library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007-2011 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("Claim.class.php");
  10
  11 function gen_x12_837($pid, $encounter, &$log, $encounter_claim=false) {
  12
  13   $today = time();
  14   $out = '';
  15   $claim = new Claim($pid, $encounter);
  16   $edicount = 0;
  17
  18   $log .= "Generating claim $pid-$encounter for " .
  19     $claim->patientFirstName()  . ' ' .
  20     $claim->patientMiddleName() . ' ' .
  21     $claim->patientLastName()   . ' on ' .
  22     date('Y-m-d H:i', $today) . ".\n";
  23
  24   $out .= "ISA" .
  25     "*00" .
  26     "*          " .
  27     "*00" .
  28     "*          " .
  29     "*" . $claim->x12gsisa05() .
  30     "*" . $claim->x12gssenderid() .
  31     "*" . $claim->x12gsisa07() .
  32     "*" . $claim->x12gsreceiverid() .
  33     "*030911" .
  34     "*1630" .
  35     "*U" .
  36     "*00401" .
  37     "*000000001" .
  38     "*" . $claim->x12gsisa14() .
  39     "*" . $claim->x12gsisa15() .
  40     "*:" .
  41     "~\n";
  42
  43   $out .= "GS" .
  44     "*HC" .
  45     "*" . $claim->x12gsgs02() .
  46     "*" . trim($claim->x12gsreceiverid()) .
  47     "*" . date('Ymd', $today) .
  48     "*" . date('Hi', $today) .
  49     "*1" .
  50     "*X" .
  51     "*" . $claim->x12gsversionstring() .
  52     "~\n";
  53
  54   ++$edicount;
  55   $out .= "ST" .
  56     "*837" .
  57     "*0021" .
  58     "~\n";
  59
  60   ++$edicount;
  61   $out .= "BHT" .
  62     "*0019" .
  63     "*00" .
  64     "*0123" .
  65     "*" . date('Ymd', $today) .
  66     "*1023" .
  67     ($encounter_claim ? "*RP" : "*CH") .
  68     "~\n";
  69
  70   ++$edicount;
  71   $out .= "REF" .
  72     "*87" .
  73     "*" . $claim->x12gsversionstring() .
  74     "~\n";
  75
  76   ++$edicount;
  77   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
  78   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
  79   $out .= "NM1" .       // Loop 1000A Submitter
  80     "*41" .
  81     "*2" .
  82     "*" . $billingFacilityName .
  83     "*" .
  84     "*" .
  85     "*" .
  86     "*" .
  87     "*46";
  88    if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
  89     $out  .=  "*" . $claim->clearingHouseETIN();
  90    } else {
  91     $out  .=  "*" . $claim->billingFacilityETIN();
  92    }
  93     $out .= "~\n";
  94
  95   ++$edicount;
  96   $out .= "PER" .
  97     "*IC" .
  98     "*" . $claim->billingContactName() .
  99     "*TE" .
 100     "*" . $claim->billingContactPhone();
 101   if ($claim->x12gsper06()) {
 102     $out .= "*ED*" . $claim->x12gsper06();
 103   }
 104   $out .= "~\n";
 105
 106   ++$edicount;
 107   $out .= "NM1" .       // Loop 1000B Receiver
 108     "*40" .
 109     "*2" .
 110     "*" . $claim->clearingHouseName() .
 111     "*" .
 112     "*" .
 113     "*" .
 114     "*" .
 115     "*46" .
 116     "*" . $claim->clearingHouseETIN() .
 117     "~\n";
 118
 119   $HLcount = 1;
 120
 121   ++$edicount;
 122   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 123     "*$HLcount" .
 124     "*" .
 125     "*20" .
 126     "*1" .
 127     "~\n";
 128
 129   $HLBillingPayToProvider = $HLcount++;
 130
 131   ++$edicount;
 132   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 133   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
 134   $out .= "NM1" .       // Loop 2010AA Billing Provider
 135     "*85" .
 136     "*2" .
 137     "*" . $billingFacilityName .
 138     "*" .
 139     "*" .
 140     "*" .
 141     "*";
 142   if ($claim->billingFacilityNPI()) {
 143     $out .= "*XX*" . $claim->billingFacilityNPI();
 144   } else {
 145     $log .= "*** Billing facility has no NPI.\n";
 146     $out .= "*24*" . $claim->billingFacilityETIN();
 147   }
 148   $out .= "~\n";
 149
 150   ++$edicount;
 151   $out .= "N3" .
 152     "*" . $claim->billingFacilityStreet() .
 153     "~\n";
 154
 155   ++$edicount;
 156   $out .= "N4" .
 157     "*" . $claim->billingFacilityCity() .
 158     "*" . $claim->billingFacilityState() .
 159     "*" . $claim->billingFacilityZip() .
 160     "~\n";
 161
 162   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 163   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 164     ++$edicount;
 165     $out .= "REF" ;
 166         if($claim->federalIdType()){
 167       $out .= "*" . $claim->federalIdType();
 168         }
 169         else{
 170           $out .= "*EI";//For dealing with the situation before adding selection for TaxId type In facility ie default to EIN.
 171         }
 172       $out .=  "*" . $claim->billingFacilityETIN() .
 173       "~\n";
 174   }
 175
 176   if ($claim->providerNumberType() && $claim->providerNumber()) {
 177     ++$edicount;
 178     $out .= "REF" .
 179       "*" . $claim->providerNumberType() .
 180       "*" . $claim->providerNumber() .
 181       "~\n";
 182   }
 183   else if ($claim->providerNumber()) {
 184     $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 185   }
 186
 187   ++$edicount;
 188   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 189   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
 190   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 191     "*87" .
 192     "*2" .
 193     "*" . $billingFacilityName .
 194     "*" .
 195     "*" .
 196     "*" .
 197     "*";
 198   if ($claim->billingFacilityNPI())
 199     $out .= "*XX*" . $claim->billingFacilityNPI();
 200   else
 201     $out .= "*24*" . $claim->billingFacilityETIN();
 202   $out .= "~\n";
 203
 204   ++$edicount;
 205   $out .= "N3" .
 206     "*" . $claim->billingFacilityStreet() .
 207     "~\n";
 208
 209   ++$edicount;
 210   $out .= "N4" .
 211     "*" . $claim->billingFacilityCity() .
 212     "*" . $claim->billingFacilityState() .
 213     "*" . $claim->billingFacilityZip() .
 214     "~\n";
 215
 216   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 217     ++$edicount;
 218     $out .= "REF" .
 219       "*EI" .
 220       "*" . $claim->billingFacilityETIN() .
 221       "~\n";
 222   }
 223   if($claim->isSelfOfInsured()){
 224   $PatientHL = 0;
 225   }
 226   else{
 227   $PatientHL = 1;
 228   }
 229
 230   ++$edicount;
 231   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 232     "*$HLcount" .
 233     "*$HLBillingPayToProvider" .
 234     "*22" .
 235     "*$PatientHL" .
 236     "~\n";
 237
 238   $HLSubscriber = $HLcount++;
 239
 240   if (!$claim->payerSequence()) {
 241     $log .= "*** Error: Insurance information is missing!\n";
 242   }
 243   ++$edicount;
 244   $x="";
 245   if($claim->isSelfOfInsured()){
 246   $x=18;
 247   }
 248   $out .= "SBR" .       // Subscriber Information
 249     "*" . $claim->payerSequence() .
 250     "*" . $x .
 251     "*" . $claim->groupNumber() .
 252     "*" . $claim->groupName() .
 253     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 254     "*" .
 255     "*" .
 256     "*" .
 257     "*" . $claim->claimType() . // Zirmed replaces this
 258     "~\n";
 259
 260   ++$edicount;
 261   $out .= "NM1" .       // Loop 2010BA Subscriber
 262     "*IL" .
 263     "*1" .
 264     "*" . $claim->insuredLastName() .
 265     "*" . $claim->insuredFirstName() .
 266     "*" . $claim->insuredMiddleName() .
 267     "*" .
 268     "*" .
 269     "*MI" .
 270     "*" . $claim->policyNumber() .
 271     "~\n";
 272
 273   ++$edicount;
 274   $out .= "N3" .
 275     "*" . $claim->insuredStreet() .
 276     "~\n";
 277
 278   ++$edicount;
 279   $out .= "N4" .
 280     "*" . $claim->insuredCity() .
 281     "*" . $claim->insuredState() .
 282     "*" . $claim->insuredZip() .
 283     "~\n";
 284
 285   ++$edicount;
 286   $out .= "DMG" .
 287     "*D8" .
 288     "*" . $claim->insuredDOB() .
 289     "*" . $claim->insuredSex() .
 290     "~\n";
 291
 292   ++$edicount;
 293   //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 294   $payerName=substr($claim->payerName(),0,35);
 295   $out .= "NM1" .       // Loop 2010BB Payer
 296     "*PR" .
 297     "*2" .
 298     "*" . $payerName .
 299     "*" .
 300     "*" .
 301     "*" .
 302     "*" .
 303     "*PI" .
 304     // Zirmed ignores this if using payer name matching:
 305     "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 306     "~\n";
 307
 308   // if (!$claim->payerID()) {
 309   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 310   // }
 311
 312   ++$edicount;
 313   $out .= "N3" .
 314     "*" . $claim->payerStreet() .
 315     "~\n";
 316
 317   ++$edicount;
 318   $out .= "N4" .
 319     "*" . $claim->payerCity() .
 320     "*" . $claim->payerState() .
 321     "*" . $claim->payerZip() .
 322     "~\n";
 323
 324   if (! $claim->isSelfOfInsured()) {
 325     ++$edicount;
 326     $out .= "HL" .        // Loop 2000C Patient Information
 327       "*$HLcount" .
 328       "*$HLSubscriber" .
 329       "*23" .
 330       "*0" .
 331       "~\n";
 332
 333     $HLcount++;
 334
 335     ++$edicount;
 336     $out .= "PAT" .
 337       "*" . $claim->insuredRelationship() .
 338       "~\n";
 339
 340     ++$edicount;
 341     $out .= "NM1" .       // Loop 2010CA Patient
 342       "*QC" .
 343       "*1" .
 344       "*" . $claim->patientLastName() .
 345       "*" . $claim->patientFirstName() .
 346       "*" . $claim->patientMiddleName() .
 347       "~\n";
 348
 349     ++$edicount;
 350     $out .= "N3" .
 351       "*" . $claim->patientStreet() .
 352       "~\n";
 353
 354     ++$edicount;
 355     $out .= "N4" .
 356       "*" . $claim->patientCity() .
 357       "*" . $claim->patientState() .
 358       "*" . $claim->patientZip() .
 359       "~\n";
 360
 361     ++$edicount;
 362     $out .= "DMG" .
 363       "*D8" .
 364       "*" . $claim->patientDOB() .
 365       "*" . $claim->patientSex() .
 366       "~\n";
 367   } // end of patient different from insured
 368
 369   $proccount = $claim->procCount();
 370
 371   $clm_total_charges = 0;
 372   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 373     $clm_total_charges += $claim->cptCharges($prockey);
 374   }
 375
 376   if (!$clm_total_charges) {
 377     $log .= "*** This claim has no charges!\n";
 378   }
 379
 380
 381   ++$edicount;
 382   $out .= "CLM" .       // Loop 2300 Claim
 383     "*$pid-$encounter" .
 384     "*"  . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 385     "*"  .
 386     "*"  .
 387     "*" . sprintf('%02d', $claim->facilityPOS()) . "::" . $claim->frequencyTypeCode() . // Changed to correct single digit output
 388     "*Y" .
 389     "*A" .
 390     "*"  . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 391     "*Y" .
 392     "*C" .
 393     "~\n";
 394
 395   if ($claim->dateInitialTreatment()) {
 396     ++$edicount;
 397     $out .= "DTP" .       // Date of Initial Treatment
 398       "*454" .
 399       "*D8" .
 400       "*" . $claim->dateInitialTreatment() .
 401       "~\n";
 402   }
 403
 404   ++$edicount;
 405   $out .= "DTP" .       // Date of Onset
 406     "*431" .
 407     "*D8" .
 408     "*" . $claim->onsetDate() .
 409     "~\n";
 410
 411   if (strcmp($claim->facilityPOS(),'21') == 0) {
 412     ++$edicount;
 413     $out .= "DTP" .     // Date of Hospitalization
 414       "*435" .
 415       "*D8" .
 416       "*" . $claim->onsetDate() .
 417       "~\n";
 418   }
 419
 420   $patientpaid = $claim->patientPaidAmount();
 421   if ($patientpaid != 0) {
 422     ++$edicount;
 423     $out .= "AMT" .     // Patient paid amount. Page 220.
 424       "*F5" .
 425       "*" . $patientpaid .
 426       "~\n";
 427   }
 428
 429   if ($claim->priorAuth()) {
 430     ++$edicount;
 431     $out .= "REF" .     // Prior Authorization Number
 432       "*G1" .
 433       "*" . $claim->priorAuth() .
 434       "~\n";
 435   }
 436
 437   if ($claim->cliaCode() and $claim->claimType() === 'MB') {
 438     // Required by Medicare when in-house labs are done.
 439     ++$edicount;
 440     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 441       "*X4" .
 442       "*" . $claim->cliaCode() .
 443       "~\n";
 444   }
 445
 446   // Note: This would be the place to implement the NTE segment for loop 2300.
 447   if ($claim->additionalNotes()) {
 448     // Claim note.
 449     ++$edicount;
 450     $out .= "NTE" .     // comments box 19
 451       "*" .
 452       "*" . $claim->additionalNotes() .
 453       "~\n";
 454   }
 455
 456   // Diagnoses, up to 8 per HI segment.
 457   $da = $claim->diagArray();
 458   $diag_type_code = 'BK';
 459   $tmp = 0;
 460   foreach ($da as $diag) {
 461     if ($tmp % 8 == 0) {
 462       if ($tmp) $out .= "~\n";
 463       ++$edicount;
 464       $out .= "HI";         // Health Diagnosis Codes
 465     }
 466     $out .= "*$diag_type_code:" . $diag;
 467     $diag_type_code = 'BF';
 468     ++$tmp;
 469   }
 470   if ($tmp) $out .= "~\n";
 471
 472   if ($claim->referrerLastName()) {
 473     // Medicare requires referring provider's name and UPIN.
 474     ++$edicount;
 475     $out .= "NM1" .     // Loop 2310A Referring Provider
 476       "*DN" .
 477       "*1" .
 478       "*" . $claim->referrerLastName() .
 479       "*" . $claim->referrerFirstName() .
 480       "*" . $claim->referrerMiddleName() .
 481       "*" .
 482       "*";
 483     if ($claim->referrerNPI()) { $out .=
 484       "*XX" .
 485       "*" . $claim->referrerNPI();
 486     } else { $out .=
 487       "*34" .
 488       "*" . $claim->referrerSSN();
 489     }
 490     $out .= "~\n";
 491
 492     if ($claim->referrerTaxonomy()) {
 493       ++$edicount;
 494       $out .= "PRV" .
 495         "*RF" . // ReFerring provider
 496         "*ZZ" .
 497         "*" . $claim->referrerTaxonomy() .
 498         "~\n";
 499     }
 500
 501     if ($claim->referrerUPIN()) {
 502       ++$edicount;
 503       $out .= "REF" .   // Referring Provider Secondary Identification
 504         "*1G" .
 505         "*" . $claim->referrerUPIN() .
 506         "~\n";
 507     }
 508   }
 509
 510   ++$edicount;
 511   $out .= "NM1" .       // Loop 2310B Rendering Provider
 512     "*82" .
 513     "*1" .
 514     "*" . $claim->providerLastName() .
 515     "*" . $claim->providerFirstName() .
 516     "*" . $claim->providerMiddleName() .
 517     "*" .
 518     "*";
 519   if ($claim->providerNPI()) { $out .=
 520     "*XX" .
 521     "*" . $claim->providerNPI();
 522   } else { $out .=
 523     "*34" .
 524     "*" . $claim->providerSSN();
 525     $log .= "*** Rendering provider has no NPI.\n";
 526   }
 527   $out .= "~\n";
 528
 529   if ($claim->providerTaxonomy()) {
 530     ++$edicount;
 531     $out .= "PRV" .
 532       "*PE" . // PErforming provider
 533       "*ZZ" .
 534       "*" . $claim->providerTaxonomy() .
 535       "~\n";
 536   }
 537
 538   // REF*1C is required here for the Medicare provider number if NPI was
 539   // specified in NM109.  Not sure if other payers require anything here.
 540   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 541
 542    if (trim($claim->x12gsreceiverid()) != '470819582') { // if NOT ECLAIMS EDI
 543       if ($claim->providerNumber()) {
 544         ++$edicount;
 545         $out .= "REF" .
 546           "*" . $claim->providerNumberType() .
 547           "*" . $claim->providerNumber() .
 548           "~\n";
 549       }
 550    }
 551
 552   // Loop 2310D is omitted in the case of home visits (POS=12).
 553   if ($claim->facilityPOS() != 12) {
 554     ++$edicount;
 555     $out .= "NM1" .       // Loop 2310D Service Location
 556       "*77" .
 557       "*2";
 558    //Field length is limited to 35. See nucc dataset page 77 www.nucc.org
 559         $facilityName=substr($claim->facilityName(),0,35);
 560     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 561       "*" . $facilityName;
 562     }
 563     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 564       "*" .
 565       "*" .
 566       "*" .
 567       "*";
 568       if ($claim->facilityNPI()) { $out .=
 569         "*XX*" . $claim->facilityNPI();
 570       } else { $out .=
 571         "*24*" . $claim->facilityETIN();
 572         $log .= "*** Service location has no NPI.\n";
 573       }
 574     }
 575     $out .= "~\n";
 576     if ($claim->facilityStreet()) {
 577       ++$edicount;
 578       $out .= "N3" .
 579         "*" . $claim->facilityStreet() .
 580         "~\n";
 581     }
 582     if ($claim->facilityState()) {
 583       ++$edicount;
 584       $out .= "N4" .
 585         "*" . $claim->facilityCity() .
 586         "*" . $claim->facilityState() .
 587         "*" . $claim->facilityZip() .
 588         "~\n";
 589     }
 590   }
 591
 592   // Loop 2310E, Supervising Provider
 593   //
 594   if ($claim->supervisorLastName()) {
 595     ++$edicount;
 596     $out .= "NM1" .
 597       "*DQ" . // Supervising Physician
 598       "*1" .  // Person
 599       "*" . $claim->supervisorLastName() .
 600       "*" . $claim->supervisorFirstName() .
 601       "*" . $claim->supervisorMiddleName() .
 602       "*" .   // NM106 not used
 603       "*";    // Name Suffix
 604     if ($claim->supervisorNPI()) { $out .=
 605       "*XX" .
 606       "*" . $claim->supervisorNPI();
 607     } else { $out .=
 608       "*34" .
 609       "*" . $claim->supervisorSSN();
 610     }
 611     $out .= "~\n";
 612
 613     if ($claim->supervisorNumber()) {
 614       ++$edicount;
 615       $out .= "REF" .
 616         "*" . $claim->supervisorNumberType() .
 617         "*" . $claim->supervisorNumber() .
 618         "~\n";
 619     }
 620   }
 621
 622   $prev_pt_resp = $clm_total_charges; // for computation below
 623
 624   // Loops 2320 and 2330*, other subscriber/payer information.
 625   //
 626   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 627
 628     $tmp1 = $claim->claimType($ins);
 629     $tmp2 = 'C1'; // Here a kludge. See page 321.
 630     if ($tmp1 === 'CI') $tmp2 = 'C1';
 631     if ($tmp1 === 'AM') $tmp2 = 'AP';
 632     if ($tmp1 === 'HM') $tmp2 = 'HM';
 633     if ($tmp1 === 'MB') $tmp2 = 'MB';
 634     if ($tmp1 === 'MC') $tmp2 = 'MC';
 635     if ($tmp1 === '09') $tmp2 = 'PP';
 636     ++$edicount;
 637     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 638       "*" . $claim->payerSequence($ins) .
 639       "*" . $claim->insuredRelationship($ins) .
 640       "*" . $claim->groupNumber($ins) .
 641       "*" . $claim->groupName($ins) .
 642       "*" . $tmp2 .
 643       "*" .
 644       "*" .
 645       "*" .
 646       "*" . $claim->claimType($ins) .
 647       "~\n";
 648
 649     // Things that apply only to previous payers, not future payers.
 650     //
 651     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 652
 653       // Generate claim-level adjustments.
 654       $aarr = $claim->payerAdjustments($ins);
 655       foreach ($aarr as $a) {
 656         ++$edicount;
 657         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 658           "*" . $a[1] .
 659           "*" . $a[2] .
 660           "*" . $a[3] .
 661           "~\n";
 662       }
 663
 664       $payerpaid = $claim->payerTotals($ins);
 665       ++$edicount;
 666       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 667         "*D" .
 668         "*" . $payerpaid[1] .
 669         "~\n";
 670
 671       // Patient responsibility amount as of this previous payer.
 672       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 673       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 674
 675       ++$edicount;
 676       $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 677         "*B6" .
 678         "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 679         "~\n";
 680
 681       ++$edicount;
 682       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 683         "*F2" .
 684         "*" . sprintf('%.2f', $prev_pt_resp) .
 685         "~\n";
 686
 687     } // End of things that apply only to previous payers.
 688
 689     ++$edicount;
 690     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 691       "*D8" .
 692       "*" . $claim->insuredDOB($ins) .
 693       "*" . $claim->insuredSex($ins) .
 694       "~\n";
 695
 696     ++$edicount;
 697     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 698       "*" .
 699       "*" .
 700       "*Y" .
 701       "*B" .
 702       "*" .
 703       "*Y" .
 704       "~\n";
 705
 706     ++$edicount;
 707     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 708       "*IL" .
 709       "*1" .
 710       "*" . $claim->insuredLastName($ins) .
 711       "*" . $claim->insuredFirstName($ins) .
 712       "*" . $claim->insuredMiddleName($ins) .
 713       "*" .
 714       "*" .
 715       "*MI" .
 716       "*" . $claim->policyNumber($ins) .
 717       "~\n";
 718
 719     ++$edicount;
 720     $out .= "N3" .
 721       "*" . $claim->insuredStreet($ins) .
 722       "~\n";
 723
 724     ++$edicount;
 725     $out .= "N4" .
 726       "*" . $claim->insuredCity($ins) .
 727       "*" . $claim->insuredState($ins) .
 728       "*" . $claim->insuredZip($ins) .
 729       "~\n";
 730
 731     ++$edicount;
 732     //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 733     $payerName=substr($claim->payerName($ins),0,35);
 734     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 735       "*PR" .
 736       "*2" .
 737       "*" . $payerName .
 738       "*" .
 739       "*" .
 740       "*" .
 741       "*" .
 742       "*PI" .
 743       "*" . $claim->payerID($ins) .
 744       "~\n";
 745
 746     // if (!$claim->payerID($ins)) {
 747     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 748     // }
 749
 750     // Payer address (N3 and N4) are added below so that Gateway EDI can
 751     // auto-generate secondary claims.  These do NOT appear in my copy of
 752     // the spec!  -- Rod 2008-06-12
 753
 754     if (trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 755       ++$edicount;
 756       $out .= "N3" .
 757         "*" . $claim->payerStreet($ins) .
 758         "~\n";
 759       //
 760       ++$edicount;
 761       $out .= "N4" .
 762         "*" . $claim->payerCity($ins) .
 763         "*" . $claim->payerState($ins) .
 764         "*" . $claim->payerZip($ins) .
 765         "~\n";
 766     } // end Gateway EDI
 767
 768   } // End loops 2320/2330*.
 769
 770   $loopcount = 0;
 771
 772   // Procedure loop starts here.
 773   //
 774   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 775     ++$loopcount;
 776
 777     ++$edicount;
 778     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 779       "*$loopcount" .
 780       "~\n";
 781
 782     ++$edicount;
 783     $out .= "SV1" .     // Professional Service. Page 400.
 784       "*HC:" . $claim->cptKey($prockey) .
 785       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 786       "*UN" .
 787       "*" . $claim->cptUnits($prockey) .
 788       "*" .
 789       "*" .
 790       "*";
 791     $dia = $claim->diagIndexArray($prockey);
 792     $i = 0;
 793     foreach ($dia as $dindex) {
 794       if ($i) $out .= ':';
 795       $out .= $dindex;
 796       if (++$i >= 4) break;
 797     }
 798     $out .= "~\n";
 799
 800     if (!$claim->cptCharges($prockey)) {
 801       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 802     }
 803
 804     if (empty($dia)) {
 805       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 806     }
 807
 808     ++$edicount;
 809     $out .= "DTP" .     // Date of Service. Page 435.
 810       "*472" .
 811       "*D8" .
 812       "*" . $claim->serviceDate() .
 813       "~\n";
 814
 815     // AMT*AAE segment for Approved Amount from previous payer.
 816     // Medicare secondaries seem to require this.
 817     //
 818     for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
 819       if ($claim->payerSequence($ins) > $claim->payerSequence())
 820         continue; // payer is future, not previous
 821       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 822       ++$edicount;
 823       $out .= "AMT" . // Approved amount per previous payer. Page 485.
 824         "*AAE" .
 825         "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
 826         "~\n";
 827       break;
 828     }
 829
 830     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 831     // with HCPCS codes.
 832     //
 833     $ndc = $claim->cptNDCID($prockey);
 834     if ($ndc) {
 835       ++$edicount;
 836       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 837         "*" .         // Per addendum, LIN01 is not used.
 838         "*N4" .
 839         "*" . $ndc .
 840         "~\n";
 841
 842       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp) && !preg_match('/^\d{11}$/', $ndc)) {
 843         $log .= "*** NDC code '$ndc' has invalid format!\n";
 844       }
 845
 846       ++$edicount;
 847       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 848       if (!$tmpunits) $tmpunits = 1;
 849       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 850         "*" .
 851         "*" .
 852         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 853         "*" . $claim->cptNDCQuantity($prockey) .
 854         "*" . $claim->cptNDCUOM($prockey) .
 855         "~\n";
 856     }
 857
 858     // Loop 2420A, Rendering Provider (service-specific).
 859     // Used if the rendering provider for this service line is different
 860     // from that in loop 2310B.
 861     //
 862     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
 863       ++$edicount;
 864       $out .= "NM1" .       // Loop 2310B Rendering Provider
 865         "*82" .
 866         "*1" .
 867         "*" . $claim->providerLastName($prockey) .
 868         "*" . $claim->providerFirstName($prockey) .
 869         "*" . $claim->providerMiddleName($prockey) .
 870         "*" .
 871         "*";
 872       if ($claim->providerNPI($prockey)) { $out .=
 873         "*XX" .
 874         "*" . $claim->providerNPI($prockey);
 875       } else { $out .=
 876         "*34" .
 877         "*" . $claim->providerSSN($prockey);
 878         $log .= "*** Rendering provider has no NPI.\n";
 879       }
 880       $out .= "~\n";
 881
 882       if ($claim->providerTaxonomy($prockey)) {
 883         ++$edicount;
 884         $out .= "PRV" .
 885           "*PE" . // PErforming provider
 886           "*ZZ" .
 887           "*" . $claim->providerTaxonomy($prockey) .
 888           "~\n";
 889       }
 890
 891       // REF*1C is required here for the Medicare provider number if NPI was
 892       // specified in NM109.  Not sure if other payers require anything here.
 893       if ($claim->providerNumber($prockey)) {
 894         ++$edicount;
 895         $out .= "REF" .
 896           "*" . $claim->providerNumberType($prockey) .
 897           "*" . $claim->providerNumber($prockey) .
 898           "~\n";
 899       }
 900     }
 901
 902     // Loop 2430, adjudication by previous payers.
 903     //
 904     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 905       if ($claim->payerSequence($ins) > $claim->payerSequence())
 906         continue; // payer is future, not previous
 907
 908       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 909       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 910
 911       if ($payerpaid[1] == 0 && !count($aarr)) {
 912         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 913           "' has no payments or adjustments from previous payer!\n";
 914         continue;
 915       }
 916
 917       ++$edicount;
 918       $out .= "SVD" . // Service line adjudication. Page 554.
 919         "*" . $claim->payerID($ins) .
 920         "*" . $payerpaid[1] .
 921         "*HC:" . $claim->cptKey($prockey) .
 922         "*" .
 923         "*" . $claim->cptUnits($prockey) .
 924         "~\n";
 925
 926       $tmpdate = $payerpaid[0];
 927       foreach ($aarr as $a) {
 928         ++$edicount;
 929         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 930           "*" . $a[1] .
 931           "*" . $a[2] .
 932           "*" . $a[3] .
 933           "~\n";
 934         if (!$tmpdate) $tmpdate = $a[0];
 935         if ( isset($a[4]) &&
 936                 $a[4] != null ) {
 937                 $out .= "CAS02" . // Previous payer's adjustment reason
 938                   "*" . $a[4] .
 939                   "~\n";
 940         }
 941       }
 942
 943       if ($tmpdate) {
 944         ++$edicount;
 945         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 946           "*573" .
 947           "*D8" .
 948           "*$tmpdate" .
 949           "~\n";
 950       }
 951     } // end loop 2430
 952   } // end this procedure
 953
 954   ++$edicount;
 955   $out .= "SE" .        // SE Trailer
 956     "*$edicount" .
 957     "*0021" .
 958     "~\n";
 959
 960   $out .= "GE" .        // GE Trailer
 961     "*1" .
 962     "*1" .
 963     "~\n";
 964
 965   $out .= "IEA" .       // IEA Trailer
 966     "*1" .
 967     "*000000001" .
 968     "~\n";
 969
 970   $log .= "\n";
 971   return $out;
 972 }
 973 ?>