Healthcare Edi Converter

A Python library that can be used to convert EDI file content strings into objects. Initially it supports just the EDI x12 837p (Claims submitted to payor requesting payment)

Installation

pip install healthcare-edi-converter

Basic Use

Parse an EDI File

    from healthcare_edi_converter.converter import process_file
    
    with open("sample837p_01.txt", "r") as f:
        edi_content = f.read() 
    converter = process_file('837', edi_content)
    print(converter)

Generate an EDI File

    from healthcare_edi_converter.converter import generate_edi
    from healthcare_edi_converter.models.claim_dto import ClaimData, ClaimLine, Payer,RenderingProvider
    payer = Payer('Payer Name', '12345', '123 Sesame Street','555-1212')
    rendering_provider = RenderingProvider('Provider Name','1003002510',None,'123 Sesame Street')


    claimlines =[]
    claimlines.append(ClaimLine('11111111', '19110', 'Claim Line 1',0.00,2,None,['N61']))
    claimlines.append(ClaimLine('11111111', '19110', 'Claim Line 2',0.00,2,None,['N61']))
    claimlines.append(ClaimLine('11111111', '19110', 'Claim Line 3',0.00,2,None,['N61']))

    claim = ClaimData('11111111','2025-01-22','Jane','Doe','1973-10-08','F','12345678',payer,rendering_provider,0.00,['A31','B25'],'TESTCASE','A34512355',claimlines)

    gen = generate_edi('Big Sender', 'Sad Receiver', claim) 

837P File Overall Structure

The 837P consists of envelopes, headers, loops, and segments:

1. Interchange Control Header (ISA) - The outermost wrapper for the EDI file. Contains metadata for sender/receiver identification, control numbers, date/time, and separators.

2. Functional Group Header (GS) - Groups related transaction sets together (e.g., all claims for one sender). Identifies the sender, receiver, version, and date/time of the transaction group.

3. Transaction Set Header (ST) - Marks the beginning of an individual claim transaction. Contains the transaction set identifier and control numbers.

Loops and Segments

Loop 1000: Submitter and Receiver Information Identifies the sender (submitter) and the recipient (receiver) of the claim.

1000A – Submitter Name NM1: Submitter's name and ID. PER: Submitter's contact information.

1000B – Receiver Name NM1: Receiver's name and ID.

Loop 2000: Billing/Subscriber/Patient Information

This loop contains hierarchical levels (HL) to organize the billing provider, subscriber, and patient data.

2000A: Billing Provider HL: Hierarchical structure (billing provider). PRV: Billing provider taxonomy (e.g., specialty). NM1: Billing provider’s name and ID.

2000B: Subscriber HL: Hierarchical structure (subscriber). SBR: Subscriber relationship to the insured (e.g., self, spouse). NM1: Subscriber’s name and ID. DMG: Subscriber’s demographic information (e.g., date of birth, gender).

2000C: Patient (if different from the subscriber) HL: Hierarchical structure (patient). PAT: Patient relationship to subscriber (e.g., child). NM1: Patient’s name.

Loop 2300: Claim Information

Details about the specific claim being submitted.

CLM: Claim information (e.g., amount, claim number). DTP: Date(s) of service or admission. HI: Diagnosis codes (e.g., ICD-10 codes). CN1: Contract information (if applicable).

Loop 2400: Service Line Information

Details about individual services provided.

SV1: Service line details (e.g., CPT code, service amount). DTP: Service line dates. REF: Reference IDs (e.g., prior authorization number).

Loop 2420: Service Provider Information

Identifies additional providers involved in the claim.

NM1: Referring provider, rendering provider, or supervising provider. PRV: Provider taxonomy (e.g., specialty). REF: Provider identification numbers.

Control Segments

1. Transaction Set Trailer (SE) Indicates the end of a transaction set. Contains a count of all segments in the transaction.
2. Functional Group Trailer (GE) Indicates the end of a functional group. Includes control numbers.
3. Interchange Control Trailer (IEA) Indicates the end of the interchange envelope. Includes the total number of functional groups and control numbers.