library/gen_x12_837.inc.php

   1 <?php
   2 /*
   3  * This program creates a 5010 837P file
   4  *
   5  * @package OpenEMR
   6  * @author Rod Roark <rod@sunsetsystems.com>
   7  * @author Stephen Waite <stephen.waite@cmsvt.com>
   8  * @copyright Copyright (c) 2009 Rod Roark <rod@sunsetsystems.com>
   9  * @copyright Copyright (c) 2017 Stephen Waite <stephen.waite@cmsvt.com>
  10  * @link https://github.com/openemr/openemr/tree/master
  11  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once(dirname(__FILE__) . "/invoice_summary.inc.php");
  15
  16 use OpenEMR\Billing\Claim;
  17
  18 function stripZipCode($zip)
  19 {
  20     return preg_replace('/[-\s]*/', '', $zip);
  21 }
  22
  23 function gen_x12_837($pid, $encounter, &$log, $encounter_claim = false)
  24 {
  25     $today = time();
  26     $out = '';
  27     $claim = new Claim($pid, $encounter);
  28     $edicount = 0;
  29     $HLcount = 0;
  30
  31     $log .= "Generating claim $pid" . "-" . $encounter . " for " .
  32     $claim->patientFirstName() . ' ' .
  33     $claim->patientMiddleName() . ' ' .
  34     $claim->patientLastName() . ' on ' .
  35     date('Y-m-d H:i', $today) . ".\n";
  36
  37     $out .= "ISA" .
  38     "*" . $claim->x12gsisa01() .
  39     "*" . $claim->x12gsisa02() .
  40     "*" . $claim->x12gsisa03() .
  41     "*" . $claim->x12gsisa04() .
  42     "*" . $claim->x12gsisa05() .
  43     "*" . $claim->x12gssenderid() .
  44     "*" . $claim->x12gsisa07() .
  45     "*" . $claim->x12gsreceiverid() .
  46     "*" . "030911" .  // dummy data replace by billing_process.php
  47     "*" . "1630" . // ditto
  48     "*" . "^" .
  49     "*" . "00501" .
  50     "*" . "000000001" .
  51     "*" . $claim->x12gsisa14() .
  52     "*" . $claim->x12gsisa15() .
  53     "*:" .
  54     "~\n";
  55
  56     $out .= "GS" .
  57     "*" . "HC" .
  58     "*" . $claim->x12gsgs02() .
  59     "*" . trim($claim->x12gs03()) .
  60     "*" . date('Ymd', $today) .
  61     "*" . date('Hi', $today) .
  62     "*" . "1" .
  63     "*" . "X" .
  64     "*" . $claim->x12gsversionstring() .
  65     "~\n";
  66
  67     ++$edicount;
  68     $out .= "ST" .
  69     "*" . "837" .
  70     "*" . "0021" .
  71     "*" . $claim->x12gsversionstring() .
  72     "~\n";
  73
  74     ++$edicount;
  75     $out .= "BHT" .
  76     "*" . "0019" .                             // 0019 is required here
  77     "*" . "00" .                               // 00 = original transmission
  78     "*" . "0123" .                             // reference identification
  79     "*" . date('Ymd', $today) .           // transaction creation date
  80     "*" . date('Hi', $today) .            // transaction creation time
  81     "*" . ($encounter_claim ? "RP" : "CH") .  // RP = reporting, CH = chargeable
  82     "~\n";
  83
  84     ++$edicount;
  85     if ($claim->federalIdType() == "SY") { // check entity type for NM*102 1 == person, 2 == non-person entity
  86         $firstName = $claim->providerFirstName();
  87         $lastName = $claim->providerLastName();
  88         $middleName = $claim->providerMiddleName();
  89         $suffixName = $claim->providerSuffixName();
  90         $out .= "NM1" . // Loop 1000A Submitter
  91         "*" . "41" .
  92         "*" . "1" .
  93         "*" . $lastName .
  94         "*" . $firstName .
  95         "*" . $middleName .
  96         "*" . // Name Prefix not used
  97         "*" . $suffixName .
  98         "*" . "46";
  99     } else {
 100         $billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
 101         if ($billingFacilityName == '') {
 102             $log .= "*** billing facility name in 1000A loop is empty\n";
 103         }
 104         $out .= "NM1" .
 105         "*" . "41" .
 106         "*" . "2" .
 107         "*" . $billingFacilityName .
 108         "*" .
 109         "*" .
 110         "*" .
 111         "*" .
 112         "*" . "46";
 113     }
 114     $out .= "*" . $claim->billingFacilityETIN();
 115     $out .= "~\n";
 116
 117     ++$edicount;
 118     $out .= "PER" .
 119     "*" . "IC" .
 120     "*" . $claim->billingContactName() .
 121     "*" . "TE" .
 122     "*" . $claim->billingContactPhone() .
 123     "*" . "EM" .
 124     "*" . $claim->billingContactEmail();
 125     $out .= "~\n";
 126
 127     ++$edicount;
 128     $out .= "NM1" .    // Loop 1000B Receiver
 129     "*" . "40" .
 130     "*" . "2" .
 131     "*" . $claim->clearingHouseName() .
 132     "*" .
 133     "*" .
 134     "*" .
 135     "*" .
 136     "*" . "46" .
 137     "*" . $claim->clearingHouseETIN() .
 138     "~\n";
 139
 140     ++$HLcount;
 141     ++$edicount;
 142     $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 143     "*" . $HLcount .
 144     "*" .
 145     "*" . "20" .
 146     "*" . "1" .              // 1 indicates there are child segments
 147     "~\n";
 148
 149     $HLBillingPayToProvider = $HLcount++;
 150     // Situational PRV segment for provider taxonomy code for Medicaid.
 151     if ($claim->claimType() == 'MC') {
 152         ++$edicount;
 153         $out .= "PRV" .
 154         "*" . "BI" .
 155         "*" . "ZZ" .
 156         "*" . $claim->providerTaxonomy() .
 157         "~\n";
 158     }
 159
 160     // Situational CUR segment (foreign currency information) omitted here.
 161     ++$edicount;
 162     if ($claim->federalIdType() == "SY") { // check for entity type like in 1000A
 163         $firstName = $claim->providerFirstName();
 164         $lastName = $claim->providerLastName();
 165         $middleName = $claim->providerMiddleName();
 166         $out .= "NM1" .
 167         "*" . "85" .
 168         "*" . "1" .
 169         "*" . $lastName .
 170         "*" . $firstName .
 171         "*" . $middleName .
 172         "*" . // Name Prefix not used
 173         "*";
 174     } else {
 175         $billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
 176         if ($billingFacilityName == '') {
 177             $log .= "*** billing facility name in 2010A loop is empty\n";
 178         }
 179         $out .= "NM1" . // Loop 2010AA Billing Provider
 180         "*" . "85" .
 181         "*" . "2" .
 182         "*" . $billingFacilityName .
 183         "*" .
 184         "*" .
 185         "*" .
 186         "*";
 187     }
 188     if ($claim->billingFacilityNPI()) {
 189         $out .= "*XX*" . $claim->billingFacilityNPI();
 190     } else {
 191         $log .= "*** Billing facility has no NPI.\n";
 192     }
 193     $out .= "~\n";
 194
 195     ++$edicount;
 196     $out .= "N3" .
 197     "*" . $claim->billingFacilityStreet() .
 198     "~\n";
 199
 200     ++$edicount;
 201     $out .= "N4" .
 202     "*" . $claim->billingFacilityCity() .
 203     "*" . $claim->billingFacilityState() .
 204     "*" . stripZipCode($claim->billingFacilityZip()) .
 205     "~\n";
 206
 207     if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 208         ++$edicount;
 209         $out .= "REF";
 210         if ($claim->federalIdType()) {
 211             $out .= "*" . $claim->federalIdType();
 212         } else {
 213             $out .= "*EI"; // For dealing with the situation before adding TaxId type In facility.
 214         }
 215         $out .= "*" . $claim->billingFacilityETIN() . "~\n";
 216     } else {
 217         $log .= "*** No billing facility NPI and/or ETIN.\n";
 218     }
 219     if ($claim->providerNumberType() && $claim->providerNumber() && !$claim->billingFacilityNPI()) {
 220         ++$edicount;
 221         $out .= "REF" .
 222             "*" . $claim->providerNumberType() .
 223             "*" . $claim->providerNumber() .
 224             "~\n";
 225     } else if ($claim->providerNumber() && !$claim->providerNumberType()) {
 226         $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 227     }
 228
 229     // Situational PER*1C segment omitted.
 230
 231     // Pay-To Address defaults to billing provider and is no longer required in 5010 but may be useful
 232     if ($claim->facilityStreet() != $claim->billingFacilityStreet()) {
 233         ++$edicount;
 234         $billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
 235         $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 236             "*" . "87" .
 237             "*" . "2" .
 238             "*" . $billingFacilityName .
 239             "*" .
 240             "*" .
 241             "*" .
 242             "*";
 243         if ($claim->billingFacilityNPI()) {
 244             $out .= "*XX*" . $claim->billingFacilityNPI();
 245         }
 246         $out .= "~\n";
 247
 248         ++$edicount;
 249         $out .= "N3" .
 250             "*" . $claim->billingFacilityStreet() .
 251             "~\n";
 252
 253         ++$edicount;
 254         $out .= "N4" .
 255             "*" . $claim->billingFacilityCity() .
 256             "*" . $claim->billingFacilityState() .
 257             "*" . stripZipCode($claim->billingFacilityZip()) .
 258             "~\n";
 259
 260         if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 261             ++$edicount;
 262             $out .= "REF" .
 263                 "*" . "EI" .
 264                 "*" . $claim->billingFacilityETIN() .
 265                 "~\n";
 266         }
 267     }
 268
 269     // Loop 2010AC Pay-To Plan Name omitted.  Includes:
 270     // NM1*PE, N3, N4, REF*2U, REF*EI
 271
 272     $PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
 273     $HLSubscriber = $HLcount++;
 274
 275     ++$edicount;
 276     $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 277         "*" . $HLSubscriber .
 278         "*" . $HLBillingPayToProvider .
 279         "*" . "22" .
 280         "*" . $PatientHL .
 281         "~\n";
 282
 283     if (!$claim->payerSequence()) {
 284         $log .= "*** Error: Insurance information is missing!\n";
 285     }
 286
 287     ++$edicount;
 288     $out .= "SBR" .    // Subscriber Information
 289         "*" . $claim->payerSequence() .
 290         "*" . ($claim->isSelfOfInsured() ? '18' : '') .
 291         "*" . $claim->groupNumber() .
 292         "*" . $claim->groupName() .
 293         "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 294         "*" .
 295         "*" .
 296         "*" .
 297         "*" . $claim->claimType() .
 298         "~\n";
 299
 300     // Segment PAT omitted.
 301
 302     ++$edicount;
 303     $out .= "NM1" .       // Loop 2010BA Subscriber
 304         "*" . "IL" .
 305         "*" . "1" . // 1 = person, 2 = non-person
 306         "*" . $claim->insuredLastName() .
 307         "*" . $claim->insuredFirstName() .
 308         "*" . $claim->insuredMiddleName() .
 309         "*" .
 310         "*" . // Name Suffix not used
 311         "*" . "MI" .
 312         // "MI" = Member Identification Number
 313         // "II" = Standard Unique Health Identifier, "Required if the
 314         //        HIPAA Individual Patient Identifier is mandated use."
 315         //        Here we presume that is not true yet.
 316         "*" . $claim->policyNumber() .
 317         "~\n";
 318
 319     // For 5010, further subscriber info is sent only if they are the patient.
 320     if ($claim->isSelfOfInsured()) {
 321         ++$edicount;
 322         $out .= "N3" .
 323             "*" . $claim->insuredStreet() .
 324             "~\n";
 325
 326         ++$edicount;
 327         $out .= "N4" .
 328             "*" . $claim->insuredCity() .
 329             "*" . $claim->insuredState() .
 330             "*" . stripZipCode($claim->insuredZip()) .
 331             "~\n";
 332
 333         ++$edicount;
 334         $out .= "DMG" .
 335             "*" . "D8" .
 336             "*" . $claim->insuredDOB() .
 337             "*" . $claim->insuredSex() .
 338             "~\n";
 339     }
 340
 341     // Segment REF*SY (Subscriber Secondary Identification) omitted.
 342     // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 343     // Segment PER*IC (Property and Casualty Subscriber Contact Information) omitted.
 344
 345     ++$edicount;
 346     $payerName = substr($claim->payerName(), 0, 60);
 347     $out .= "NM1" .       // Loop 2010BB Payer
 348         "*" . "PR" .
 349         "*" . "2" .
 350         "*" . $payerName .
 351         "*" .
 352         "*" .
 353         "*" .
 354         "*" .
 355         "*" . "PI" .
 356         "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 357         "~\n";
 358     if (!$claim->payerID()) {
 359         $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 360     }
 361
 362     ++$edicount;
 363     $out .= "N3" .
 364         "*" . $claim->payerStreet() .
 365         "~\n";
 366
 367     ++$edicount;
 368     $out .= "N4" .
 369         "*" . $claim->payerCity() .
 370         "*" . $claim->payerState() .
 371         "*" . stripZipCode($claim->payerZip()) .
 372         "~\n";
 373
 374     // Segment REF (Payer Secondary Identification) omitted.
 375     // Segment REF (Billing Provider Secondary Identification) omitted.
 376
 377     if ($claim->isSelfOfInsured()) {
 378         ++$edicount;
 379         $out .= "HL" .        // Loop 2000C Patient Information
 380             "*" . $HLcount .
 381             "*" . $HLSubscriber .
 382             "*" . "23" .
 383             "*" . "0" .
 384             "~\n";
 385
 386         $HLcount++;
 387         ++$edicount;
 388         $out .= "PAT" .
 389             "*" . $claim->insuredRelationship() .
 390             "~\n";
 391
 392         ++$edicount;
 393         $out .= "NM1" .       // Loop 2010CA Patient
 394             "*" . "QC" .
 395             "*" . "1" .
 396             "*" . $claim->patientLastName() .
 397             "*" . $claim->patientFirstName();
 398
 399         if ($claim->patientMiddleName() !== '') {
 400             $out .= "*" . $claim->patientMiddleName();
 401         }
 402
 403         $out .= "~\n";
 404
 405         ++$edicount;
 406         $out .= "N3" .
 407             "*" . $claim->patientStreet() .
 408             "~\n";
 409
 410         ++$edicount;
 411         $out .= "N4" .
 412             "*" . $claim->patientCity() .
 413             "*" . $claim->patientState() .
 414             "*" . stripZipCode($claim->patientZip()) .
 415             "~\n";
 416
 417         ++$edicount;
 418         $out .= "DMG" .
 419             "*" . "D8" .
 420             "*" . $claim->patientDOB() .
 421             "*" . $claim->patientSex() .
 422             "~\n";
 423
 424         // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 425         // Segment REF (Property and Casualty Patient Identifier) omitted.
 426         // Segment PER (Property and Casualty Patient Contact Information) omitted.
 427     } // end of patient different from insured
 428
 429     $proccount = $claim->procCount();
 430     $clm_total_charges = 0;
 431     for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 432         $clm_total_charges += $claim->cptCharges($prockey);
 433     }
 434     if (!$clm_total_charges) {
 435         $log .= "*** This claim has no charges!\n";
 436     }
 437
 438     ++$edicount;
 439     $out .= "CLM" .    // Loop 2300 Claim
 440         "*" . $pid . "-" . $encounter .
 441         "*" . sprintf("%.2f", $clm_total_charges) .
 442         "*" .
 443         "*" .
 444         "*" . sprintf('%02d', $claim->facilityPOS()) . ":" . "B" . ":" . $claim->frequencyTypeCode() .
 445         "*" . "Y" .
 446         "*" . "A" .
 447         "*" . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 448         "*" . "Y" .
 449         "~\n";
 450
 451     if ($claim->onsetDate() && ($claim->onsetDate() !== $claim->serviceDate()) && ($claim->onsetDateValid())) {
 452         ++$edicount;
 453         $out .= "DTP" .       // Date of Onset
 454             "*" . "431" .
 455             "*" . "D8" .
 456             "*" . $claim->onsetDate() .
 457             "~\n";
 458     }
 459
 460     // above is for historical use of encounter onset date, now in misc_billing_options
 461     // Segment DTP*431 (Onset of Current Symptoms or Illness)
 462     // Segment DTP*484 (Last Menstrual Period Date)
 463
 464     if ($claim->miscOnsetDate() && ($claim->box14Qualifier()) && ($claim->miscOnsetDateValid())) {
 465         ++$edicount;
 466         $out .= "DTP" .       // Date Last Seen
 467             "*" . $claim->box14Qualifier() .
 468             "*" . "D8" .
 469             "*" . $claim->miscOnsetDate() .
 470             "~\n";
 471     }
 472
 473     // Segment DTP*454 (Initial Treatment Date)
 474     // Segment DTP*304 (Last Seen Date)
 475     // Segment DTP*453 (Acute Manifestation Date)
 476     // Segment DTP*439 (Accident Date)
 477     // Segment DTP*455 (Last X-Ray Date)
 478     // Segment DTP*471 (Hearing and Vision Prescription Date)
 479     // Segment DTP*314 (Disability) omitted.
 480     // Segment DTP*360 (Initial Disability Period Start) omitted.
 481     // Segment DTP*361 (Initial Disability Period End) omitted.
 482     // Segment DTP*297 (Last Worked Date)
 483     // Segment DTP*296 (Authorized Return to Work Date)
 484
 485     if ($claim->dateInitialTreatment() && ($claim->box15Qualifier()) && ($claim->dateInitialTreatmentValid())) {
 486         ++$edicount;
 487         $out .= "DTP" .       // Date Last Seen
 488         "*" . $claim->box15Qualifier() .
 489         "*" . "D8" .
 490         "*" . $claim->dateInitialTreatment() .
 491         "~\n";
 492     }
 493
 494     if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->onsetDateValid()) {
 495         ++$edicount;
 496         $out .= "DTP" .     // Date of Hospitalization
 497         "*" . "435" .
 498         "*" . "D8" .
 499         "*" . $claim->onsetDate() .
 500         "~\n";
 501     }
 502
 503     // above is for historical use of encounter onset date, now in misc_billing_options
 504     if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->hospitalizedFromDateValid()) {
 505         ++$edicount;
 506         $out .= "DTP" .     // Date of Admission
 507         "*" . "435" .
 508         "*" . "D8" .
 509         "*" . $claim->hospitalizedFrom() .
 510         "~\n";
 511     }
 512
 513     // Segment DTP*096 (Discharge Date)
 514     if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->hospitalizedToDateValid()) {
 515         ++$edicount;
 516         $out .= "DTP" .     // Date of Discharge
 517         "*" . "96" .
 518         "*" . "D8" .
 519         "*" . $claim->hospitalizedTo() .
 520         "~\n";
 521     }
 522
 523     // Segments DTP (Assumed and Relinquished Care Dates) omitted.
 524     // Segment DTP*444 (Property and Casualty Date of First Contact) omitted.
 525     // Segment DTP*050 (Repricer Received Date) omitted.
 526     // Segment PWK (Claim Supplemental Information) omitted.
 527     // Segment CN1 (Contract Information) omitted.
 528
 529     $patientpaid = $claim->patientPaidAmount();
 530     if ($patientpaid != 0) {
 531         ++$edicount;
 532         $out .= "AMT" .     // Patient paid amount. Page 190/220.
 533         "*" . "F5" .
 534         "*" . $patientpaid .
 535         "~\n";
 536     }
 537
 538     // Segment REF*4N (Service Authorization Exception Code) omitted.
 539     // Segment REF*F5 (Mandatory Medicare Crossover Indicator) omitted.
 540     // Segment REF*EW (Mammography Certification Number) omitted.
 541     // Segment REF*9F (Referral Number) omitted.
 542
 543     if ($claim->priorAuth()) {
 544         ++$edicount;
 545         $out .= "REF" .     // Prior Authorization Number
 546         "*" . "G1" .
 547         "*" . $claim->priorAuth() .
 548         "~\n";
 549     }
 550
 551     // Segment REF*F8 Payer Claim Control Number for claim re-submission.icn_resubmission_number
 552     if (trim($claim->billing_options['icn_resubmission_number']) > 3) {
 553         ++$edicount;
 554         error_log("Method 1: " . $claim->billing_options['icn_resubmission_number'], 0);
 555         $out .= "REF" .
 556         "*" . "F8" .
 557         "*" . $claim->icnResubmissionNumber() .
 558         "~\n";
 559     }
 560
 561     if ($claim->cliaCode() && ($claim->claimType() === 'MB')) {
 562         // Required by Medicare when in-house labs are done.
 563         ++$edicount;
 564         $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 565         "*" . "X4" .
 566         "*" . $claim->cliaCode() .
 567         "~\n";
 568     }
 569
 570     // Segment REF*9A (Repriced Claim Number) omitted.
 571     // Segment REF*9C (Adjusted Repriced Claim Number) omitted.
 572     // Segment REF*LX (Investigational Device Exemption Number) omitted.
 573     // Segment REF*D9 (Claim Identifier for Transmission Intermediaries) omitted.
 574     // Segment REF*EA (Medical Record Number) omitted.
 575     // Segment REF*P4 (Demonstration Project Identifier) omitted.
 576     // Segment REF*1J (Care Plan Oversight) omitted.
 577     // Segment K3 (File Information) omitted.
 578     if ($claim->additionalNotes()) {
 579         // Claim note.
 580         ++$edicount;
 581         $out .= "NTE" .     // comments box 19
 582         "*" . "ADD" .
 583         "*" . $claim->additionalNotes() .
 584         "~\n";
 585     }
 586
 587     // Segment CR1 (Ambulance Transport Information) omitted.
 588     // Segment CR2 (Spinal Manipulation Service Information) omitted.
 589     // Segment CRC (Ambulance Certification) omitted.
 590     // Segment CRC (Patient Condition Information: Vision) omitted.
 591     // Segment CRC (Homebound Indicator) omitted.
 592     // Segment CRC (EPSDT Referral).
 593     if ($claim->epsdtFlag()) {
 594         ++$edicount;
 595         $out .= "CRC" .
 596         "*" . "ZZ" .
 597         "*" . "Y" .
 598         "*" . $claim->medicaidReferralCode() .
 599         "~\n";
 600     }
 601
 602     // Diagnoses, up to $max_per_seg per HI segment.
 603     $max_per_seg = 12;
 604     $da = $claim->diagArray();
 605     if ($claim->diagtype == "ICD9") {
 606         $diag_type_code = 'BK';
 607     } else {
 608         $diag_type_code = 'ABK';
 609     }
 610     $tmp = 0;
 611     foreach ($da as $diag) {
 612         if ($tmp % $max_per_seg == 0) {
 613             if ($tmp) {
 614                 $out .= "~\n";
 615             }
 616             ++$edicount;
 617             $out .= "HI";         // Health Diagnosis Codes
 618         }
 619         $out .= "*" . $diag_type_code . ":" . $diag;
 620         if ($claim->diagtype == "ICD9") {
 621             $diag_type_code = 'BF';
 622         } else {
 623             $diag_type_code = 'ABF';
 624         }
 625         ++$tmp;
 626     }
 627
 628     if ($tmp) {
 629         $out .= "~\n";
 630     }
 631
 632     // Segment HI*BP (Anesthesia Related Procedure) omitted.
 633     // Segment HI*BG (Condition Information) omitted.
 634     // Segment HCP (Claim Pricing/Repricing Information) omitted.
 635     if ($claim->referrerLastName()) {
 636         // Medicare requires referring provider's name and UPIN.
 637         ++$edicount;
 638         $out .= "NM1" .     // Loop 2310A Referring Provider
 639         "*" . "DN" .
 640         "*" . "1" .
 641         "*" . $claim->referrerLastName() .
 642         "*" . $claim->referrerFirstName() .
 643         "*" . $claim->referrerMiddleName() .
 644         "*" .
 645         "*";
 646         if ($claim->referrerNPI()) {
 647             $out .=
 648             "*" . "XX" .
 649             "*" . $claim->referrerNPI();
 650         } else {
 651             $log .= "*** Referring provider has no NPI.\n";
 652         }
 653         $out .= "~\n";
 654     }
 655
 656     // Per the implementation guide lines, only include this information if it is different
 657     // than the Loop 2010AA information
 658     if ($claim->providerNPIValid() && ($claim->billingFacilityNPI() !== $claim->providerNPI())) {
 659         ++$edicount;
 660         $out .= "NM1" .       // Loop 2310B Rendering Provider
 661         "*" . "82" .
 662         "*" . "1" .
 663         "*" . $claim->providerLastName() .
 664         "*" . $claim->providerFirstName() .
 665         "*" . $claim->providerMiddleName() .
 666         "*" .
 667         "*";
 668         if ($claim->providerNPI()) {
 669             $out .=
 670             "*" . "XX" .
 671             "*" . $claim->providerNPI();
 672         } else {
 673             $log .= "*** Rendering provider has no NPI.\n";
 674         }
 675         $out .= "~\n";
 676
 677         if ($claim->providerTaxonomy()) {
 678             ++$edicount;
 679             $out .= "PRV" .
 680             "*" . "PE" . // Performing provider
 681             "*" . ($claim->claimType() != 'MC' ? "PXC" : "ZZ") .
 682             "*" . $claim->providerTaxonomy() .
 683             "~\n";
 684         } else {
 685             $log .= "*** Performing provider has no taxonomy code.\n";
 686         }
 687     } else {
 688         $log .= "*** Rendering provider is billing under a group.\n";
 689     }
 690     if (!$claim->providerNPIValid()) {
 691         // If the loop was skipped because the provider NPI was invalid, generate a warning for the log.
 692         $log .= "*** Skipping 2310B because " . $claim->providerLastName() . "," . $claim->providerFirstName() . " has invalid NPI.\n";
 693     }
 694
 695     if (!$claim->providerNPI() && in_array($claim->providerNumberType(), array('0B', '1G', 'G2', 'LU'))) {
 696         if ($claim->providerNumber()) {
 697             ++$edicount;
 698             $out .= "REF" .
 699             "*" . $claim->providerNumberType() .
 700             "*" . $claim->providerNumber() .
 701             "~\n";
 702         }
 703     }
 704     // End of Loop 2310B
 705
 706     // Loop 2310C is omitted in the case of home visits (POS=12).
 707     if ($claim->facilityPOS() != 12 && ($claim->facilityNPI() != $claim->billingFacilityNPI())) {
 708         ++$edicount;
 709         $out .= "NM1" .       // Loop 2310C Service Location
 710         "*" . "77" .
 711         "*" . "2";
 712         $facilityName = substr($claim->facilityName(), 0, 60);
 713         if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) {
 714             $out .=
 715             "*" . $facilityName;
 716         } else {
 717             $log .= "*** Check for invalid facility name, NPI, and/or tax id.\n";
 718         }
 719         if ($claim->facilityNPI() || $claim->facilityETIN()) {
 720             $out .=
 721             "*" .
 722             "*" .
 723             "*" .
 724             "*";
 725             if ($claim->facilityNPI()) {
 726                 $out .=
 727                 "*" . "XX" . "*" . $claim->facilityNPI();
 728             } else {
 729                 $out .=
 730                 "*" . "24" . "*" . $claim->facilityETIN();
 731             }
 732             if (!$claim->facilityNPI()) {
 733                 $log .= "*** Service location has no NPI.\n";
 734             }
 735         }
 736
 737         $out .= "~\n";
 738         if ($claim->facilityStreet()) {
 739             ++$edicount;
 740             $out .= "N3" .
 741             "*" . $claim->facilityStreet() .
 742             "~\n";
 743         }
 744
 745         if ($claim->facilityState()) {
 746             ++$edicount;
 747             $out .= "N4" .
 748             "*" . $claim->facilityCity() .
 749             "*" . $claim->facilityState() .
 750             "*" . stripZipCode($claim->facilityZip()) .
 751             "~\n";
 752         }
 753     }
 754     // Segment REF (Service Facility Location Secondary Identification) omitted.
 755     // Segment PER (Service Facility Contact Information) omitted.
 756
 757     // Loop 2310E, Supervising Provider
 758     if ($claim->supervisorLastName()) {
 759         ++$edicount;
 760         $out .= "NM1" .
 761         "*" . "DQ" . // Supervising Physician
 762         "*" . "1" .  // Person
 763         "*" . $claim->supervisorLastName() .
 764         "*" . $claim->supervisorFirstName() .
 765         "*" . $claim->supervisorMiddleName() .
 766         "*" .   // NM106 not used
 767         "*";    // Name Suffix not used
 768         if ($claim->supervisorNPI()) {
 769             $out .=
 770             "*" . "XX" .
 771             "*" . $claim->supervisorNPI();
 772         } else {
 773             $log .= "*** Supervising Provider has no NPI.\n";
 774         }
 775         $out .= "~\n";
 776
 777         if ($claim->supervisorNumber()) {
 778             ++$edicount;
 779             $out .= "REF" .
 780             "*" . $claim->supervisorNumberType() .
 781             "*" . $claim->supervisorNumber() .
 782             "~\n";
 783         }
 784     } else {
 785         $log .= "*** Supervising provider has invalid last name.\n";
 786     }
 787
 788     // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
 789     // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
 790
 791     // Loops 2320 and 2330, other subscriber/payer information.
 792     // Remember that insurance index 0 is always for the payer being billed
 793     // by this claim, and 1 and above are always for the "other" payers.
 794
 795     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 796         $tmp1 = $claim->claimType($ins);
 797         $tmp2 = 'C1'; // Here a kludge. See page 321.
 798         if ($tmp1 === 'CI') {
 799             $tmp2 = 'C1';
 800         }
 801         if ($tmp1 === 'AM') {
 802             $tmp2 = 'AP';
 803         }
 804         if ($tmp1 === 'HM') {
 805             $tmp2 = 'HM';
 806         }
 807         if ($tmp1 === 'MB') {
 808             $tmp2 = 'MB';
 809         }
 810         if ($tmp1 === 'MC') {
 811             $tmp2 = 'MC';
 812         }
 813         if ($tmp1 === '09') {
 814             $tmp2 = 'PP';
 815         }
 816
 817         ++$edicount;
 818         $out .= "SBR" . // Loop 2320, Subscriber Information - page 297/318
 819         "*" . $claim->payerSequence($ins) .
 820         "*" . $claim->insuredRelationship($ins) .
 821         "*" . $claim->groupNumber($ins) .
 822         "*" . $claim->groupName($ins) .
 823         "*" . $claim->insuredTypeCode($ins) .
 824         "*" .
 825         "*" .
 826         "*" .
 827         "*" . $claim->claimType($ins) .
 828         "~\n";
 829
 830         // Things that apply only to previous payers, not future payers.
 831         if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 832             // Generate claim-level adjustments.
 833             $aarr = $claim->payerAdjustments($ins);
 834             foreach ($aarr as $a) {
 835                 ++$edicount;
 836                 $out .= "CAS" . // Previous payer's claim-level adjustments. Page 301/323.
 837                 "*" . $a[1] .
 838                 "*" . $a[2] .
 839                 "*" . $a[3] .
 840                 "~\n";
 841             }
 842
 843             $payerpaid = $claim->payerTotals($ins);
 844             ++$edicount;
 845             $out .= "AMT" . // Previous payer's paid amount. Page 307/332.
 846             "*" . "D" .
 847             "*" . $payerpaid[1] .
 848             "~\n";
 849             // Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
 850             // Segment AMT*EAF (Remaining Patient Liability) omitted.
 851         }   // End of things that apply only to previous payers.
 852
 853         ++$edicount;
 854         $out .= "OI" .  // Other Insurance Coverage Information. Page 310/344.
 855         "*" .
 856         "*" .
 857         "*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
 858         // For this next item, the 5010 example in the spec does not match its
 859         // description.  So this might be wrong.
 860         "*" .
 861         "*" .
 862         "*" .
 863         "Y" .
 864         "~\n";
 865
 866         // Segment MOA (Medicare Outpatient Adjudication) omitted.
 867         ++$edicount;
 868         $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
 869         "*" . "IL" .
 870         "*" . "1" .
 871         "*" . $claim->insuredLastName($ins) .
 872         "*" . $claim->insuredFirstName($ins) .
 873         "*" . $claim->insuredMiddleName($ins) .
 874         "*" .
 875         "*" .
 876         "*" . "MI" .
 877         "*" . $claim->policyNumber($ins) .
 878         "~\n";
 879
 880         ++$edicount;
 881         $out .= "N3" .
 882         "*" . $claim->insuredStreet($ins) .
 883         "~\n";
 884
 885         ++$edicount;
 886         $out .= "N4" .
 887         "*" . $claim->insuredCity($ins) .
 888         "*" . $claim->insuredState($ins) .
 889         "*" . stripZipCode($claim->insuredZip($ins)) .
 890         "~\n";
 891
 892         // Segment REF (Other Subscriber Secondary Identification) omitted.
 893         ++$edicount;
 894         $payerName = substr($claim->payerName($ins), 0, 60);
 895         $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 322/359.
 896         "*" . "PR" .
 897         "*" . "2" .
 898         "*" . $payerName .
 899         "*" .
 900         "*" .
 901         "*" .
 902         "*" .
 903         "*" . "PI" .
 904         "*" . $claim->payerID($ins) .
 905         "~\n";
 906
 907         if (!$claim->payerID($ins)) {
 908             $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 909         }
 910
 911         ++$edicount;
 912         $out .= "N3" .
 913         "*" . $claim->payerStreet($ins) .
 914         "~\n";
 915
 916         ++$edicount;
 917         $out .= "N4" .
 918         "*" . $claim->payerCity($ins) .
 919         "*" . $claim->payerState($ins) .
 920         "*" . stripZipCode($claim->payerZip($ins)) .
 921         "~\n";
 922         // Segment DTP*573 (Claim Check or Remittance Date) omitted.
 923         // Segment REF (Other Payer Secondary Identifier) omitted.
 924         // Segment REF*G1 (Other Payer Prior Authorization Number) omitted.
 925         // Segment REF*9F (Other Payer Referral Number) omitted.
 926         // Segment REF*T4 (Other Payer Claim Adjustment Indicator) omitted.
 927         // Segment REF*F8 (Other Payer Claim Control Number) omitted.
 928         // Segment NM1 (Other Payer Referring Provider) omitted.
 929         // Segment REF (Other Payer Referring Provider Secondary Identification) omitted.
 930         // Segment NM1 (Other Payer Rendering Provider) omitted.
 931         // Segment REF (Other Payer Rendering Provider Secondary Identification) omitted.
 932         // Segment NM1 (Other Payer Service Facility Location) omitted.
 933         // Segment REF (Other Payer Service Facility Location Secondary Identification) omitted.
 934         // Segment NM1 (Other Payer Supervising Provider) omitted.
 935         // Segment REF (Other Payer Supervising Provider Secondary Identification) omitted.
 936         // Segment NM1 (Other Payer Billing Provider) omitted.
 937         // Segment REF (Other Payer Billing Provider Secondary Identification) omitted.
 938     } // End loops 2320/2330*.
 939
 940     $loopcount = 0;
 941
 942     // Procedure loop starts here.
 943     for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 944         ++$loopcount;
 945         ++$edicount;
 946         $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 947         "*" . $loopcount .
 948         "~\n";
 949
 950         ++$edicount;
 951         $out .= "SV1" .     // Professional Service. Page 400.
 952         "*" . "HC:" . $claim->cptKey($prockey) .
 953         "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 954         "*" . "UN" .
 955         "*" . $claim->cptUnits($prockey) .
 956         "*" .
 957         "*" .
 958         "*";
 959         $dia = $claim->diagIndexArray($prockey);
 960         $i = 0;
 961         foreach ($dia as $dindex) {
 962             if ($i) {
 963                 $out .= ':';
 964             }
 965
 966             $out .= $dindex;
 967             if (++$i >= 4) {
 968                 break;
 969             }
 970         }
 971
 972         # needed for epstd
 973         if ($claim->epsdtFlag()) {
 974             $out .= "*" .
 975             "*" .
 976             "*" .
 977             "*" . "Y" .
 978             "~\n";
 979         } else {
 980             $out .= "~\n";
 981         }
 982
 983         if (!$claim->cptCharges($prockey)) {
 984             $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 985         }
 986
 987         if (empty($dia)) {
 988             $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 989         }
 990
 991         // Segment SV5 (Durable Medical Equipment Service) omitted.
 992         // Segment PWK (Line Supplemental Information) omitted.
 993         // Segment PWK (Durable Medical Equipment Certificate of Medical Necessity Indicator) omitted.
 994         // Segment CR1 (Ambulance Transport Information) omitted.
 995         // Segment CR3 (Durable Medical Equipment Certification) omitted.
 996         // Segment CRC (Ambulance Certification) omitted.
 997         // Segment CRC (Hospice Employee Indicator) omitted.
 998         // Segment CRC (Condition Indicator / Durable Medical Equipment) omitted.
 999
1000         ++$edicount;
1001         $out .= "DTP" .     // Date of Service. Page 435.
1002         "*" . "472" .
1003         "*" . "D8" .
1004         "*" . $claim->serviceDate() .
1005         "~\n";
1006
1007         $testnote = rtrim($claim->cptNotecodes($prockey));
1008         if (!empty($testnote)) {
1009             ++$edicount;
1010             $out .= "NTE" .     // Explain Unusual Circumstances.
1011             "*" . "ADD" .
1012             "*" . $claim->cptNotecodes($prockey) .
1013             "~\n";
1014         }
1015
1016         // Segment DTP*471 (Prescription Date) omitted.
1017         // Segment DTP*607 (Revision/Recertification Date) omitted.
1018         // Segment DTP*463 (Begin Therapy Date) omitted.
1019         // Segment DTP*461 (Last Certification Date) omitted.
1020         // Segment DTP*304 (Last Seen Date) omitted.
1021         // Segment DTP (Test Date) omitted.
1022         // Segment DTP*011 (Shipped Date) omitted.
1023         // Segment DTP*455 (Last X-Ray Date) omitted.
1024         // Segment DTP*454 (Initial Treatment Date) omitted.
1025         // Segment QTY (Ambulance Patient Count) omitted.
1026         // Segment QTY (Obstetric Anesthesia Additional Units) omitted.
1027         // Segment MEA (Test Result) omitted.
1028         // Segment CN1 (Contract Information) omitted.
1029         // Segment REF*9B (Repriced Line Item Reference Number) omitted.
1030         // Segment REF*9D (Adjusted Repriced Line Item Reference Number) omitted.
1031         // Segment REF*G1 (Prior Authorization) omitted.
1032         // Segment REF*6R (Line Item Control Number) omitted.
1033         //   (Really oughta have this for robust 835 posting!)
1034         // Segment REF*EW (Mammography Certification Number) omitted.
1035         // Segment REF*X4 (CLIA Number) omitted.
1036         // Segment REF*F4 (Referring CLIA Facility Identification) omitted.
1037         // Segment REF*BT (Immunization Batch Number) omitted.
1038         // Segment REF*9F (Referral Number) omitted.
1039         // Segment AMT*T (Sales Tax Amount) omitted.
1040         // Segment AMT*F4 (Postage Claimed Amount) omitted.
1041         // Segment K3 (File Information) omitted.
1042         // Segment NTE (Line Note) omitted.
1043         // Segment NTE (Third Party Organization Notes) omitted.
1044         // Segment PS1 (Purchased Service Information) omitted.
1045         // Segment HCP (Line Pricing/Repricing Information) omitted.
1046     }
1047
1048     // Loop 2410, Drug Information. Medicaid insurers seem to want this
1049     // with HCPCS codes.
1050     //
1051     $ndc = $claim->cptNDCID($prockey);
1052
1053     if ($ndc) {
1054         ++$edicount;
1055     }
1056     $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
1057     "*" .         // Per addendum, LIN01 is not used.
1058     "*" . "N4" .
1059     "*" . $ndc .
1060     "~\n";
1061
1062     if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp) && !preg_match('/^\d{11}$/', $ndc)) {
1063         $log .= "*** NDC code '$ndc' has invalid format!\n";
1064     }
1065
1066     ++$edicount;
1067     $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
1068     "*" .
1069     "*" .
1070     "*" .
1071     "*" . $claim->cptNDCQuantity($prockey) .
1072     "*" . $claim->cptNDCUOM($prockey) .
1073     // Note: 5010 documents "ME" (Milligrams) as an additional unit of measure.
1074     "~\n";
1075
1076
1077     // Segment REF (Prescription or Compound Drug Association Number) omitted.
1078
1079     // Loop 2420A, Rendering Provider (service-specific).
1080     // Used if the rendering provider for this service line is different
1081     // from that in loop 2310B.
1082     //
1083     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
1084         ++$edicount;
1085         $out .= "NM1" .       // Loop 2310B Rendering Provider
1086         "*" . "82" .
1087         "*" . "1" .
1088         "*" . $claim->providerLastName($prockey) .
1089         "*" . $claim->providerFirstName($prockey) .
1090         "*" . $claim->providerMiddleName($prockey) .
1091         "*" .
1092         "*";
1093         if ($claim->providerNPI($prockey)) {
1094             $out .=
1095             "*" . "XX" .
1096             "*" . $claim->providerNPI($prockey);
1097         } else {
1098             $log .= "*** Rendering provider has no NPI.\n";
1099         }
1100         $out .= "~\n";
1101
1102         if ($claim->providerTaxonomy($prockey)) {
1103             ++$edicount;
1104             $out .= "PRV" .
1105             "*" . "PE" . // PErforming provider
1106             "*" . "PXC" .
1107             "*" . $claim->providerTaxonomy($prockey) .
1108             "~\n";
1109         }
1110
1111         // Segment PRV*PE (Rendering Provider Specialty Information) omitted.
1112         // Segment REF (Rendering Provider Secondary Identification) omitted.
1113         // Segment NM1 (Purchased Service Provider Name) omitted.
1114         // Segment REF (Purchased Service Provider Secondary Identification) omitted.
1115         // Segment NM1,N3,N4 (Service Facility Location) omitted.
1116         // Segment REF (Service Facility Location Secondary Identification) omitted.
1117         // Segment NM1 (Supervising Provider Name) omitted.
1118         // Segment REF (Supervising Provider Secondary Identification) omitted.
1119         // Segment NM1,N3,N4 (Ordering Provider) omitted.
1120         // Segment REF (Ordering Provider Secondary Identification) omitted.
1121         // Segment PER (Ordering Provider Contact Information) omitted.
1122         // Segment NM1 (Referring Provider Name) omitted.
1123         // Segment REF (Referring Provider Secondary Identification) omitted.
1124         // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
1125         // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
1126
1127         // REF*1C is required here for the Medicare provider number if NPI was
1128         // specified in NM109.  Not sure if other payers require anything here.
1129         ++$edicount;
1130         $out .= "REF" .
1131             "*" . $claim->providerNumberType($prockey) .
1132             // Note: 5010 documents that type 1D (Medicaid) is changed to G2.
1133             "*" . $claim->providerNumber($prockey) .
1134             "~\n";
1135
1136         // Loop 2430, adjudication by previous payers.
1137         //
1138         for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
1139             if ($claim->payerSequence($ins) > $claim->payerSequence()) {
1140                 continue; // payer is future, not previous
1141             }
1142
1143             $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1144             $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
1145
1146             if ($payerpaid[1] == 0 && !count($aarr)) {
1147                 $log .= "*** Procedure '" . $claim->cptKey($prockey) .
1148                     "' has no payments or adjustments from previous payer!\n";
1149                 continue;
1150             }
1151
1152             ++$edicount;
1153             $out .= "SVD" . // Service line adjudication. Page 554.
1154             "*" . $claim->payerID($ins) .
1155             "*" . $payerpaid[1] .
1156             "*" . "HC:" . $claim->cptKey($prockey) .
1157             "*" .
1158             "*" . $claim->cptUnits($prockey) .
1159             "~\n";
1160
1161             $tmpdate = $payerpaid[0];
1162             foreach ($aarr as $a) {
1163                 ++$edicount;
1164                 $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
1165                 "*" . $a[1] .
1166                 "*" . $a[2] .
1167                 "*" . $a[3] .
1168                 "~\n";
1169                 if (!$tmpdate) {
1170                     $tmpdate = $a[0];
1171                 }
1172             }
1173
1174             if ($tmpdate) {
1175                 ++$edicount;
1176                 $out .= "DTP" . // Previous payer's line adjustment date. Page 493/566.
1177                 "*" . "573" .
1178                 "*" . "D8" .
1179                 "*" . $tmpdate .
1180                 "~\n";
1181             }
1182
1183             // Segment AMT*EAF (Remaining Patient Liability) omitted.
1184             // Segment LQ (Form Identification Code) omitted.
1185             // Segment FRM (Supporting Documentation) omitted.
1186         } // end loop 2430
1187     } // end this procedure
1188
1189     ++$edicount;
1190     $out .= "SE" .        // SE Trailer
1191     "*" . $edicount .
1192     "*" . "0021" .
1193     "~\n";
1194
1195     $out .= "GE" .        // GE Trailer
1196     "*" . "1" .
1197     "*" . "1" .
1198     "~\n";
1199
1200     $out .= "IEA" .       // IEA Trailer
1201     "*" . "1" .
1202     "*" . "000000001" .
1203     "~\n";
1204
1205     // Remove any trailing empty fields (delimiters) from each segment.
1206     $out = preg_replace('/\*+~/', '~', $out);
1207
1208     $log .= "\n";
1209     return $out;
1210 }