library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007 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) {
  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     "*ZZ" .
  30     "*" . $claim->x12gssenderid() .
  31     "*ZZ" .
  32     "*" . $claim->x12gsreceiverid() .
  33     "*030911" .
  34     "*1630" .
  35     "*U" .
  36     "*00401" .
  37     "*000000001" .
  38     "*0" .
  39     "*P" .
  40     "*:" .
  41     "~\n";
  42
  43   $out .= "GS" .
  44     "*HC" .
  45     "*" . $claim->x12gssenderid() .
  46     "*" . $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', $today) .
  66     "*1023" .
  67     "*CH" .
  68     "~\n";
  69
  70   ++$edicount;
  71   $out .= "REF" .
  72     "*87" .
  73     "*" . $claim->x12gsversionstring() .
  74     "~\n";
  75
  76   ++$edicount;
  77   $out .= "NM1" .       // Loop 1000A Submitter
  78     "*41" .
  79     "*2" .
  80     "*" . $claim->billingFacilityName() .
  81     "*" .
  82     "*" .
  83     "*" .
  84     "*" .
  85     "*46" .
  86     "*" . $claim->billingFacilityETIN() .
  87     "~\n";
  88
  89   ++$edicount;
  90   $out .= "PER" .
  91     "*IC" .
  92     "*" . $claim->billingContactName() .
  93     "*TE" .
  94     "*" . $claim->billingContactPhone() .
  95     "~\n";
  96
  97   ++$edicount;
  98   $out .= "NM1" .       // Loop 1000B Receiver
  99     "*40" .
 100     "*2" .
 101     "*" . $claim->clearingHouseName() .
 102     "*" .
 103     "*" .
 104     "*" .
 105     "*" .
 106     "*46" .
 107     "*" . $claim->clearingHouseETIN() .
 108     "~\n";
 109
 110   $HLcount = 1;
 111
 112   ++$edicount;
 113   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 114     "*$HLcount" .
 115     "*" .
 116     "*20" .
 117     "*1" .
 118     "~\n";
 119
 120   $HLBillingPayToProvider = $HLcount++;
 121
 122   ++$edicount;
 123   $out .= "NM1" .       // Loop 2010AA Billing Provider
 124     "*85" .
 125     "*2" .
 126     "*" . $claim->billingFacilityName() .
 127     "*" .
 128     "*" .
 129     "*" .
 130     "*";
 131   if ($claim->billingFacilityNPI()) {
 132     $out .= "*XX*" . $claim->billingFacilityNPI();
 133   } else {
 134     $log .= "*** Billing facility has no NPI.\n";
 135     $out .= "*24*" . $claim->billingFacilityETIN();
 136   }
 137   $out .= "~\n";
 138
 139   ++$edicount;
 140   $out .= "N3" .
 141     "*" . $claim->billingFacilityStreet() .
 142     "~\n";
 143
 144   ++$edicount;
 145   $out .= "N4" .
 146     "*" . $claim->billingFacilityCity() .
 147     "*" . $claim->billingFacilityState() .
 148     "*" . $claim->billingFacilityZip() .
 149     "~\n";
 150
 151   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 152   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 153     ++$edicount;
 154     $out .= "REF" .
 155       "*EI" .
 156       "*" . $claim->billingFacilityETIN() .
 157       "~\n";
 158   }
 159
 160   ++$edicount;
 161   $out .= "REF" .
 162     "*" . $claim->providerNumberType() .
 163     "*" . $claim->providerNumber() .
 164     "~\n";
 165
 166   ++$edicount;
 167   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 168     "*87" .
 169     "*2" .
 170     "*" . $claim->billingFacilityName() .
 171     "*" .
 172     "*" .
 173     "*" .
 174     "*";
 175   if ($claim->billingFacilityNPI())
 176     $out .= "*XX*" . $claim->billingFacilityNPI();
 177   else
 178     $out .= "*24*" . $claim->billingFacilityETIN();
 179   $out .= "~\n";
 180
 181   ++$edicount;
 182   $out .= "N3" .
 183     "*" . $claim->billingFacilityStreet() .
 184     "~\n";
 185
 186   ++$edicount;
 187   $out .= "N4" .
 188     "*" . $claim->billingFacilityCity() .
 189     "*" . $claim->billingFacilityState() .
 190     "*" . $claim->billingFacilityZip() .
 191     "~\n";
 192
 193   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 194     ++$edicount;
 195     $out .= "REF" .
 196       "*EI" .
 197       "*" . $claim->billingFacilityETIN() .
 198       "~\n";
 199   }
 200
 201   $PatientHL = 0;
 202
 203   ++$edicount;
 204   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 205     "*$HLcount" .
 206     "*$HLBillingPayToProvider" .
 207     "*22" .
 208     "*$PatientHL" .
 209     "~\n";
 210
 211   $HLSubscriber = $HLcount++;
 212
 213   if (!$claim->payerSequence()) {
 214     $log .= "*** Error: Insurance information is missing!\n";
 215   }
 216   ++$edicount;
 217   $out .= "SBR" .       // Subscriber Information
 218     "*" . $claim->payerSequence() .
 219     "*" . $claim->insuredRelationship() .
 220     "*" . $claim->groupNumber() .
 221     "*" . $claim->groupName() .
 222     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 223     "*" .
 224     "*" .
 225     "*" .
 226     "*" . $claim->claimType() . // Zirmed replaces this
 227     "~\n";
 228
 229   ++$edicount;
 230   $out .= "NM1" .       // Loop 2010BA Subscriber
 231     "*IL" .
 232     "*1" .
 233     "*" . $claim->insuredLastName() .
 234     "*" . $claim->insuredFirstName() .
 235     "*" . $claim->insuredMiddleName() .
 236     "*" .
 237     "*" .
 238     "*MI" .
 239     "*" . $claim->policyNumber() .
 240     "~\n";
 241
 242   ++$edicount;
 243   $out .= "N3" .
 244     "*" . $claim->insuredStreet() .
 245     "~\n";
 246
 247   ++$edicount;
 248   $out .= "N4" .
 249     "*" . $claim->insuredCity() .
 250     "*" . $claim->insuredState() .
 251     "*" . $claim->insuredZip() .
 252     "~\n";
 253
 254   ++$edicount;
 255   $out .= "DMG" .
 256     "*D8" .
 257     "*" . $claim->insuredDOB() .
 258     "*" . $claim->insuredSex() .
 259     "~\n";
 260
 261   ++$edicount;
 262   $out .= "NM1" .       // Loop 2010BB Payer
 263     "*PR" .
 264     "*2" .
 265     "*" . $claim->payerName() .
 266     "*" .
 267     "*" .
 268     "*" .
 269     "*" .
 270     "*PI" .
 271     "*" . $claim->payerID() . // Zirmed ignores this if using Payer Name Matching.
 272     "~\n";
 273
 274   // if (!$claim->payerID()) {
 275   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 276   // }
 277
 278   ++$edicount;
 279   $out .= "N3" .
 280     "*" . $claim->payerStreet() .
 281     "~\n";
 282
 283   ++$edicount;
 284   $out .= "N4" .
 285     "*" . $claim->payerCity() .
 286     "*" . $claim->payerState() .
 287     "*" . $claim->payerZip() .
 288     "~\n";
 289
 290   if (! $claim->isSelfOfInsured()) {
 291     ++$edicount;
 292     $out .= "HL" .        // Loop 2000C Patient Information
 293       "*$HLcount" .
 294       "*$HLSubscriber" .
 295       "*23" .
 296       "*0" .
 297       "~\n";
 298
 299     $HLcount++;
 300
 301     ++$edicount;
 302     $out .= "PAT" .
 303       "*" . $claim->insuredRelationship() .
 304       "~\n";
 305
 306     ++$edicount;
 307     $out .= "NM1" .       // Loop 2010CA Patient
 308       "*QC" .
 309       "*1" .
 310       "*" . $claim->patientLastName() .
 311       "*" . $claim->patientFirstName() .
 312       "*" . $claim->patientMiddleName() .
 313       "~\n";
 314
 315     ++$edicount;
 316     $out .= "N3" .
 317       "*" . $claim->patientStreet() .
 318       "~\n";
 319
 320     ++$edicount;
 321     $out .= "N4" .
 322       "*" . $claim->patientCity() .
 323       "*" . $claim->patientState() .
 324       "*" . $claim->patientZip() .
 325       "~\n";
 326
 327     ++$edicount;
 328     $out .= "DMG" .
 329       "*D8" .
 330       "*" . $claim->patientDOB() .
 331       "*" . $claim->patientSex() .
 332       "~\n";
 333   } // end of patient different from insured
 334
 335   $proccount = $claim->procCount();
 336
 337   $clm_total_charges = 0;
 338   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 339     $clm_total_charges += $claim->cptCharges($prockey);
 340   }
 341
 342   if (!$clm_total_charges) {
 343     $log .= "*** This claim has no charges!\n";
 344   }
 345
 346   ++$edicount;
 347   $out .= "CLM" .       // Loop 2300 Claim
 348     "*$pid-$encounter" .
 349     "*" . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 350     "*" .
 351     "*" .
 352     "*" . $claim->facilityPOS() . "::1" .
 353     "*Y" .
 354     "*A" .
 355     "*Y" .
 356     "*Y" .
 357     "*C" .
 358     "~\n";
 359
 360   ++$edicount;
 361   $out .= "DTP" .       // Date of Onset
 362     "*431" .
 363     "*D8" .
 364     "*" . $claim->onsetDate() .
 365     "~\n";
 366
 367   if (strcmp($claim->facilityPOS(),'21') == 0) {
 368     ++$edicount;
 369     $out .= "DTP" .     // Date of Hospitalization
 370       "*435" .
 371       "*D8" .
 372       "*" . $claim->onsetDate() .
 373       "~\n";
 374   }
 375
 376   $patientpaid = $claim->patientPaidAmount();
 377   if ($patientpaid != 0) {
 378     ++$edicount;
 379     $out .= "AMT" .     // Patient paid amount. Page 220.
 380       "*F5" .
 381       "*" . $patientpaid .
 382       "~\n";
 383   }
 384
 385   if ($claim->priorAuth()) {
 386     ++$edicount;
 387     $out .= "REF" .     // Prior Authorization Number
 388       "*G1" .
 389       "*" . $claim->priorAuth() .
 390       "~\n";
 391   }
 392
 393   if ($claim->cliaCode()) {
 394     // Required by Medicare when in-house labs are done.
 395     ++$edicount;
 396     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 397       "*X4" .
 398       "*" . $claim->cliaCode() .
 399       "~\n";
 400   }
 401
 402   $da = $claim->diagArray();
 403   ++$edicount;
 404   $out .= "HI";         // Health Diagnosis Codes
 405   $diag_type_code = 'BK';
 406   foreach ($da as $diag) {
 407     $out .= "*$diag_type_code:" . $diag;
 408     $diag_type_code = 'BF';
 409   }
 410   $out .= "~\n";
 411
 412   if ($claim->referrerLastName()) {
 413     // Medicare requires referring provider's name and UPIN.
 414     ++$edicount;
 415     $out .= "NM1" .     // Loop 2310A Referring Provider
 416       "*DN" .
 417       "*1" .
 418       "*" . $claim->referrerLastName() .
 419       "*" . $claim->referrerFirstName() .
 420       "*" . $claim->referrerMiddleName() .
 421       "*" .
 422       "*";
 423     if ($claim->referrerNPI()) { $out .=
 424       "*XX" .
 425       "*" . $claim->referrerNPI();
 426     } else { $out .=
 427       "*34" .
 428       "*" . $claim->referrerSSN();
 429     }
 430     $out .= "~\n";
 431
 432     ++$edicount;
 433     $out .= "REF" .     // Referring Provider Secondary Identification
 434       "*1G" .
 435       "*" . $claim->referrerUPIN() .
 436       "~\n";
 437   }
 438
 439   ++$edicount;
 440   $out .= "NM1" .       // Loop 2310B Rendering Provider
 441     "*82" .
 442     "*1" .
 443     "*" . $claim->providerLastName() .
 444     "*" . $claim->providerFirstName() .
 445     "*" . $claim->providerMiddleName() .
 446     "*" .
 447     "*";
 448   if ($claim->providerNPI()) { $out .=
 449     "*XX" .
 450     "*" . $claim->providerNPI();
 451   } else { $out .=
 452     "*34" .
 453     "*" . $claim->providerSSN();
 454     $log .= "*** Rendering provider has no NPI.\n";
 455   }
 456   $out .= "~\n";
 457
 458   ++$edicount;
 459   $out .= "PRV" .       // Rendering Provider Information
 460     "*PE" .
 461     "*ZZ" .
 462     "*207Q00000X" .
 463     "~\n";
 464
 465   // REF*1C is required here for the Medicare provider number if NPI was
 466   // specified in NM109.  Not sure if other payers require anything here.
 467   if ($claim->providerNumber()) {
 468     ++$edicount;
 469     $out .= "REF" .
 470       "*" . $claim->providerNumberType() .
 471       "*" . $claim->providerNumber() .
 472       "~\n";
 473   }
 474
 475   ++$edicount;
 476   $out .= "NM1" .       // Loop 2310D Service Location
 477     "*77" .
 478     "*2" .
 479     "*" . $claim->facilityName() .
 480     "*" .
 481     "*" .
 482     "*" .
 483     "*";
 484   if ($claim->facilityNPI()) { $out .=
 485     "*XX*" . $claim->facilityNPI();
 486   } else { $out .=
 487     "*24*" . $claim->facilityETIN();
 488     $log .= "*** Service location has no NPI.\n";
 489   }
 490   $out .= "~\n";
 491
 492   ++$edicount;
 493   $out .= "N3" .
 494     "*" . $claim->facilityStreet() .
 495     "~\n";
 496
 497   ++$edicount;
 498   $out .= "N4" .
 499     "*" . $claim->facilityCity() .
 500     "*" . $claim->facilityState() .
 501     "*" . $claim->facilityZip() .
 502     "~\n";
 503
 504   $prev_pt_resp = $clm_total_charges; // for computation below
 505
 506   // Loops 2320 and 2330*, other subscriber/payer information.
 507   //
 508   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 509
 510     ++$edicount;
 511     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 512       "*" . $claim->payerSequence($ins) .
 513       "*" . $claim->insuredRelationship($ins) .
 514       "*" . $claim->groupNumber($ins) .
 515       "*" . $claim->groupName($ins) .
 516       "*" .
 517       "*" .
 518       "*" .
 519       "*" .
 520       "*" . $claim->claimType($ins) .
 521       "~\n";
 522
 523     // Things that apply only to previous payers, not future payers.
 524     //
 525     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 526
 527       // Generate claim-level adjustments.
 528       $aarr = $claim->payerAdjustments($ins);
 529       foreach ($aarr as $a) {
 530         ++$edicount;
 531         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 532           "*" . $a[1] .
 533           "*" . $a[2] .
 534           "*" . $a[3] .
 535           "~\n";
 536       }
 537
 538       $payerpaid = $claim->payerTotals($ins);
 539       ++$edicount;
 540       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 541         "*D" .
 542         "*" . $payerpaid[1] .
 543         "~\n";
 544
 545       // Patient responsibility amount as of this previous payer.
 546       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 547       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 548
 549       ++$edicount;
 550       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 551         "*F2" .
 552         "*" . sprintf('%.2f', $prev_pt_resp) .
 553         "~\n";
 554
 555     } // End of things that apply only to previous payers.
 556
 557     ++$edicount;
 558     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 559       "*D8" .
 560       "*" . $claim->insuredDOB($ins) .
 561       "*" . $claim->insuredSex($ins) .
 562       "~\n";
 563
 564     ++$edicount;
 565     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 566       "*" .
 567       "*" .
 568       "*Y" .
 569       "*B" .
 570       "*" .
 571       "*Y" .
 572       "~\n";
 573
 574     ++$edicount;
 575     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 576       "*IL" .
 577       "*1" .
 578       "*" . $claim->insuredLastName($ins) .
 579       "*" . $claim->insuredFirstName($ins) .
 580       "*" . $claim->insuredMiddleName($ins) .
 581       "*" .
 582       "*" .
 583       "*MI" .
 584       "*" . $claim->policyNumber($ins) .
 585       "~\n";
 586
 587     ++$edicount;
 588     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 589       "*PR" .
 590       "*2" .
 591       "*" . $claim->payerName($ins) .
 592       "*" .
 593       "*" .
 594       "*" .
 595       "*" .
 596       "*PI" .
 597       "*" . $claim->payerID($ins) .
 598       "~\n";
 599
 600     // if (!$claim->payerID($ins)) {
 601     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 602     // }
 603
 604   } // End loops 2320/2330*.
 605
 606   $loopcount = 0;
 607
 608   // Procedure loop starts here.
 609   //
 610   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 611     ++$loopcount;
 612
 613     ++$edicount;
 614     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 615       "*$loopcount" .
 616       "~\n";
 617
 618     ++$edicount;
 619     $out .= "SV1" .     // Professional Service. Page 400.
 620       "*HC:" . $claim->cptKey($prockey) .
 621       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 622       "*UN" .
 623       "*" . $claim->cptUnits($prockey) .
 624       "*" .
 625       "*" .
 626       "*" . $claim->diagIndex($prockey) .
 627       "~\n";
 628
 629     if (!$claim->cptCharges($prockey)) {
 630       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 631     }
 632
 633     if (!$claim->diagIndex($prockey)) {
 634       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 635     }
 636
 637     ++$edicount;
 638     $out .= "DTP" .     // Date of Service. Page 435.
 639       "*472" .
 640       "*D8" .
 641       "*" . $claim->serviceDate() .
 642       "~\n";
 643
 644     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 645     // with HCPCS codes.
 646     //
 647     $ndc = $claim->cptNDCID($prockey);
 648     if ($ndc) {
 649       ++$edicount;
 650       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 651         "*4" .
 652         "*N4" .
 653         "*" . $ndc .
 654         "~\n";
 655
 656       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 657         $log .= "*** NDC code '$ndc' has invalid format!\n";
 658       }
 659
 660       ++$edicount;
 661       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 662       if (!$tmpunits) $tmpunits = 1;
 663       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 664         "*" .
 665         "*" .
 666         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 667         "*" . $claim->cptNDCQuantity($prockey) .
 668         "*" . $claim->cptNDCUOM($prockey) .
 669         "~\n";
 670     }
 671
 672     // Loop 2430, adjudication by previous payers.
 673     //
 674     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 675       if ($claim->payerSequence($ins) > $claim->payerSequence())
 676         continue; // payer is future, not previous
 677
 678       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 679       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 680
 681       if ($payerpaid[1] == 0 && !count($aarr)) {
 682         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 683           "' has no payments or adjustments from previous payer!\n";
 684         continue;
 685       }
 686
 687       ++$edicount;
 688       $out .= "SVD" . // Service line adjudication. Page 554.
 689         "*" . $claim->payerID($ins) .
 690         "*" . $payerpaid[1] .
 691         "*HC:" . $claim->cptKey($prockey) .
 692         "*" .
 693         "*" . $claim->cptUnits($prockey) .
 694         "~\n";
 695
 696       $tmpdate = $payerpaid[0];
 697       foreach ($aarr as $a) {
 698         ++$edicount;
 699         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 700           "*" . $a[1] .
 701           "*" . $a[2] .
 702           "*" . $a[3] .
 703           "~\n";
 704         if (!$tmpdate) $tmpdate = $a[0];
 705       }
 706
 707       if ($tmpdate) {
 708         ++$edicount;
 709         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 710           "*573" .
 711           "*D8" .
 712           "*$tmpdate" .
 713           "~\n";
 714       }
 715     } // end loop 2430
 716   } // end this procedure
 717
 718   ++$edicount;
 719   $out .= "SE" .        // SE Trailer
 720     "*$edicount" .
 721     "*0021" .
 722     "~\n";
 723
 724   $out .= "GE" .        // GE Trailer
 725     "*1" .
 726     "*1" .
 727     "~\n";
 728
 729   $out .= "IEA" .       // IEA Trailer
 730     "*1" .
 731     "*000000001" .
 732     "~\n";
 733
 734   $log .= "\n";
 735   return $out;
 736 }
 737 ?>