format(
         gs_sender_code, gs_receiver_code, format_datetime(), format_datetime(format_type='time'), gs06
@@ -1399,9 +1483,9 @@ def validate_claim_data_for_837p(parsed_data, config, crosswalk):
         #   FIXED: Error handling and logging added for file save failures
         #
         # REMAINING WORKFLOW ISSUES:
-        # 1. Validation still happens during encoding (too late in the process) - FUTURE ENHANCEMENT
-        # 2. No backup or rollback mechanism for crosswalk changes - FUTURE ENHANCEMENT
-        # 3. No validation of new mappings before they're added - FUTURE ENHANCEMENT
+        # 1. Validation still happens during encoding (too late in the process) - FUTURE ENHANCEMENT (High Priority - but difficult to implement)
+        # 2. No backup or rollback mechanism for crosswalk changes - FUTURE ENHANCEMENT (Lower Priority)
+        # 3. No validation of new mappings before they're added - FUTURE ENHANCEMENT (Medium Priority)
         #
         # FUTURE ENHANCEMENTS (NOT CRITICAL):
         #