library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007-2011 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("Claim.class.php");
  10
  11 function gen_x12_837($pid, $encounter, &$log, $encounter_claim=false) {
  12
  13   $today = time();
  14   $out = '';
  15   $claim = new Claim($pid, $encounter);
  16   $edicount = 0;
  17
  18   // This is true for the 5010 standard, false for 4010.
  19   // x12gsversionstring() should be "005010X222A1" or "004010X098A1".
  20   $CMS_5010 = strpos($claim->x12gsversionstring(), '5010') !== false;
  21
  22   $log .= "Generating claim $pid-$encounter for " .
  23     $claim->patientFirstName()  . ' ' .
  24     $claim->patientMiddleName() . ' ' .
  25     $claim->patientLastName()   . ' on ' .
  26     date('Y-m-d H:i', $today) . ".\n";
  27
  28   $out .= "ISA" .
  29     "*00" .
  30     "*          " .
  31     "*00" .
  32     "*          " .
  33     "*" . $claim->x12gsisa05() .
  34     "*" . $claim->x12gssenderid() .
  35     "*" . $claim->x12gsisa07() .
  36     "*" . $claim->x12gsreceiverid() .
  37     "*030911" .
  38     "*1630" .
  39     "*" . ($CMS_5010 ? "^"     : "U"    ) .
  40     "*" . ($CMS_5010 ? "00501" : "00401") .
  41     "*000000001" .
  42     "*" . $claim->x12gsisa14() .
  43     "*" . $claim->x12gsisa15() .
  44     "*:" .
  45     "~\n";
  46
  47   $out .= "GS" .
  48     "*HC" .
  49     "*" . $claim->x12gsgs02() .
  50     "*" . trim($claim->x12gsreceiverid()) .
  51     "*" . date('Ymd', $today) .
  52     "*" . date('Hi', $today) .
  53     "*1" .
  54     "*X" .
  55     "*" . $claim->x12gsversionstring() .
  56     "~\n";
  57
  58   ++$edicount;
  59   $out .= "ST" .
  60     "*837" .
  61     "*0021" .
  62     // Spec says the following is optional, so should be able to leave it out.
  63     ($CMS_5010 ? ("*" . $claim->x12gsversionstring()) : "") .
  64     "~\n";
  65
  66   ++$edicount;
  67   $out .= "BHT" .
  68     "*0019" .                             // 0019 is required here
  69     "*00" .                               // 00 = original transmission
  70     "*0123" .                             // reference identification
  71     "*" . date('Ymd', $today) .           // transaction creation date
  72     "*" . date('Hi', $today) .            // transaction creation time
  73     ($encounter_claim ? "*RP" : "*CH") .  // RP = reporting, CH = chargeable
  74     "~\n";
  75
  76   if (!$CMS_5010) {
  77     // This segment was deleted for 5010.
  78     ++$edicount;
  79     $out .= "REF" .
  80       "*87" .
  81       "*" . $claim->x12gsversionstring() .
  82       "~\n";
  83   }
  84
  85   ++$edicount;
  86   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
  87   $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
  88   $out .= "NM1" .       // Loop 1000A Submitter
  89     "*41" .
  90     "*2" .
  91     "*" . $billingFacilityName .
  92     "*" .
  93     "*" .
  94     "*" .
  95     "*" .
  96     "*46";
  97    if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
  98     $out  .=  "*" . $claim->clearingHouseETIN();
  99    } else {
 100     $out  .=  "*" . $claim->billingFacilityETIN();
 101    }
 102     $out .= "~\n";
 103
 104   ++$edicount;
 105   $out .= "PER" .
 106     "*IC" .
 107     "*" . $claim->billingContactName() .
 108     "*TE" .
 109     "*" . $claim->billingContactPhone();
 110   if (!$CMS_5010 && $claim->x12gsper06()) {
 111     $out .= "*ED*" . $claim->x12gsper06();
 112   }
 113   $out .= "~\n";
 114
 115   ++$edicount;
 116   $out .= "NM1" .       // Loop 1000B Receiver
 117     "*40" .
 118     "*2" .
 119     "*" . $claim->clearingHouseName() .
 120     "*" .
 121     "*" .
 122     "*" .
 123     "*" .
 124     "*46" .
 125     "*" . $claim->clearingHouseETIN() .
 126     "~\n";
 127
 128   $HLcount = 1;
 129
 130   ++$edicount;
 131   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 132     "*$HLcount" .
 133     "*" .
 134     "*20" .
 135     "*1" .              // 1 indicates there are child segments
 136     "~\n";
 137
 138   $HLBillingPayToProvider = $HLcount++;
 139
 140   // Situational PRV segment (for provider taxonomy code) omitted here.
 141   // Situational CUR segment (foreign currency information) omitted here.
 142
 143   ++$edicount;
 144   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 145   $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
 146   $out .= "NM1" .       // Loop 2010AA Billing Provider
 147     "*85" .
 148     "*2" .
 149     "*" . $billingFacilityName .
 150     "*" .
 151     "*" .
 152     "*" .
 153     "*";
 154   if ($claim->billingFacilityNPI()) {
 155     $out .= "*XX*" . $claim->billingFacilityNPI();
 156   }
 157   else {
 158     $log .= "*** Billing facility has no NPI.\n";
 159     if ($CMS_5010) {
 160       $out .= "*XX*";
 161     }
 162     else {
 163       $out .= "*24*" . $claim->billingFacilityETIN();
 164     }
 165   }
 166   $out .= "~\n";
 167
 168   ++$edicount;
 169   $out .= "N3" .
 170     "*" . $claim->billingFacilityStreet() .
 171     "~\n";
 172
 173   ++$edicount;
 174   $out .= "N4" .
 175     "*" . $claim->billingFacilityCity() .
 176     "*" . $claim->billingFacilityState() .
 177     "*" . $claim->billingFacilityZip() .
 178     "~\n";
 179
 180   if ($CMS_5010 || ($claim->billingFacilityNPI() && $claim->billingFacilityETIN())) {
 181     ++$edicount;
 182     $out .= "REF" ;
 183     if($claim->federalIdType()){
 184       $out .= "*" . $claim->federalIdType();
 185     }
 186     else{
 187       $out .= "*EI"; // For dealing with the situation before adding TaxId type In facility.
 188     }
 189     $out .=  "*" . $claim->billingFacilityETIN() .
 190       "~\n";
 191   }
 192
 193   if ($claim->providerNumberType() && $claim->providerNumber() &&
 194       !($CMS_5010 && $claim->billingFacilityNPI()))
 195   {
 196     ++$edicount;
 197     $out .= "REF" .
 198       "*" . $claim->providerNumberType() .
 199       "*" . $claim->providerNumber() .
 200       "~\n";
 201   }
 202   else if ($claim->providerNumber() && !$claim->providerNumberType()) {
 203     $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 204   }
 205
 206   // Situational PER*1C segment omitted.
 207
 208   // Pay-To Address defaults to billing provider and is no longer required in 5010.
 209   if (!$CMS_5010) {
 210     ++$edicount;
 211     // Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 212     $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
 213     $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 214       "*87" .
 215       "*2" .
 216       "*" . $billingFacilityName .
 217       "*" .
 218       "*" .
 219       "*" .
 220       "*";
 221     if ($claim->billingFacilityNPI())
 222       $out .= "*XX*" . $claim->billingFacilityNPI();
 223     else
 224       $out .= "*24*" . $claim->billingFacilityETIN();
 225     $out .= "~\n";
 226
 227     ++$edicount;
 228     $out .= "N3" .
 229       "*" . $claim->billingFacilityStreet() .
 230       "~\n";
 231
 232     ++$edicount;
 233     $out .= "N4" .
 234       "*" . $claim->billingFacilityCity() .
 235       "*" . $claim->billingFacilityState() .
 236       "*" . $claim->billingFacilityZip() .
 237       "~\n";
 238
 239     if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 240       ++$edicount;
 241       $out .= "REF" .
 242         "*EI" .
 243         "*" . $claim->billingFacilityETIN() .
 244         "~\n";
 245     }
 246   }
 247
 248   // Loop 2010AC Pay-To Plan Name omitted.  Includes:
 249   // NM1*PE, N3, N4, REF*2U, REF*EI
 250
 251   $PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
 252   $HLSubscriber = $HLcount++;
 253
 254   ++$edicount;
 255   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 256     "*$HLSubscriber" .
 257     "*$HLBillingPayToProvider" .
 258     "*22" .
 259     "*$PatientHL" .
 260     "~\n";
 261
 262   if (!$claim->payerSequence()) {
 263     $log .= "*** Error: Insurance information is missing!\n";
 264   }
 265
 266   ++$edicount;
 267   $out .= "SBR" .       // Subscriber Information
 268     "*" . $claim->payerSequence() .
 269     "*" . ($claim->isSelfOfInsured() ? '18' : '') .
 270     "*" . $claim->groupNumber() .
 271     "*" . (($CMS_5010 && $claim->groupNumber()) ? '' : $claim->groupName()) .
 272     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 273     "*" .
 274     "*" .
 275     "*" .
 276     "*" . $claim->claimType() . // Zirmed replaces this
 277     "~\n";
 278
 279   // Segment PAT omitted.
 280
 281   ++$edicount;
 282   $out .= "NM1" .       // Loop 2010BA Subscriber
 283     "*IL" .
 284     "*1" . // 1 = person, 2 = non-person
 285     "*" . $claim->insuredLastName() .
 286     "*" . $claim->insuredFirstName() .
 287     "*" . $claim->insuredMiddleName() .
 288     "*" .
 289     "*" . // Name Suffix
 290     "*MI" .
 291     // "MI" = Member Identification Number
 292     // "II" = Standard Unique Health Identifier, "Required if the
 293     //        HIPAA Individual Patient Identifier is mandated use."
 294     //        Here we presume that is not true yet.
 295     "*" . $claim->policyNumber() .
 296     "~\n";
 297
 298   // For 5010, further subscriber info is sent only if they are the patient.
 299   if (!$CMS_5010 || $claim->isSelfOfInsured()) {
 300     ++$edicount;
 301     $out .= "N3" .
 302       "*" . $claim->insuredStreet() .
 303       "~\n";
 304
 305     ++$edicount;
 306     $out .= "N4" .
 307       "*" . $claim->insuredCity() .
 308       "*" . $claim->insuredState() .
 309       "*" . $claim->insuredZip() .
 310       "~\n";
 311
 312     ++$edicount;
 313     $out .= "DMG" .
 314       "*D8" .
 315       "*" . $claim->insuredDOB() .
 316       "*" . $claim->insuredSex() .
 317       "~\n";
 318   }
 319
 320   // Segment REF*SY (Subscriber Secondary Identification) omitted.
 321   // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 322   // Segment PER*IC (Property and Casualty Subscriber Contact Information) omitted.
 323
 324   ++$edicount;
 325   //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 326   $payerName = substr($claim->payerName(), 0, $CMS_5010 ? 60 : 35);
 327   $out .= "NM1" .       // Loop 2010BB Payer
 328     "*PR" .
 329     "*2" .
 330     "*" . $payerName .
 331     "*" .
 332     "*" .
 333     "*" .
 334     "*" .
 335     // The 5010 spec says:
 336     // "On or after the mandated implementation date for the HIPAA
 337     // National Plan Identifier (National Plan ID), XV must be sent.
 338     // Prior to the mandated implementation date and prior to any phase-
 339     // in period identified by Federal regulation, PI must be sent."
 340     // *************** Anybody know what that date is? ***************
 341     "*PI" .
 342     // Zirmed ignores this if using payer name matching:
 343     "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 344     "~\n";
 345
 346   // if (!$claim->payerID()) {
 347   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 348   // }
 349
 350   if (true) { // !$CMS_5010
 351     // The 5010 spec says:
 352     // "Required when the payer address is available and the submitter intends
 353     // for the claim to be printed on paper at the next EDI location (for example, a
 354     // clearinghouse). If not required by this implementation guide, do not send."
 355
 356     ++$edicount;
 357     $out .= "N3" .
 358       "*" . $claim->payerStreet() .
 359       "~\n";
 360
 361     ++$edicount;
 362     $out .= "N4" .
 363       "*" . $claim->payerCity() .
 364       "*" . $claim->payerState() .
 365       "*" . $claim->payerZip() .
 366       "~\n";
 367   }
 368
 369   // Segment REF (Payer Secondary Identification) omitted.
 370   // Segment REF (Billing Provider Secondary Identification) omitted.
 371
 372   if (! $claim->isSelfOfInsured()) {
 373     ++$edicount;
 374     $out .= "HL" .        // Loop 2000C Patient Information
 375       "*$HLcount" .
 376       "*$HLSubscriber" .
 377       "*23" .
 378       "*0" .
 379       "~\n";
 380
 381     $HLcount++;
 382
 383     ++$edicount;
 384     $out .= "PAT" .
 385       "*" . $claim->insuredRelationship() .
 386       "~\n";
 387
 388     ++$edicount;
 389     $out .= "NM1" .       // Loop 2010CA Patient
 390       "*QC" .
 391       "*1" .
 392       "*" . $claim->patientLastName() .
 393       "*" . $claim->patientFirstName() .
 394       "*" . $claim->patientMiddleName() .
 395       "~\n";
 396
 397     ++$edicount;
 398     $out .= "N3" .
 399       "*" . $claim->patientStreet() .
 400       "~\n";
 401
 402     ++$edicount;
 403     $out .= "N4" .
 404       "*" . $claim->patientCity() .
 405       "*" . $claim->patientState() .
 406       "*" . $claim->patientZip() .
 407       "~\n";
 408
 409     ++$edicount;
 410     $out .= "DMG" .
 411       "*D8" .
 412       "*" . $claim->patientDOB() .
 413       "*" . $claim->patientSex() .
 414       "~\n";
 415
 416     // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 417     // Segment REF (Property and Casualty Patient Identifier) omitted.
 418     // Segment PER (Property and Casualty Patient Contact Information) omitted.
 419
 420   } // end of patient different from insured
 421
 422   $proccount = $claim->procCount();
 423
 424   $clm_total_charges = 0;
 425   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 426     $clm_total_charges += $claim->cptCharges($prockey);
 427   }
 428
 429   if (!$clm_total_charges) {
 430     $log .= "*** This claim has no charges!\n";
 431   }
 432
 433   ++$edicount;
 434   $out .= "CLM" .       // Loop 2300 Claim
 435     "*$pid-$encounter" .
 436     "*"  . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 437     "*"  .
 438     "*"  .
 439     "*"  . sprintf('%02d', $claim->facilityPOS()) . ":" .
 440            ($CMS_5010 ? "B" : "") . ":" .
 441            $claim->frequencyTypeCode() . // Changed to correct single digit output
 442     "*Y" .
 443     "*A" .
 444     "*"  . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 445     "*Y" .
 446     ($CMS_5010 ? "" : "*C") .
 447     "~\n";
 448
 449   if ($claim->onsetDate()) {
 450     ++$edicount;
 451     $out .= "DTP" .       // Date of Onset
 452       "*431" .
 453       "*D8" .
 454       "*" . $claim->onsetDate() .
 455       "~\n";
 456   }
 457
 458   if ($claim->dateInitialTreatment()) {
 459     ++$edicount;
 460     $out .= "DTP" .       // Date of Initial Treatment
 461       "*454" .
 462       "*D8" .
 463       "*" . $claim->dateInitialTreatment() .
 464       "~\n";
 465   }
 466
 467   // Segment DTP*304 (Last Seen Date) omitted.
 468   // Segment DTP*453 (Acute Manifestation Date) omitted.
 469   // Segment DTP*439 (Accident Date) omitted.
 470   // Segment DTP*484 (Last Menstrual Period Date) omitted.
 471   // Segment DTP*455 (Last X-Ray Date) omitted.
 472   // Segment DTP*471 (Hearing and Vision Prescription Date) omitted.
 473   // Segments DTP (Disability Dates) omitted.
 474   // Segment DTP*297 (Last Worked Date) omitted.
 475   // Segment DTP*296 (Authorized Return to Work Date) omitted.
 476
 477   if (strcmp($claim->facilityPOS(),'21') == 0) {
 478     ++$edicount;
 479     $out .= "DTP" .     // Date of Hospitalization
 480       "*435" .
 481       "*D8" .
 482       "*" . $claim->onsetDate() .
 483       "~\n";
 484   }
 485
 486   // Segment DTP*096 (Discharge Date) omitted.
 487   // Segments DTP (Assumed and Relinquished Care Dates) omitted.
 488   // Segment DTP*444 (Property and Casualty Date of First Contact) omitted.
 489   // Segment DTP*050 (Repricer Received Date) omitted.
 490   // Segment PWK (Claim Supplemental Information) omitted.
 491   // Segment CN1 (Contract Information) omitted.
 492
 493   $patientpaid = $claim->patientPaidAmount();
 494   if ($patientpaid != 0) {
 495     ++$edicount;
 496     $out .= "AMT" .     // Patient paid amount. Page 190/220.
 497       "*F5" .
 498       "*" . $patientpaid .
 499       "~\n";
 500   }
 501
 502   // Segment REF*4N (Service Authorization Exception Code) omitted.
 503   // Segment REF*F5 (Mandatory Medicare Crossover Indicator) omitted.
 504   // Segment REF*EW (Mammography Certification Number) omitted.
 505   // Segment REF*9F (Referral Number) omitted.
 506
 507   if ($claim->priorAuth()) {
 508     ++$edicount;
 509     $out .= "REF" .     // Prior Authorization Number
 510       "*G1" .
 511       "*" . $claim->priorAuth() .
 512       "~\n";
 513   }
 514
 515   // Segment REF*F8 (Payer Claim Control Number) omitted.
 516
 517   if ($claim->cliaCode() && ($CMS_5010 || $claim->claimType() === 'MB')) {
 518     // Required by Medicare when in-house labs are done.
 519     ++$edicount;
 520     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 521       "*X4" .
 522       "*" . $claim->cliaCode() .
 523       "~\n";
 524   }
 525
 526   // Segment REF*9A (Repriced Claim Number) omitted.
 527   // Segment REF*9C (Adjusted Repriced Claim Number) omitted.
 528   // Segment REF*LX (Investigational Device Exemption Number) omitted.
 529   // Segment REF*D9 (Claim Identifier for Transmission Intermediaries) omitted.
 530   // Segment REF*EA (Medical Record Number) omitted.
 531   // Segment REF*P4 (Demonstration Project Identifier) omitted.
 532   // Segment REF*1J (Care Plan Oversight) omitted.
 533   // Segment K3 (File Information) omitted.
 534
 535   if ($claim->additionalNotes()) {
 536     // Claim note.
 537     ++$edicount;
 538     $out .= "NTE" .     // comments box 19
 539       "*" . ($CMS_5010 ? "ADD" : "") .
 540       "*" . $claim->additionalNotes() .
 541       "~\n";
 542   }
 543
 544   // Segment CR1 (Ambulance Transport Information) omitted.
 545   // Segment CR2 (Spinal Manipulation Service Information) omitted.
 546   // Segment CRC (Ambulance Certification) omitted.
 547   // Segment CRC (Patient Condition Information: Vision) omitted.
 548   // Segment CRC (Homebound Indicator) omitted.
 549   // Segment CRC (EPSDT Referral) omitted.
 550
 551   // Diagnoses, up to $max_per_seg per HI segment.
 552   $max_per_seg = $CMS_5010 ? 12 : 8;
 553   $da = $claim->diagArray();
 554   $diag_type_code = 'BK';
 555   $tmp = 0;
 556   foreach ($da as $diag) {
 557     if ($tmp % $max_per_seg == 0) {
 558       if ($tmp) $out .= "~\n";
 559       ++$edicount;
 560       $out .= "HI";         // Health Diagnosis Codes
 561     }
 562     $out .= "*$diag_type_code:" . $diag;
 563     $diag_type_code = 'BF';
 564     ++$tmp;
 565   }
 566   if ($tmp) $out .= "~\n";
 567
 568   // Segment HI*BP (Anesthesia Related Procedure) omitted.
 569   // Segment HI*BG (Condition Information) omitted.
 570   // Segment HCP (Claim Pricing/Repricing Information) omitted.
 571
 572   if ($claim->referrerLastName()) {
 573     // Medicare requires referring provider's name and UPIN.
 574     ++$edicount;
 575     $out .= "NM1" .     // Loop 2310A Referring Provider
 576       "*DN" .
 577       "*1" .
 578       "*" . $claim->referrerLastName() .
 579       "*" . $claim->referrerFirstName() .
 580       "*" . $claim->referrerMiddleName() .
 581       "*" .
 582       "*";
 583     if ($CMS_5010 || $claim->referrerNPI()) { $out .=
 584       "*XX" .
 585       "*" . $claim->referrerNPI();
 586     } else { $out .=
 587       "*34" .                           // not allowed for 5010
 588       "*" . $claim->referrerSSN();
 589     }
 590     $out .= "~\n";
 591
 592     if (!$CMS_5010 && $claim->referrerTaxonomy()) {
 593       ++$edicount;
 594       $out .= "PRV" .
 595         "*RF" . // ReFerring provider
 596         "*ZZ" .
 597         "*" . $claim->referrerTaxonomy() .
 598         "~\n";
 599     }
 600
 601     if (!CMS_5010 && $claim->referrerUPIN()) {
 602       ++$edicount;
 603       $out .= "REF" .   // Referring Provider Secondary Identification
 604         "*1G" .
 605         "*" . $claim->referrerUPIN() .
 606         "~\n";
 607     }
 608   }
 609
 610   ++$edicount;
 611   $out .= "NM1" .       // Loop 2310B Rendering Provider
 612     "*82" .
 613     "*1" .
 614     "*" . $claim->providerLastName() .
 615     "*" . $claim->providerFirstName() .
 616     "*" . $claim->providerMiddleName() .
 617     "*" .
 618     "*";
 619   if ($CMS_5010 || $claim->providerNPI()) { $out .=
 620     "*XX" .
 621     "*" . $claim->providerNPI();
 622   } else { $out .=
 623     "*34" .                             // not allowed for 5010
 624     "*" . $claim->providerSSN();
 625     $log .= "*** Rendering provider has no NPI.\n";
 626   }
 627   $out .= "~\n";
 628
 629   if ($claim->providerTaxonomy()) {
 630     ++$edicount;
 631     $out .= "PRV" .
 632       "*PE" . // PErforming provider
 633       "*" . ($CMS_5010 ? "PXC" : "ZZ") .
 634       "*" . $claim->providerTaxonomy() .
 635       "~\n";
 636   }
 637
 638   // 4010: REF*1C is required here for the Medicare provider number if NPI was
 639   // specified in NM109.  Not sure if other payers require anything here.
 640   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 641   //
 642   // 5010 spec says nothing here if NPI was specified.
 643   //
 644   if (($CMS_5010 && !$claim->providerNPI() && in_array($claim->providerNumberType(), array('0B','1G','G2','LU')))
 645       || (!$CMS_5010 && trim($claim->x12gsreceiverid()) != '470819582')) // if NOT ECLAIMS EDI
 646   {
 647     if ($claim->providerNumber()) {
 648       ++$edicount;
 649       $out .= "REF" .
 650         "*" . $claim->providerNumberType() .
 651         "*" . $claim->providerNumber() .
 652         "~\n";
 653     }
 654   }
 655
 656   // Loop 2310D is omitted in the case of home visits (POS=12).
 657   if ($claim->facilityPOS() != 12 &&
 658       (!$CMS_5010 || $claim->facilityNPI() != $claim->billingFacilityNPI()))
 659     {
 660     ++$edicount;
 661     $out .= "NM1" .       // Loop 2310D Service Location
 662       "*77" .
 663       "*2";
 664     //Field length is limited to 35. See nucc dataset page 77 www.nucc.org
 665     $facilityName = substr($claim->facilityName(), 0, $CMS_5010 ? 60 : 35);
 666     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 667       "*" . $facilityName;
 668     }
 669     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 670       "*" .
 671       "*" .
 672       "*" .
 673       "*";
 674       if ($CMS_5010 || $claim->facilityNPI()) { $out .=
 675         "*XX*" . $claim->facilityNPI();
 676       } else { $out .=
 677         "*24*" . $claim->facilityETIN();
 678       }
 679       if (!$claim->facilityNPI()) {
 680         $log .= "*** Service location has no NPI.\n";
 681       }
 682     }
 683     $out .= "~\n";
 684     if ($claim->facilityStreet()) {
 685       ++$edicount;
 686       $out .= "N3" .
 687         "*" . $claim->facilityStreet() .
 688         "~\n";
 689     }
 690     if ($claim->facilityState()) {
 691       ++$edicount;
 692       $out .= "N4" .
 693         "*" . $claim->facilityCity() .
 694         "*" . $claim->facilityState() .
 695         "*" . $claim->facilityZip() .
 696         "~\n";
 697     }
 698   }
 699
 700   // Segment REF (Service Facility Location Secondary Identification) omitted.
 701   // Segment PER (Service Facility Contact Information) omitted.
 702
 703   // Loop 2310E, Supervising Provider
 704   //
 705   if ($claim->supervisorLastName()) {
 706     ++$edicount;
 707     $out .= "NM1" .
 708       "*DQ" . // Supervising Physician
 709       "*1" .  // Person
 710       "*" . $claim->supervisorLastName() .
 711       "*" . $claim->supervisorFirstName() .
 712       "*" . $claim->supervisorMiddleName() .
 713       "*" .   // NM106 not used
 714       "*";    // Name Suffix
 715     if ($CMS_5010 || $claim->supervisorNPI()) { $out .=
 716       "*XX" .
 717       "*" . $claim->supervisorNPI();
 718     } else { $out .=
 719       "*34" .
 720       "*" . $claim->supervisorSSN();
 721     }
 722     if (!$claim->supervisorNPI()) {
 723       $log .= "*** Supervising Provider has no NPI.\n";
 724     }
 725     $out .= "~\n";
 726
 727     if ($claim->supervisorNumber()) {
 728       ++$edicount;
 729       $out .= "REF" .
 730         "*" . $claim->supervisorNumberType() .
 731         "*" . $claim->supervisorNumber() .
 732         "~\n";
 733     }
 734   }
 735
 736   // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
 737   // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
 738
 739   $prev_pt_resp = $clm_total_charges; // for computation below
 740
 741   // Loops 2320 and 2330*, other subscriber/payer information.
 742   // Remember that insurance index 0 is always for the payer being billed
 743   // by this claim, and 1 and above are always for the "other" payers.
 744   //
 745   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 746
 747     $tmp1 = $claim->claimType($ins);
 748     $tmp2 = 'C1'; // Here a kludge. See page 321.
 749     if ($tmp1 === 'CI') $tmp2 = 'C1';
 750     if ($tmp1 === 'AM') $tmp2 = 'AP';
 751     if ($tmp1 === 'HM') $tmp2 = 'HM';
 752     if ($tmp1 === 'MB') $tmp2 = 'MB';
 753     if ($tmp1 === 'MC') $tmp2 = 'MC';
 754     if ($tmp1 === '09') $tmp2 = 'PP';
 755     ++$edicount;
 756     $out .= "SBR" . // Loop 2320, Subscriber Information - page 297/318
 757       "*" . $claim->payerSequence($ins) .
 758       "*" . $claim->insuredRelationship($ins) .
 759       "*" . $claim->groupNumber($ins) .
 760       "*" . (($CMS_5010 && $claim->groupNumber($ins)) ? '' : $claim->groupName($ins)) .
 761       "*" . ($CMS_5010 ? $claim->insuredTypeCode($ins) : $tmp2) .
 762       "*" .
 763       "*" .
 764       "*" .
 765       "*" . $claim->claimType($ins) .
 766       "~\n";
 767
 768     // Things that apply only to previous payers, not future payers.
 769     //
 770     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 771
 772       // Generate claim-level adjustments.
 773       $aarr = $claim->payerAdjustments($ins);
 774       foreach ($aarr as $a) {
 775         ++$edicount;
 776         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 301/323.
 777           "*" . $a[1] .
 778           "*" . $a[2] .
 779           "*" . $a[3] .
 780           "~\n";
 781       }
 782
 783       $payerpaid = $claim->payerTotals($ins);
 784       ++$edicount;
 785       $out .= "AMT" . // Previous payer's paid amount. Page 307/332.
 786         "*D" .
 787         "*" . $payerpaid[1] .
 788         "~\n";
 789
 790       // Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
 791       // Segment AMT*EAF (Remaining Patient Liability) omitted.
 792
 793       if (!$CMS_5010) {
 794         // Patient responsibility amount as of this previous payer.
 795         $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 796         $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 797
 798         ++$edicount;
 799         $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 800           "*B6" .
 801           "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 802           "~\n";
 803
 804         ++$edicount;
 805         $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 806           "*F2" .
 807           "*" . sprintf('%.2f', $prev_pt_resp) .
 808           "~\n";
 809       }
 810     } // End of things that apply only to previous payers.
 811
 812     if (!$CMS_5010) {
 813       ++$edicount;
 814       $out .= "DMG" . // Other subscriber demographic information. Page 342.
 815         "*D8" .
 816         "*" . $claim->insuredDOB($ins) .
 817         "*" . $claim->insuredSex($ins) .
 818         "~\n";
 819     }
 820
 821     ++$edicount;
 822     $out .= "OI" .  // Other Insurance Coverage Information. Page 310/344.
 823       "*" .
 824       "*" .
 825       "*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
 826       // For this next item, the 5010 example in the spec does not match its
 827       // description.  So this might be wrong.
 828       "*" . ($CMS_5010 ? '' : 'B') .
 829       "*" .
 830       "*Y" .
 831       "~\n";
 832
 833     // Segment MOA (Medicare Outpatient Adjudication) omitted.
 834
 835     ++$edicount;
 836     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
 837       "*IL" .
 838       "*1" .
 839       "*" . $claim->insuredLastName($ins) .
 840       "*" . $claim->insuredFirstName($ins) .
 841       "*" . $claim->insuredMiddleName($ins) .
 842       "*" .
 843       "*" .
 844       "*MI" .
 845       "*" . $claim->policyNumber($ins) .
 846       "~\n";
 847
 848     ++$edicount;
 849     $out .= "N3" .
 850       "*" . $claim->insuredStreet($ins) .
 851       "~\n";
 852
 853     ++$edicount;
 854     $out .= "N4" .
 855       "*" . $claim->insuredCity($ins) .
 856       "*" . $claim->insuredState($ins) .
 857       "*" . $claim->insuredZip($ins) .
 858       "~\n";
 859
 860     // Segment REF (Other Subscriber Secondary Identification) omitted.
 861
 862     ++$edicount;
 863     //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 864     $payerName = substr($claim->payerName($ins), 0, $CMS_5010 ? 60 : 35);
 865     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 322/359.
 866       "*PR" .
 867       "*2" .
 868       "*" . $payerName .
 869       "*" .
 870       "*" .
 871       "*" .
 872       "*" .
 873       "*PI" .
 874       "*" . $claim->payerID($ins) .
 875       "~\n";
 876
 877     // if (!$claim->payerID($ins)) {
 878     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 879     // }
 880
 881     // Payer address (N3 and N4) are added below so that Gateway EDI can
 882     // auto-generate secondary claims.  These do NOT appear in my copy of
 883     // the spec!  -- Rod 2008-06-12
 884
 885     if ($CMS_5010 || trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 886       ++$edicount;
 887       $out .= "N3" .
 888         "*" . $claim->payerStreet($ins) .
 889         "~\n";
 890       //
 891       ++$edicount;
 892       $out .= "N4" .
 893         "*" . $claim->payerCity($ins) .
 894         "*" . $claim->payerState($ins) .
 895         "*" . $claim->payerZip($ins) .
 896         "~\n";
 897     } // end Gateway EDI
 898
 899     // Segment DTP*573 (Claim Check or Remittance Date) omitted.
 900     // Segment REF (Other Payer Secondary Identifier) omitted.
 901     // Segment REF*G1 (Other Payer Prior Authorization Number) omitted.
 902     // Segment REF*9F (Other Payer Referral Number) omitted.
 903     // Segment REF*T4 (Other Payer Claim Adjustment Indicator) omitted.
 904     // Segment REF*F8 (Other Payer Claim Control Number) omitted.
 905     // Segment NM1 (Other Payer Referring Provider) omitted.
 906     // Segment REF (Other Payer Referring Provider Secondary Identification) omitted.
 907     // Segment NM1 (Other Payer Rendering Provider) omitted.
 908     // Segment REF (Other Payer Rendering Provider Secondary Identification) omitted.
 909     // Segment NM1 (Other Payer Service Facility Location) omitted.
 910     // Segment REF (Other Payer Service Facility Location Secondary Identification) omitted.
 911     // Segment NM1 (Other Payer Supervising Provider) omitted.
 912     // Segment REF (Other Payer Supervising Provider Secondary Identification) omitted.
 913     // Segment NM1 (Other Payer Billing Provider) omitted.
 914     // Segment REF (Other Payer Billing Provider Secondary Identification) omitted.
 915
 916   } // End loops 2320/2330*.
 917
 918   $loopcount = 0;
 919
 920   // Procedure loop starts here.
 921   //
 922   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 923     ++$loopcount;
 924
 925     ++$edicount;
 926     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 927       "*$loopcount" .
 928       "~\n";
 929
 930     ++$edicount;
 931     $out .= "SV1" .     // Professional Service. Page 400.
 932       "*HC:" . $claim->cptKey($prockey) .
 933       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 934       "*UN" .
 935       "*" . $claim->cptUnits($prockey) .
 936       "*" .
 937       "*" .
 938       "*";
 939     $dia = $claim->diagIndexArray($prockey);
 940     $i = 0;
 941     foreach ($dia as $dindex) {
 942       if ($i) $out .= ':';
 943       $out .= $dindex;
 944       if (++$i >= 4) break;
 945     }
 946     $out .= "~\n";
 947
 948     if (!$claim->cptCharges($prockey)) {
 949       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 950     }
 951
 952     if (empty($dia)) {
 953       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 954     }
 955
 956     // Segment SV5 (Durable Medical Equipment Service) omitted.
 957     // Segment PWK (Line Supplemental Information) omitted.
 958     // Segment PWK (Durable Medical Equipment Certificate of Medical Necessity Indicator) omitted.
 959     // Segment CR1 (Ambulance Transport Information) omitted.
 960     // Segment CR3 (Durable Medical Equipment Certification) omitted.
 961     // Segment CRC (Ambulance Certification) omitted.
 962     // Segment CRC (Hospice Employee Indicator) omitted.
 963     // Segment CRC (Condition Indicator / Durable Medical Equipment) omitted.
 964
 965     ++$edicount;
 966     $out .= "DTP" .     // Date of Service. Page 435.
 967       "*472" .
 968       "*D8" .
 969       "*" . $claim->serviceDate() .
 970       "~\n";
 971
 972     $testnote = rtrim($claim->cptNotecodes($prockey));
 973     if (!empty($testnote)) {
 974       ++$edicount;
 975       $out .= "NTE" .     // Explain Unusual Circumstances.
 976         "*ADD" .
 977         "*" . $claim->cptNotecodes($prockey) .
 978         "~\n";
 979     }
 980
 981     // Segment DTP*471 (Prescription Date) omitted.
 982     // Segment DTP*607 (Revision/Recertification Date) omitted.
 983     // Segment DTP*463 (Begin Therapy Date) omitted.
 984     // Segment DTP*461 (Last Certification Date) omitted.
 985     // Segment DTP*304 (Last Seen Date) omitted.
 986     // Segment DTP (Test Date) omitted.
 987     // Segment DTP*011 (Shipped Date) omitted.
 988     // Segment DTP*455 (Last X-Ray Date) omitted.
 989     // Segment DTP*454 (Initial Treatment Date) omitted.
 990     // Segment QTY (Ambulance Patient Count) omitted.
 991     // Segment QTY (Obstetric Anesthesia Additional Units) omitted.
 992     // Segment MEA (Test Result) omitted.
 993     // Segment CN1 (Contract Information) omitted.
 994     // Segment REF*9B (Repriced Line Item Reference Number) omitted.
 995     // Segment REF*9D (Adjusted Repriced Line Item Reference Number) omitted.
 996     // Segment REF*G1 (Prior Authorization) omitted.
 997     // Segment REF*6R (Line Item Control Number) omitted.
 998     //   (Really oughta have this for robust 835 posting!)
 999     // Segment REF*EW (Mammography Certification Number) omitted.
1000     // Segment REF*X4 (CLIA Number) omitted.
1001     // Segment REF*F4 (Referring CLIA Facility Identification) omitted.
1002     // Segment REF*BT (Immunization Batch Number) omitted.
1003     // Segment REF*9F (Referral Number) omitted.
1004     // Segment AMT*T (Sales Tax Amount) omitted.
1005     // Segment AMT*F4 (Postage Claimed Amount) omitted.
1006     // Segment K3 (File Information) omitted.
1007     // Segment NTE (Line Note) omitted.
1008     // Segment NTE (Third Party Organization Notes) omitted.
1009     // Segment PS1 (Purchased Service Information) omitted.
1010     // Segment HCP (Line Pricing/Repricing Information) omitted.
1011
1012     if (!$CMS_5010) {
1013       // This segment was deleted for 5010.
1014       //
1015       // AMT*AAE segment for Approved Amount from previous payer.
1016       // Medicare secondaries seem to require this.
1017       //
1018       for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
1019         if ($claim->payerSequence($ins) > $claim->payerSequence())
1020           continue; // payer is future, not previous
1021         $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1022         ++$edicount;
1023         $out .= "AMT" . // Approved amount per previous payer. Page 485.
1024           "*AAE" .
1025           "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
1026           "~\n";
1027         break;
1028       }
1029     }
1030
1031     // Loop 2410, Drug Information. Medicaid insurers seem to want this
1032     // with HCPCS codes.
1033     //
1034     $ndc = $claim->cptNDCID($prockey);
1035     if ($ndc) {
1036       ++$edicount;
1037       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
1038         "*" .         // Per addendum, LIN01 is not used.
1039         "*N4" .
1040         "*" . $ndc .
1041         "~\n";
1042
1043       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp) && !preg_match('/^\d{11}$/', $ndc)) {
1044         $log .= "*** NDC code '$ndc' has invalid format!\n";
1045       }
1046
1047       ++$edicount;
1048       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
1049       if (!$tmpunits) $tmpunits = 1;
1050       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
1051         "*" .
1052         "*" .
1053         "*" . ($CMS_5010 ? '' : sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits)) .
1054         "*" . $claim->cptNDCQuantity($prockey) .
1055         "*" . $claim->cptNDCUOM($prockey) .
1056         // Note: 5010 documents "ME" (Milligrams) as an additional unit of measure.
1057         "~\n";
1058     }
1059
1060     // Segment REF (Prescription or Compound Drug Association Number) omitted.
1061
1062     // Loop 2420A, Rendering Provider (service-specific).
1063     // Used if the rendering provider for this service line is different
1064     // from that in loop 2310B.
1065     //
1066     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
1067       ++$edicount;
1068       $out .= "NM1" .       // Loop 2310B Rendering Provider
1069         "*82" .
1070         "*1" .
1071         "*" . $claim->providerLastName($prockey) .
1072         "*" . $claim->providerFirstName($prockey) .
1073         "*" . $claim->providerMiddleName($prockey) .
1074         "*" .
1075         "*";
1076       if ($CMS_5010 || $claim->providerNPI($prockey)) { $out .=
1077         "*XX" .
1078         "*" . $claim->providerNPI($prockey);
1079       } else { $out .=
1080         "*34" .                         // Not allowed for 5010
1081         "*" . $claim->providerSSN($prockey);
1082       }
1083       if (!$claim->providerNPI($prockey)) {
1084         $log .= "*** Rendering provider has no NPI.\n";
1085       }
1086       $out .= "~\n";
1087
1088       if ($claim->providerTaxonomy($prockey)) {
1089         ++$edicount;
1090         $out .= "PRV" .
1091           "*PE" . // PErforming provider
1092           "*" . ($CMS_5010 ? "PXC" : "ZZ") .
1093           "*" . $claim->providerTaxonomy($prockey) .
1094           "~\n";
1095       }
1096
1097       // Segment PRV*PE (Rendering Provider Specialty Information) omitted.
1098       // Segment REF (Rendering Provider Secondary Identification) omitted.
1099       // Segment NM1 (Purchased Service Provider Name) omitted.
1100       // Segment REF (Purchased Service Provider Secondary Identification) omitted.
1101       // Segment NM1,N3,N4 (Service Facility Location) omitted.
1102       // Segment REF (Service Facility Location Secondary Identification) omitted.
1103       // Segment NM1 (Supervising Provider Name) omitted.
1104       // Segment REF (Supervising Provider Secondary Identification) omitted.
1105       // Segment NM1,N3,N4 (Ordering Provider) omitted.
1106       // Segment REF (Ordering Provider Secondary Identification) omitted.
1107       // Segment PER (Ordering Provider Contact Information) omitted.
1108       // Segment NM1 (Referring Provider Name) omitted.
1109       // Segment REF (Referring Provider Secondary Identification) omitted.
1110       // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
1111       // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
1112
1113       // REF*1C is required here for the Medicare provider number if NPI was
1114       // specified in NM109.  Not sure if other payers require anything here.
1115       if (!$CMS_5010 && $claim->providerNumber($prockey)) {
1116         ++$edicount;
1117         $out .= "REF" .
1118           "*" . $claim->providerNumberType($prockey) .
1119           // Note: 5010 documents that type 1D (Medicaid) is changed to G2.
1120           "*" . $claim->providerNumber($prockey) .
1121           "~\n";
1122       }
1123     }
1124
1125     // Loop 2430, adjudication by previous payers.
1126     //
1127     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
1128       if ($claim->payerSequence($ins) > $claim->payerSequence())
1129         continue; // payer is future, not previous
1130
1131       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1132       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
1133
1134       if ($payerpaid[1] == 0 && !count($aarr)) {
1135         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
1136           "' has no payments or adjustments from previous payer!\n";
1137         continue;
1138       }
1139
1140       ++$edicount;
1141       $out .= "SVD" . // Service line adjudication. Page 554.
1142         "*" . $claim->payerID($ins) .
1143         "*" . $payerpaid[1] .
1144         "*HC:" . $claim->cptKey($prockey) .
1145         "*" .
1146         "*" . $claim->cptUnits($prockey) .
1147         "~\n";
1148
1149       $tmpdate = $payerpaid[0];
1150       foreach ($aarr as $a) {
1151         ++$edicount;
1152         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
1153           "*" . $a[1] .
1154           "*" . $a[2] .
1155           "*" . $a[3] .
1156           "~\n";
1157         if (!$tmpdate) $tmpdate = $a[0];
1158
1159         // WTH is this??
1160         /*************************************************************
1161         if ( isset($a[4]) &&
1162                 $a[4] != null ) {
1163                 $out .= "CAS02" . // Previous payer's adjustment reason
1164                   "*" . $a[4] .
1165                   "~\n";
1166         }
1167         *************************************************************/
1168       }
1169
1170       if ($tmpdate) {
1171         ++$edicount;
1172         $out .= "DTP" . // Previous payer's line adjustment date. Page 493/566.
1173           "*573" .
1174           "*D8" .
1175           "*$tmpdate" .
1176           "~\n";
1177       }
1178
1179       // Segment AMT*EAF (Remaining Patient Liability) omitted.
1180       // Segment LQ (Form Identification Code) omitted.
1181       // Segment FRM (Supporting Documentation) omitted.
1182
1183     } // end loop 2430
1184   } // end this procedure
1185
1186   ++$edicount;
1187   $out .= "SE" .        // SE Trailer
1188     "*$edicount" .
1189     "*0021" .
1190     "~\n";
1191
1192   $out .= "GE" .        // GE Trailer
1193     "*1" .
1194     "*1" .
1195     "~\n";
1196
1197   $out .= "IEA" .       // IEA Trailer
1198     "*1" .
1199     "*000000001" .
1200     "~\n";
1201
1202   // Remove any trailing empty fields (delimiters) from each segment.
1203   $out = preg_replace('/\*+~/', '~', $out);
1204
1205   $log .= "\n";
1206   return $out;
1207 }
1208 ?>