library/gen_hcfa_1500.inc.php

   1 <?php
   2 // Copyright (C) 2008-2011 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 require_once("gen_hfca_1500_02_12.inc.php");
  11
  12 $hcfa_curr_line = 1;
  13 $hcfa_curr_col = 1;
  14 $hcfa_data = '';
  15 $hcfa_proc_index = 0;
  16
  17
  18 /**
  19  * take the data element and place it at the correct coordinates on the page
  20  *
  21  * @global int $hcfa_curr_line
  22  * @global type $hcfa_curr_col
  23  * @global type $hcfa_data
  24  * @param type $line
  25  * @param type $col
  26  * @param type $maxlen
  27  * @param type $data
  28  * @param type $strip   regular expression for what to strip from the data. period and has are the defaults
  29  *                      02/12 version needs to include periods in the diagnoses hence the need to override
  30  */
  31 function put_hcfa($line, $col, $maxlen, $data,$strip='/[.#]/') {
  32   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  33   if ($line < $hcfa_curr_line)
  34     die("Data item at ($line, $col) precedes current line.");
  35   while ($hcfa_curr_line < $line) {
  36     $hcfa_data .= "\n";
  37     ++$hcfa_curr_line;
  38     $hcfa_curr_col = 1;
  39   }
  40   if ($col < $hcfa_curr_col)
  41     die("Data item at ($line, $col) precedes current column.");
  42   while ($hcfa_curr_col < $col) {
  43     $hcfa_data .= " ";
  44     ++$hcfa_curr_col;
  45   }
  46   $data = preg_replace($strip, '', strtoupper($data));
  47   $len = min(strlen($data), $maxlen);
  48   $hcfa_data .= substr($data, 0, $len);
  49   $hcfa_curr_col += $len;
  50 }
  51
  52 function gen_hcfa_1500($pid, $encounter, &$log) {
  53   global $hcfa_data, $hcfa_proc_index;
  54
  55   $hcfa_data = '';
  56   $hcfa_proc_index = 0;
  57
  58   $today = time();
  59   $claim = new Claim($pid, $encounter);
  60
  61   $log .= "Generating HCFA claim $pid-$encounter for " .
  62     $claim->patientFirstName()  . ' ' .
  63     $claim->patientMiddleName() . ' ' .
  64     $claim->patientLastName()   . ' on ' .
  65     date('Y-m-d H:i', $today) . ".\n";
  66
  67   while ($hcfa_proc_index < $claim->procCount()) {
  68     if ($hcfa_proc_index) $hcfa_data .= "\014"; // append form feed for new page
  69     gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  70   }
  71
  72   $log .= "\n";
  73   return $hcfa_data;
  74 }
  75
  76 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim) {
  77   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  78
  79   $hcfa_curr_line = 1;
  80   $hcfa_curr_col = 1;
  81
  82   // According to:
  83   // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
  84   // Medicare interprets sections 9 and 11 of the claim form in its own
  85   // special way.  This flag tells us to do that.  However I'm not 100%
  86   // sure that it applies nationwide, and if you find that it is not right
  87   // for you then set it to false.  -- Rod 2009-03-26
  88   $new_medicare_logic = $claim->claimType() == 'MB';
  89
  90   // Payer name, attn, street.
  91   put_hcfa(2, 41, 31, $claim->payerName());
  92   put_hcfa(3, 41, 31, $claim->payerAttn());
  93   put_hcfa(4, 41, 31, $claim->payerStreet());
  94
  95   // Payer city, state, zip.
  96   $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
  97   put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
  98
  99   // Box 1. Insurance Type
 100   $ct = $claim->claimType();
 101   $tmpcol = 45;                        // Other
 102   if      ($ct === 'MB') $tmpcol =  1; // Medicare
 103   else if ($ct === 'MC') $tmpcol =  8; // Medicaid
 104   else if ($ct === 'CH') $tmpcol = 15; // Champus
 105   else if ($ct === 'CH') $tmpcol = 24; // Champus VA (why same code?)
 106   else if ($ct === 'BL') $tmpcol = 31; // Group Health Plan (only BCBS?)
 107   else if ($ct === '16') $tmpcol = 39; // FECA
 108   put_hcfa(8, $tmpcol, 1, 'X');
 109
 110   // Box 1a. Insured's ID Number
 111   put_hcfa(8, 50, 17, $claim->policyNumber());
 112
 113   // Box 2. Patient's Name
 114   $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 115   if ($claim->patientMiddleName())
 116     $tmp .= ', ' . substr($claim->patientMiddleName(),0,1);
 117   put_hcfa(10, 1, 28, $tmp);
 118
 119   // Box 3. Patient's Birth Date and Sex
 120   $tmp = $claim->patientDOB();
 121   put_hcfa(10, 31, 2, substr($tmp,4,2));
 122   put_hcfa(10, 34, 2, substr($tmp,6,2));
 123   put_hcfa(10, 37, 4, substr($tmp,0,4));
 124   put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 125
 126   // Box 4. Insured's Name
 127   $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 128   if ($claim->insuredMiddleName())
 129     $tmp .= ', ' . substr($claim->insuredMiddleName(),0,1);
 130   put_hcfa(10, 50, 28, $tmp);
 131
 132   // Box 5. Patient's Address
 133   put_hcfa(12, 1, 28, $claim->patientStreet());
 134
 135   // Box 6. Patient Relationship to Insured
 136   $tmp = $claim->insuredRelationship();
 137   $tmpcol = 47;                         // Other
 138   if      ($tmp === '18') $tmpcol = 33; // self
 139   else if ($tmp === '01') $tmpcol = 38; // spouse
 140   else if ($tmp === '19') $tmpcol = 42; // child
 141   put_hcfa(12, $tmpcol, 1, 'X');
 142
 143   // Box 7. Insured's Address
 144   put_hcfa(12, 50, 28, $claim->insuredStreet());
 145
 146   // Box 5 continued. Patient's City and State
 147   put_hcfa(14,  1, 20, $claim->patientCity());
 148   put_hcfa(14, 26,  2, $claim->patientState());
 149
 150   // Box 8. Patient (Marital) Status
 151   if(!hcfa_1500_version_02_12())  // Box 8 Reserved for NUCC Use in 02/12
 152   {
 153     $tmp = $claim->patientStatus();
 154     $tmpcol = 47;                        // Other
 155     if      ($tmp === 'S') $tmpcol = 35; // Single
 156     else if ($tmp === 'M') $tmpcol = 41; // Married
 157     put_hcfa(14, $tmpcol, 1, 'X');
 158   }
 159
 160   // Box 7 continued. Insured's City and State
 161   put_hcfa(14, 50, 20, $claim->insuredCity());
 162   put_hcfa(14, 74,  2, $claim->insuredState());
 163
 164   // Box 5 continued. Patient's Zip Code and Telephone
 165   put_hcfa(16,  1, 10, $claim->patientZip());
 166   $tmp = $claim->patientPhone();
 167   put_hcfa(16, 15,  3, substr($tmp,0,3));
 168   put_hcfa(16, 19,  7, substr($tmp,3));
 169
 170   // Box 8 continued. Patient (Employment) Status
 171   if(!hcfa_1500_version_02_12())  // Box 8 Reserved for NUCC Use in 02/12
 172   {
 173     $tmp = $claim->patientOccupation();
 174     if      ($tmp === 'STUDENT'   ) put_hcfa(16, 41, 1, 'X');
 175     else if ($tmp === 'PT STUDENT') put_hcfa(16, 47, 1, 'X');
 176     else if ($tmp !== 'UNEMPLOYED') put_hcfa(16, 35, 1, 'X');
 177   }
 178
 179   // Box 7 continued. Insured's Zip Code and Telephone
 180   put_hcfa(16, 50, 10, $claim->insuredZip());
 181   $tmp = $claim->insuredPhone();
 182   put_hcfa(16, 65,  3, substr($tmp,0,3));
 183   put_hcfa(16, 69,  7, substr($tmp,3));
 184
 185   // Box 9. Other Insured's Name
 186   if ($new_medicare_logic) {
 187     // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 188   }
 189   else {
 190     if ($claim->payerCount() > 1) {
 191       $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 192       if ($claim->insuredMiddleName(1))
 193         $tmp .= ', ' . substr($claim->insuredMiddleName(1),0,1);
 194       put_hcfa(18, 1, 28, $tmp);
 195     }
 196   }
 197
 198   // Box 11. Insured's Group Number
 199   if ($new_medicare_logic) {
 200     // If this is Medicare secondary then we need the primary's policy number
 201     // here, otherwise the word "NONE".
 202     $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 203   }
 204   else {
 205     $tmp = $claim->groupNumber();
 206   }
 207   put_hcfa(18, 50, 30, $tmp);
 208
 209   // Box 9a. Other Insured's Policy or Group Number
 210   if ($new_medicare_logic) {
 211     // TBD: Medigap stuff?
 212   }
 213   else {
 214     if ($claim->payerCount() > 1) {
 215       put_hcfa(20, 1, 28, $claim->policyNumber(1));
 216     }
 217   }
 218
 219   // Box 10a. Employment Related
 220   put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 221
 222   // Box 11a. Insured's Birth Date and Sex
 223   if ($new_medicare_logic) {
 224     $tmpdob = $tmpsex = '';
 225     if ($claim->payerSequence() != 'P') {
 226       $tmpdob = $claim->insuredDOB(1);
 227       $tmpsex = $claim->insuredSex(1);
 228     }
 229    }
 230   else {
 231     $tmpdob = $claim->insuredDOB();
 232     $tmpsex = $claim->insuredSex();
 233   }
 234   if ($tmpdob) {
 235     put_hcfa(20, 53, 2, substr($tmpdob,4,2));
 236     put_hcfa(20, 56, 2, substr($tmpdob,6,2));
 237     put_hcfa(20, 59, 4, substr($tmpdob,0,4));
 238   }
 239   if ($tmpsex) {
 240     put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 241   }
 242
 243   // Box 9b. Other Insured's Birth Date and Sex
 244   if(!hcfa_1500_version_02_12())  // Box 9b Reserved for NUCC Use in 02/12
 245   {
 246     if ($new_medicare_logic) {
 247       // TBD: Medigap stuff?
 248     }
 249     else {
 250       if ($claim->payerCount() > 1) {
 251         $tmp = $claim->insuredDOB(1);
 252         put_hcfa(22, 2, 2, substr($tmp,4,2));
 253         put_hcfa(22, 5, 2, substr($tmp,6,2));
 254         put_hcfa(22, 8, 4, substr($tmp,0,4));
 255         put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 256       }
 257     }
 258   }
 259
 260   // Box 10b. Auto Accident
 261   put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 262   if ($claim->isRelatedAuto())
 263     put_hcfa(22, 45, 2, $claim->autoAccidentState());
 264
 265   // Box 11b. Insured's Employer/School Name
 266   if ($new_medicare_logic) {
 267     $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 268   }
 269   else {
 270     $tmp = $claim->groupName();
 271   }
 272   put_hcfa(22, 50, 30, $tmp);
 273
 274   // Box 9c. Other Insured's Employer/School Name
 275   if(!hcfa_1500_version_02_12())  // Box 9c Reserved for NUCC Use in 02/12
 276   {
 277     if ($new_medicare_logic) {
 278       // TBD: Medigap stuff?
 279     }
 280     else {
 281       if ($claim->payerCount() > 1) {
 282         put_hcfa(24, 1, 28, $claim->groupName(1));
 283       }
 284     }
 285   }
 286
 287   // Box 10c. Other Accident
 288   put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 289
 290   // Box 11c. Insurance Plan Name or Program Name
 291   if ($new_medicare_logic) {
 292     $tmp = '';
 293     if ($claim->payerSequence() != 'P') {
 294       $tmp = $claim->planName(1);
 295       if (!$tmp) $tmp = $claim->payerName(1);
 296     }
 297   }
 298   else {
 299     $tmp = $claim->planName();
 300   }
 301   put_hcfa(24, 50, 30, $tmp);
 302
 303   // Box 9d. Other Insurance Plan Name or Program Name
 304   if ($new_medicare_logic) {
 305     // TBD: Medigap stuff?
 306   }
 307   else {
 308     if ($claim->payerCount() > 1) {
 309       put_hcfa(26, 1, 28, $claim->planName(1));
 310     }
 311   }
 312
 313   // Box 11d. Is There Another Health Benefit Plan
 314   if (!$new_medicare_logic) {
 315     put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 316   }
 317
 318   // Box 12. Patient's or Authorized Person's Signature
 319   put_hcfa(29, 7, 17, 'Signature on File');
 320   // Note: Date does not apply unless the person physically signs the form.
 321
 322   // Box 13. Insured's or Authorized Person's Signature
 323   put_hcfa(29, 55, 17, 'Signature on File');
 324
 325   // Box 14. Date of Current Illness/Injury/Pregnancy
 326   $tmp = $claim->onsetDate();
 327   put_hcfa(32, 2, 2, substr($tmp,4,2));
 328   put_hcfa(32, 5, 2, substr($tmp,6,2));
 329   put_hcfa(32, 8, 4, substr($tmp,0,4));
 330
 331   if(hcfa_1500_version_02_12())
 332   {
 333     put_hcfa(32, 16, 3, $claim->box14qualifier());
 334
 335   }
 336   // Box 15. First Date of Same or Similar Illness, if applicable
 337   $tmp = $claim->dateInitialTreatment();
 338   if(hcfa_1500_version_02_12() && !empty($tmp))
 339   {
 340     put_hcfa(32, 31, 3, $claim->box15qualifier());
 341   }
 342
 343
 344   put_hcfa(32,37, 2, substr($tmp,4,2));
 345   put_hcfa(32,40, 2, substr($tmp,6,2));
 346   put_hcfa(32,43, 4, substr($tmp,0,4));
 347
 348
 349   // Box 16. Dates Patient Unable to Work in Current Occupation
 350   if ($claim->isUnableToWork()) {
 351     $tmp = $claim->offWorkFrom();
 352     put_hcfa(32, 54, 2, substr($tmp,4,2));
 353     put_hcfa(32, 57, 2, substr($tmp,6,2));
 354     put_hcfa(32, 60, 4, substr($tmp,0,4));
 355     $tmp = $claim->offWorkTo();
 356     put_hcfa(32, 68, 2, substr($tmp,4,2));
 357     put_hcfa(32, 71, 2, substr($tmp,6,2));
 358     put_hcfa(32, 74, 4, substr($tmp,0,4));
 359   }
 360
 361   // Referring provider stuff.  Reports are that for primary care doctors,
 362   // Medicare forbids an entry here and other payers require one.
 363   // There is still confusion over this.
 364   //
 365   if ($claim->referrerLastName() &&
 366     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB'))
 367   {
 368     // Box 17a. Referring Provider Alternate Identifier
 369     if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 370       put_hcfa(33, 30,  2, '1G');
 371       put_hcfa(33, 33, 15, $claim->referrerUPIN());
 372     }
 373
 374     // Box 17. Name of Referring Provider or Other Source
 375     $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 376     if ($claim->referrerMiddleName())
 377       $tmp .= ', ' . substr($claim->referrerMiddleName(),0,1);
 378     put_hcfa(34, 1, 25, $tmp);
 379
 380     // Box 17b. Referring Provider NPI
 381     if ($claim->referrerNPI()) {
 382       put_hcfa(34, 33, 15, $claim->referrerNPI());
 383     }
 384   }
 385
 386   // Box 18. Hospitalization Dates Related to Current Services
 387   if ($claim->isHospitalized()) {
 388     $tmp = $claim->hospitalizedFrom();
 389     put_hcfa(34, 54, 2, substr($tmp,4,2));
 390     put_hcfa(34, 57, 2, substr($tmp,6,2));
 391     put_hcfa(34, 60, 4, substr($tmp,0,4));
 392     $tmp = $claim->hospitalizedTo();
 393     put_hcfa(34, 68, 2, substr($tmp,4,2));
 394     put_hcfa(34, 71, 2, substr($tmp,6,2));
 395     put_hcfa(34, 74, 4, substr($tmp,0,4));
 396   }
 397
 398   // Box 19. Reserved for Local Use
 399   put_hcfa(36, 1, 48, $claim->additionalNotes());
 400
 401   // Box 20. Outside Lab
 402   put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 403   if ($claim->isOutsideLab()) {
 404     // Note here that put_hcfa strips the decimal point, as required.
 405     // We right-justify this amount (ending in col. 69).
 406     put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 407   }
 408
 409   if(hcfa_1500_version_02_12())
 410   {
 411       process_diagnoses_02_12($claim,$log);
 412   }
 413   else
 414   {
 415         // Box 21. Diagnoses
 416         $tmp = $claim->diagArray();
 417         $diags = array();
 418         foreach ($tmp as $diag) $diags[] = $diag;
 419         if (!empty($diags[0])) {
 420           put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 421           put_hcfa(38, 7, 2, substr($diags[0], 3));
 422         }
 423         if (!empty($diags[2])) {
 424           put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 425           put_hcfa(38, 34, 2, substr($diags[2], 3));
 426         }
 427
 428         // Box 22. Medicaid Resubmission Code and Original Ref. No.
 429         put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 430         put_hcfa(38, 62, 10, $claim->medicaidOriginalReference());
 431
 432         // Box 21 continued. Diagnoses
 433         if (!empty($diags[1])) {
 434           put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 435           put_hcfa(40, 7, 2, substr($diags[1], 3));
 436         }
 437         if (!empty($diags[3])) {
 438           put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 439           put_hcfa(40, 34, 2, substr($diags[3], 3));
 440         }
 441
 442         // Box 23. Prior Authorization Number
 443         put_hcfa(40, 50, 28, $claim->priorAuth());
 444   }
 445   $proccount = $claim->procCount(); // number of procedures
 446
 447   // Charges, adjustments and payments are accumulated by line item so that
 448   // each page of a multi-page claim will stand alone.  Payments include the
 449   // co-pay for the first page only.
 450   $clm_total_charges = 0;
 451   $clm_amount_adjusted = 0;
 452   $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 453
 454   // Procedure loop starts here.
 455   //
 456   for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 457     $dia = $claim->diagIndexArray($hcfa_proc_index);
 458
 459     if (!$claim->cptCharges($hcfa_proc_index)) {
 460       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 461         "' has no charges!\n";
 462     }
 463
 464     if (empty($dia)) {
 465       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 466         "' is not justified!\n";
 467     }
 468
 469     $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 470
 471     // Compute prior payments and "hard" adjustments.
 472     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 473       if ($claim->payerSequence($ins) > $claim->payerSequence())
 474         continue; // skip future payers
 475       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 476       $clm_amount_paid += $payerpaid[1];
 477       $clm_amount_adjusted += $payerpaid[2];
 478     }
 479
 480     ++$svccount;
 481     $lino = $svccount * 2 + 41;
 482
 483     // Drug Information. Medicaid insurers want this with HCPCS codes.
 484     //
 485     $ndc = $claim->cptNDCID($hcfa_proc_index);
 486     if ($ndc) {
 487       if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 488         $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 489       }
 490       else if(preg_match('/^\d{11}$/', $ndc)){
 491
 492       }
 493       else {
 494         $log .= "*** NDC code '$ndc' has invalid format!\n";
 495       }
 496       put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 497         $claim->cptNDCQuantity($hcfa_proc_index));
 498     }
 499
 500     //Note Codes.
 501     put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 502
 503     // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 504     if ($claim->supervisorNumber()) {
 505       // If there is a supervising provider and that person has a
 506       // payer-specific provider number, then we assume that the SP
 507       // must be identified on the claim and this is how we do it
 508       // (but the NPI of the actual rendering provider appears below).
 509       // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 510       put_hcfa($lino, 65,  2, $claim->supervisorNumberType());
 511       put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 512     }
 513     else if ($claim->providerNumber($hcfa_proc_index)) {
 514       put_hcfa($lino, 65,  2, $claim->providerNumberType($hcfa_proc_index));
 515       put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 516     }
 517
 518     ++$lino;
 519
 520     // 24a. Date of Service
 521     $tmp = $claim->serviceDate();
 522     put_hcfa($lino, 1, 2, substr($tmp,4,2));
 523     put_hcfa($lino, 4, 2, substr($tmp,6,2));
 524     put_hcfa($lino, 7, 2, substr($tmp,2,2));
 525     put_hcfa($lino,10, 2, substr($tmp,4,2));
 526     put_hcfa($lino,13, 2, substr($tmp,6,2));
 527     put_hcfa($lino,16, 2, substr($tmp,2,2));
 528
 529     // 24b. Place of Service
 530     put_hcfa($lino, 19, 2, $claim->facilityPOS());
 531
 532     // 24c. EMG
 533     // Not currently supported.
 534
 535     // 24d. Procedures, Services or Supplies
 536     put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 537     // replace colon with space for printing
 538     put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 539
 540     // 24e. Diagnosis Pointer
 541     $tmp = '';
 542     foreach ($claim->diagIndexArray($hcfa_proc_index) as $value)
 543     {
 544         if(hcfa_1500_version_02_12())// For 02/12 Version convert number to letter.
 545         {
 546             // ASCII A is 65, since diagIndexArray is ones based, this will make 1->A, 2->B...
 547             $value=chr($value+64);
 548         }
 549         $tmp .= $value;
 550     }
 551     put_hcfa($lino, 45, 4, $tmp);
 552
 553     // 24f. Charges
 554     put_hcfa($lino, 50, 8, str_replace('.', ' ',
 555       sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
 556
 557     // 24g. Days or Units
 558     put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 559
 560     // 24h. EPSDT Family Plan
 561     // Not currently supported.
 562
 563     // 24j. Rendering Provider NPI
 564     put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 565   }
 566
 567   // 25. Federal Tax ID Number
 568   // FrreB hard coded EIN. Changed it to included SSN as well.
 569   put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 570   if($claim->federalIdType()=='SY'){
 571   put_hcfa(56, 16, 1, 'X'); // The SSN checkbox
 572   }
 573   else{
 574   put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 575   }
 576
 577   // 26. Patient's Account No.
 578   // Instructions say hyphens are not allowed, but freeb used them.
 579   put_hcfa(56, 23, 15, "$pid-$encounter");
 580
 581   // 27. Accept Assignment
 582   put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 583
 584   // 28. Total Charge
 585   put_hcfa(56, 52, 8, str_replace('.',' ',sprintf('%8.2f',$clm_total_charges)));
 586   if (!$clm_total_charges) {
 587     $log .= "*** This claim has no charges!\n";
 588   }
 589
 590   // 29. Amount Paid
 591   put_hcfa(56, 62, 8, str_replace('.',' ',sprintf('%8.2f',$clm_amount_paid)));
 592
 593   // 30. Balance Due
 594   // For secondary payers this reflects primary "contracted rate" adjustments,
 595   // so in general box 30 will not equal box 28 minus box 29.
 596   if(!hcfa_1500_version_02_12())  // Box 30 Reserved for NUCC Use in 02/12
 597   {
 598       put_hcfa(56, 71, 8, str_replace('.',' ',sprintf('%8.2f',
 599         $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
 600   }
 601
 602   // 33. Billing Provider: Phone Number
 603   $tmp = $claim->billingContactPhone();
 604   put_hcfa(57, 66,  3, substr($tmp,0,3));
 605   put_hcfa(57, 70,  7, substr($tmp,3));
 606
 607   // 32. Service Facility Location Information: Name
 608   put_hcfa(58, 23, 25, $claim->facilityName());
 609
 610   // 33. Billing Provider: Name
 611   put_hcfa(58, 50, 25, $claim->billingFacilityName());
 612
 613   // 32. Service Facility Location Information: Street
 614   put_hcfa(59, 23, 25, $claim->facilityStreet());
 615
 616   // 33. Billing Provider: Name
 617   put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 618
 619   // 31. Signature of Physician or Supplier
 620   // FreeB printed the rendering provider's name and the current date here,
 621   // but according to my instructions it must be a real signature and date,
 622   // or else "Signature on File" or "SOF".
 623
 624    if($GLOBALS['cms_1500_box_31_format']==0)
 625    {
 626       put_hcfa(60, 1, 20, 'Signature on File');
 627    }
 628    else if($GLOBALS['cms_1500_box_31_format']==1)
 629    {
 630       put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 631    }
 632   //
 633   // $tmp = $claim->providerFirstName();
 634   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 635   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 636
 637   // 32. Service Facility Location Information: City State Zip
 638   $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 639   put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 640     $claim->facilityZip());
 641
 642   // 33. Billing Provider: City State Zip
 643   $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 644   put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 645     $claim->billingFacilityZip());
 646
 647   // 31. Signature of Physician or Supplier: Date
 648    if($GLOBALS['cms_1500_box_31_date']>0)
 649    {
 650        if($GLOBALS['cms_1500_box_31_date']==1)
 651        {
 652             $date_of_service= $claim->serviceDate();
 653             $MDY=substr($date_of_service,4,2)." ".substr($date_of_service,6,2)." ".substr($date_of_service,2,2);
 654        }
 655        else if($GLOBALS['cms_1500_box_31_date']==2)
 656        {
 657            $MDY=date("m/d/y");
 658        }
 659        put_hcfa(61,6,10,$MDY);
 660    }
 661
 662   // 32a. Service Facility NPI
 663   put_hcfa(61, 24, 10, $claim->facilityNPI());
 664
 665   // 32b. Service Facility Other ID
 666   // Note that Medicare does NOT want this any more.
 667   if ($claim->providerGroupNumber()) {
 668     put_hcfa(61, 36,  2, $claim->providerNumberType());
 669     put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 670   }
 671
 672   // 33a. Billing Facility NPI
 673   put_hcfa(61, 51, 10, $claim->billingFacilityNPI());
 674
 675   // 33b. Billing Facility Other ID
 676   // Note that Medicare does NOT want this any more.
 677   if ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 678     put_hcfa(61, 63,  2, $claim->providerNumberType());
 679     put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 680   }
 681
 682   // Put an extra line here for compatibility with old hcfa text generated form
 683     put_hcfa(62, 1, 1, ' ');
 684
 685   return;
 686 }
 687 ?>