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 function stripZipCode($zip)
  11 {
  12     return str_replace('-','',$zip);
  13 }
  14 function gen_x12_837($pid, $encounter, &$log, $encounter_claim=false) {
  15
  16   $today = time();
  17   $out = '';
  18   $claim = new Claim($pid, $encounter);
  19   $edicount = 0;
  20
  21   // This is true for the 5010 standard, false for 4010.
  22   // x12gsversionstring() should be "005010X222A1" or "004010X098A1".
  23   $CMS_5010 = strpos($claim->x12gsversionstring(), '5010') !== false;
  24
  25   $log .= "Generating claim $pid-$encounter for " .
  26     $claim->patientFirstName()  . ' ' .
  27     $claim->patientMiddleName() . ' ' .
  28     $claim->patientLastName()   . ' on ' .
  29     date('Y-m-d H:i', $today) . ".\n";
  30
  31   $out .= "ISA" .
  32     "*00" .
  33     "*          " .
  34     "*00" .
  35     "*          " .
  36     "*" . $claim->x12gsisa05() .
  37     "*" . $claim->x12gssenderid() .
  38     "*" . $claim->x12gsisa07() .
  39     "*" . $claim->x12gsreceiverid() .
  40     "*030911" .
  41     "*1630" .
  42     "*" . ($CMS_5010 ? "^"     : "U"    ) .
  43     "*" . ($CMS_5010 ? "00501" : "00401") .
  44     "*000000001" .
  45     "*" . $claim->x12gsisa14() .
  46     "*" . $claim->x12gsisa15() .
  47     "*:" .
  48     "~\n";
  49
  50   $out .= "GS" .
  51     "*HC" .
  52     "*" . $claim->x12gsgs02() .
  53     "*" . trim($claim->x12gs03()) .
  54     "*" . date('Ymd', $today) .
  55     "*" . date('Hi', $today) .
  56     "*1" .
  57     "*X" .
  58     "*" . $claim->x12gsversionstring() .
  59     "~\n";
  60
  61   ++$edicount;
  62   $out .= "ST" .
  63     "*837" .
  64     "*0021" .
  65     // Spec says the following is optional, so should be able to leave it out.
  66     ($CMS_5010 ? ("*" . $claim->x12gsversionstring()) : "") .
  67     "~\n";
  68
  69   ++$edicount;
  70   $out .= "BHT" .
  71     "*0019" .                             // 0019 is required here
  72     "*00" .                               // 00 = original transmission
  73     "*0123" .                             // reference identification
  74     "*" . date('Ymd', $today) .           // transaction creation date
  75     "*" . date('Hi', $today) .            // transaction creation time
  76     ($encounter_claim ? "*RP" : "*CH") .  // RP = reporting, CH = chargeable
  77     "~\n";
  78
  79   if (!$CMS_5010) {
  80     // This segment was deleted for 5010.
  81     ++$edicount;
  82     $out .= "REF" .
  83       "*87" .
  84       "*" . $claim->x12gsversionstring() .
  85       "~\n";
  86   }
  87
  88   ++$edicount;
  89   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
  90   $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
  91   $out .= "NM1" .       // Loop 1000A Submitter
  92     "*41" .
  93     "*2" .
  94     "*" . $billingFacilityName .
  95     "*" .
  96     "*" .
  97     "*" .
  98     "*" .
  99     "*46";
 100    if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
 101     $out  .=  "*" . $claim->clearingHouseETIN();
 102    } else {
 103     $out  .=  "*" . $claim->billingFacilityETIN();
 104    }
 105     $out .= "~\n";
 106
 107   ++$edicount;
 108   $out .= "PER" .
 109     "*IC" .
 110     "*" . $claim->billingContactName() .
 111     "*TE" .
 112     "*" . $claim->billingContactPhone();
 113   if (!$CMS_5010 && $claim->x12gsper06()) {
 114     $out .= "*ED*" . $claim->x12gsper06();
 115   }
 116   $out .= "~\n";
 117
 118   ++$edicount;
 119   $out .= "NM1" .       // Loop 1000B Receiver
 120     "*40" .
 121     "*2" .
 122     "*" . $claim->clearingHouseName() .
 123     "*" .
 124     "*" .
 125     "*" .
 126     "*" .
 127     "*46" .
 128     "*" . $claim->clearingHouseETIN() .
 129     "~\n";
 130
 131   $HLcount = 1;
 132
 133   ++$edicount;
 134   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 135     "*$HLcount" .
 136     "*" .
 137     "*20" .
 138     "*1" .              // 1 indicates there are child segments
 139     "~\n";
 140
 141   $HLBillingPayToProvider = $HLcount++;
 142
 143   // Situational PRV segment (for provider taxonomy code) omitted here.
 144   // Situational CUR segment (foreign currency information) omitted here.
 145
 146   ++$edicount;
 147   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 148   $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
 149   $out .= "NM1" .       // Loop 2010AA Billing Provider
 150     "*85" .
 151     "*2" .
 152     "*" . $billingFacilityName .
 153     "*" .
 154     "*" .
 155     "*" .
 156     "*";
 157   if ($claim->billingFacilityNPI()) {
 158     $out .= "*XX*" . $claim->billingFacilityNPI();
 159   }
 160   else {
 161     $log .= "*** Billing facility has no NPI.\n";
 162     if ($CMS_5010) {
 163       $out .= "*XX*";
 164     }
 165     else {
 166       $out .= "*24*" . $claim->billingFacilityETIN();
 167     }
 168   }
 169   $out .= "~\n";
 170
 171   ++$edicount;
 172   $out .= "N3" .
 173     "*" . $claim->billingFacilityStreet() .
 174     "~\n";
 175
 176   ++$edicount;
 177   $out .= "N4" .
 178     "*" . $claim->billingFacilityCity() .
 179     "*" . $claim->billingFacilityState() .
 180     "*" . stripZipCode($claim->billingFacilityZip()) .
 181     "~\n";
 182
 183   if ($CMS_5010 || ($claim->billingFacilityNPI() && $claim->billingFacilityETIN())) {
 184     ++$edicount;
 185     $out .= "REF" ;
 186     if($claim->federalIdType()){
 187       $out .= "*" . $claim->federalIdType();
 188     }
 189     else{
 190       $out .= "*EI"; // For dealing with the situation before adding TaxId type In facility.
 191     }
 192     $out .=  "*" . $claim->billingFacilityETIN() .
 193       "~\n";
 194   }
 195
 196   if ($claim->providerNumberType() && $claim->providerNumber() &&
 197       !($CMS_5010 && $claim->billingFacilityNPI()))
 198   {
 199     ++$edicount;
 200     $out .= "REF" .
 201       "*" . $claim->providerNumberType() .
 202       "*" . $claim->providerNumber() .
 203       "~\n";
 204   }
 205   else if ($claim->providerNumber() && !$claim->providerNumberType()) {
 206     $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 207   }
 208
 209   // Situational PER*1C segment omitted.
 210
 211   // Pay-To Address defaults to billing provider and is no longer required in 5010.
 212   if (!$CMS_5010) {
 213     ++$edicount;
 214     // Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 215     $billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
 216     $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 217       "*87" .
 218       "*2" .
 219       "*" . $billingFacilityName .
 220       "*" .
 221       "*" .
 222       "*" .
 223       "*";
 224     if ($claim->billingFacilityNPI())
 225       $out .= "*XX*" . $claim->billingFacilityNPI();
 226     else
 227       $out .= "*24*" . $claim->billingFacilityETIN();
 228     $out .= "~\n";
 229
 230     ++$edicount;
 231     $out .= "N3" .
 232       "*" . $claim->billingFacilityStreet() .
 233       "~\n";
 234
 235     ++$edicount;
 236     $out .= "N4" .
 237       "*" . $claim->billingFacilityCity() .
 238       "*" . $claim->billingFacilityState() .
 239       "*" . stripZipCode($claim->billingFacilityZip()) .
 240       "~\n";
 241
 242     if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 243       ++$edicount;
 244       $out .= "REF" .
 245         "*EI" .
 246         "*" . $claim->billingFacilityETIN() .
 247         "~\n";
 248     }
 249   }
 250
 251   // Loop 2010AC Pay-To Plan Name omitted.  Includes:
 252   // NM1*PE, N3, N4, REF*2U, REF*EI
 253
 254   $PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
 255   $HLSubscriber = $HLcount++;
 256
 257   ++$edicount;
 258   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 259     "*$HLSubscriber" .
 260     "*$HLBillingPayToProvider" .
 261     "*22" .
 262     "*$PatientHL" .
 263     "~\n";
 264
 265   if (!$claim->payerSequence()) {
 266     $log .= "*** Error: Insurance information is missing!\n";
 267   }
 268
 269   ++$edicount;
 270   $out .= "SBR" .       // Subscriber Information
 271     "*" . $claim->payerSequence() .
 272     "*" . ($claim->isSelfOfInsured() ? '18' : '') .
 273     "*" . $claim->groupNumber() .
 274     "*" . (($CMS_5010 && $claim->groupNumber()) ? '' : $claim->groupName()) .
 275     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 276     "*" .
 277     "*" .
 278     "*" .
 279     "*" . $claim->claimType() . // Zirmed replaces this
 280     "~\n";
 281
 282   // Segment PAT omitted.
 283
 284   ++$edicount;
 285   $out .= "NM1" .       // Loop 2010BA Subscriber
 286     "*IL" .
 287     "*1" . // 1 = person, 2 = non-person
 288     "*" . $claim->insuredLastName() .
 289     "*" . $claim->insuredFirstName() .
 290     "*" . $claim->insuredMiddleName() .
 291     "*" .
 292     "*" . // Name Suffix
 293     "*MI" .
 294     // "MI" = Member Identification Number
 295     // "II" = Standard Unique Health Identifier, "Required if the
 296     //        HIPAA Individual Patient Identifier is mandated use."
 297     //        Here we presume that is not true yet.
 298     "*" . $claim->policyNumber() .
 299     "~\n";
 300
 301   // For 5010, further subscriber info is sent only if they are the patient.
 302   if (!$CMS_5010 || $claim->isSelfOfInsured()) {
 303     ++$edicount;
 304     $out .= "N3" .
 305       "*" . $claim->insuredStreet() .
 306       "~\n";
 307
 308     ++$edicount;
 309     $out .= "N4" .
 310       "*" . $claim->insuredCity() .
 311       "*" . $claim->insuredState() .
 312       "*" . stripZipCode($claim->insuredZip()) .
 313       "~\n";
 314
 315     ++$edicount;
 316     $out .= "DMG" .
 317       "*D8" .
 318       "*" . $claim->insuredDOB() .
 319       "*" . $claim->insuredSex() .
 320       "~\n";
 321   }
 322
 323   // Segment REF*SY (Subscriber Secondary Identification) omitted.
 324   // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 325   // Segment PER*IC (Property and Casualty Subscriber Contact Information) omitted.
 326
 327   ++$edicount;
 328   //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 329   $payerName = substr($claim->payerName(), 0, $CMS_5010 ? 60 : 35);
 330   $out .= "NM1" .       // Loop 2010BB Payer
 331     "*PR" .
 332     "*2" .
 333     "*" . $payerName .
 334     "*" .
 335     "*" .
 336     "*" .
 337     "*" .
 338     // The 5010 spec says:
 339     // "On or after the mandated implementation date for the HIPAA
 340     // National Plan Identifier (National Plan ID), XV must be sent.
 341     // Prior to the mandated implementation date and prior to any phase-
 342     // in period identified by Federal regulation, PI must be sent."
 343     // *************** Anybody know what that date is? ***************
 344     "*PI" .
 345     // Zirmed ignores this if using payer name matching:
 346     "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 347     "~\n";
 348
 349   // if (!$claim->payerID()) {
 350   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 351   // }
 352
 353   if (true) { // !$CMS_5010
 354     // The 5010 spec says:
 355     // "Required when the payer address is available and the submitter intends
 356     // for the claim to be printed on paper at the next EDI location (for example, a
 357     // clearinghouse). If not required by this implementation guide, do not send."
 358
 359     ++$edicount;
 360     $out .= "N3" .
 361       "*" . $claim->payerStreet() .
 362       "~\n";
 363
 364     ++$edicount;
 365     $out .= "N4" .
 366       "*" . $claim->payerCity() .
 367       "*" . $claim->payerState() .
 368       "*" . stripZipCode($claim->payerZip()) .
 369       "~\n";
 370   }
 371
 372   // Segment REF (Payer Secondary Identification) omitted.
 373   // Segment REF (Billing Provider Secondary Identification) omitted.
 374
 375   if (! $claim->isSelfOfInsured()) {
 376     ++$edicount;
 377     $out .= "HL" .        // Loop 2000C Patient Information
 378       "*$HLcount" .
 379       "*$HLSubscriber" .
 380       "*23" .
 381       "*0" .
 382       "~\n";
 383
 384     $HLcount++;
 385
 386     ++$edicount;
 387     $out .= "PAT" .
 388       "*" . $claim->insuredRelationship() .
 389       "~\n";
 390
 391     ++$edicount;
 392     $out .= "NM1" .       // Loop 2010CA Patient
 393       "*QC" .
 394       "*1" .
 395       "*" . $claim->patientLastName() .
 396       "*" . $claim->patientFirstName() .
 397       "*" . $claim->patientMiddleName() .
 398       "~\n";
 399
 400     ++$edicount;
 401     $out .= "N3" .
 402       "*" . $claim->patientStreet() .
 403       "~\n";
 404
 405     ++$edicount;
 406     $out .= "N4" .
 407       "*" . $claim->patientCity() .
 408       "*" . $claim->patientState() .
 409       "*" . stripZipCode($claim->patientZip()) .
 410       "~\n";
 411
 412     ++$edicount;
 413     $out .= "DMG" .
 414       "*D8" .
 415       "*" . $claim->patientDOB() .
 416       "*" . $claim->patientSex() .
 417       "~\n";
 418
 419     // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 420     // Segment REF (Property and Casualty Patient Identifier) omitted.
 421     // Segment PER (Property and Casualty Patient Contact Information) omitted.
 422
 423   } // end of patient different from insured
 424
 425   $proccount = $claim->procCount();
 426
 427   $clm_total_charges = 0;
 428   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 429     $clm_total_charges += $claim->cptCharges($prockey);
 430   }
 431
 432   if (!$clm_total_charges) {
 433     $log .= "*** This claim has no charges!\n";
 434   }
 435
 436   ++$edicount;
 437   $out .= "CLM" .       // Loop 2300 Claim
 438     "*$pid-$encounter" .
 439     "*"  . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 440     "*"  .
 441     "*"  .
 442     "*"  . sprintf('%02d', $claim->facilityPOS()) . ":" .
 443            ($CMS_5010 ? "B" : "") . ":" .
 444            $claim->frequencyTypeCode() . // Changed to correct single digit output
 445     "*Y" .
 446     "*A" .
 447     "*"  . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 448     "*Y" .
 449     ($CMS_5010 ? "" : "*C") .
 450     "~\n";
 451
 452   if ($claim->onsetDate() &&
 453       ($claim->onsetDate()!== $claim->serviceDate()) &&
 454       ($claim->onsetDateValid())
 455      ) {
 456     ++$edicount;
 457     $out .= "DTP" .       // Date of Onset
 458       "*431" .
 459       "*D8" .
 460       "*" . $claim->onsetDate() .
 461       "~\n";
 462   }
 463
 464   if ($claim->dateInitialTreatment() && ($claim->onsetDateValid())) {
 465     ++$edicount;
 466     $out .= "DTP" .       // Date of Initial Treatment
 467       "*454" .
 468       "*D8" .
 469       "*" . $claim->dateInitialTreatment() .
 470       "~\n";
 471   }
 472
 473   // Segment DTP*304 (Last Seen Date) omitted.
 474   // Segment DTP*453 (Acute Manifestation Date) omitted.
 475   // Segment DTP*439 (Accident Date) omitted.
 476   // Segment DTP*484 (Last Menstrual Period Date) omitted.
 477   // Segment DTP*455 (Last X-Ray Date) omitted.
 478   // Segment DTP*471 (Hearing and Vision Prescription Date) omitted.
 479   // Segments DTP (Disability Dates) omitted.
 480   // Segment DTP*297 (Last Worked Date) omitted.
 481   // Segment DTP*296 (Authorized Return to Work Date) omitted.
 482
 483   if (strcmp($claim->facilityPOS(),'21') == 0 && $claim->onsetDateValid() ) {
 484     ++$edicount;
 485     $out .= "DTP" .     // Date of Hospitalization
 486       "*435" .
 487       "*D8" .
 488       "*" . $claim->onsetDate() .
 489       "~\n";
 490   }
 491
 492   // Segment DTP*096 (Discharge Date) omitted.
 493   // Segments DTP (Assumed and Relinquished Care Dates) omitted.
 494   // Segment DTP*444 (Property and Casualty Date of First Contact) omitted.
 495   // Segment DTP*050 (Repricer Received Date) omitted.
 496   // Segment PWK (Claim Supplemental Information) omitted.
 497   // Segment CN1 (Contract Information) omitted.
 498
 499   $patientpaid = $claim->patientPaidAmount();
 500   if ($patientpaid != 0) {
 501     ++$edicount;
 502     $out .= "AMT" .     // Patient paid amount. Page 190/220.
 503       "*F5" .
 504       "*" . $patientpaid .
 505       "~\n";
 506   }
 507
 508   // Segment REF*4N (Service Authorization Exception Code) omitted.
 509   // Segment REF*F5 (Mandatory Medicare Crossover Indicator) omitted.
 510   // Segment REF*EW (Mammography Certification Number) omitted.
 511   // Segment REF*9F (Referral Number) omitted.
 512
 513   if ($claim->priorAuth()) {
 514     ++$edicount;
 515     $out .= "REF" .     // Prior Authorization Number
 516       "*G1" .
 517       "*" . $claim->priorAuth() .
 518       "~\n";
 519   }
 520
 521   // Segment REF*F8 (Payer Claim Control Number) omitted.
 522
 523   if ($claim->cliaCode() && ($CMS_5010 || $claim->claimType() === 'MB')) {
 524     // Required by Medicare when in-house labs are done.
 525     ++$edicount;
 526     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 527       "*X4" .
 528       "*" . $claim->cliaCode() .
 529       "~\n";
 530   }
 531
 532   // Segment REF*9A (Repriced Claim Number) omitted.
 533   // Segment REF*9C (Adjusted Repriced Claim Number) omitted.
 534   // Segment REF*LX (Investigational Device Exemption Number) omitted.
 535   // Segment REF*D9 (Claim Identifier for Transmission Intermediaries) omitted.
 536   // Segment REF*EA (Medical Record Number) omitted.
 537   // Segment REF*P4 (Demonstration Project Identifier) omitted.
 538   // Segment REF*1J (Care Plan Oversight) omitted.
 539   // Segment K3 (File Information) omitted.
 540
 541   if ($claim->additionalNotes()) {
 542     // Claim note.
 543     ++$edicount;
 544     $out .= "NTE" .     // comments box 19
 545       "*" . ($CMS_5010 ? "ADD" : "") .
 546       "*" . $claim->additionalNotes() .
 547       "~\n";
 548   }
 549
 550   // Segment CR1 (Ambulance Transport Information) omitted.
 551   // Segment CR2 (Spinal Manipulation Service Information) omitted.
 552   // Segment CRC (Ambulance Certification) omitted.
 553   // Segment CRC (Patient Condition Information: Vision) omitted.
 554   // Segment CRC (Homebound Indicator) omitted.
 555   // Segment CRC (EPSDT Referral) omitted.
 556
 557   // Diagnoses, up to $max_per_seg per HI segment.
 558   $max_per_seg = $CMS_5010 ? 12 : 8;
 559   $da = $claim->diagArray();
 560   $diag_type_code = 'BK';
 561   $tmp = 0;
 562   foreach ($da as $diag) {
 563     if ($tmp % $max_per_seg == 0) {
 564       if ($tmp) $out .= "~\n";
 565       ++$edicount;
 566       $out .= "HI";         // Health Diagnosis Codes
 567     }
 568     $out .= "*$diag_type_code:" . $diag;
 569     $diag_type_code = 'BF';
 570     ++$tmp;
 571   }
 572   if ($tmp) $out .= "~\n";
 573
 574   // Segment HI*BP (Anesthesia Related Procedure) omitted.
 575   // Segment HI*BG (Condition Information) omitted.
 576   // Segment HCP (Claim Pricing/Repricing Information) omitted.
 577
 578   if ($claim->referrerLastName()) {
 579     // Medicare requires referring provider's name and UPIN.
 580     ++$edicount;
 581     $out .= "NM1" .     // Loop 2310A Referring Provider
 582       "*DN" .
 583       "*1" .
 584       "*" . $claim->referrerLastName() .
 585       "*" . $claim->referrerFirstName() .
 586       "*" . $claim->referrerMiddleName() .
 587       "*" .
 588       "*";
 589     if ($CMS_5010 || $claim->referrerNPI()) { $out .=
 590       "*XX" .
 591       "*" . $claim->referrerNPI();
 592     } else { $out .=
 593       "*34" .                           // not allowed for 5010
 594       "*" . $claim->referrerSSN();
 595     }
 596     $out .= "~\n";
 597
 598     if (!$CMS_5010 && $claim->referrerTaxonomy()) {
 599       ++$edicount;
 600       $out .= "PRV" .
 601         "*RF" . // ReFerring provider
 602         "*ZZ" .
 603         "*" . $claim->referrerTaxonomy() .
 604         "~\n";
 605     }
 606
 607     if (!CMS_5010 && $claim->referrerUPIN()) {
 608       ++$edicount;
 609       $out .= "REF" .   // Referring Provider Secondary Identification
 610         "*1G" .
 611         "*" . $claim->referrerUPIN() .
 612         "~\n";
 613     }
 614   }
 615
 616
 617   /* Per the implementation guide lines, only include this information if it is different
 618    * than the Loop 2010AA information
 619    */
 620   if(!$CMS_5010 ||
 621           ($claim->providerNPIValid() &&
 622           $claim->billingFacilityNPI() !== $claim->providerNPI() ))
 623   {
 624     ++$edicount;
 625     $out .= "NM1" .       // Loop 2310B Rendering Provider
 626         "*82" .
 627         "*1" .
 628         "*" . $claim->providerLastName() .
 629         "*" . $claim->providerFirstName() .
 630         "*" . $claim->providerMiddleName() .
 631         "*" .
 632         "*";
 633     if ($CMS_5010 || $claim->providerNPI()) { $out .=
 634         "*XX" .
 635         "*" . $claim->providerNPI();
 636     } else { $out .=
 637         "*34" .                             // not allowed for 5010
 638         "*" . $claim->providerSSN();
 639         $log .= "*** Rendering provider has no NPI.\n";
 640     }
 641     $out .= "~\n";
 642
 643     if ($claim->providerTaxonomy()) {
 644         ++$edicount;
 645         $out .= "PRV" .
 646         "*PE" . // PErforming provider
 647         "*" . ($CMS_5010 ? "PXC" : "ZZ") .
 648         "*" . $claim->providerTaxonomy() .
 649         "~\n";
 650     }
 651     // End of Loop 2310B
 652   }
 653   else
 654   {
 655     // This loop can only get skipped if we are generating a 5010 claim
 656     if(!($claim->providerNPIValid()))
 657     {
 658         /* If the loop was skipped because the provider NPI was invalid, generate
 659          * a warning for the log.*/
 660         $log.="*** Skipping 2310B because ".$claim->providerLastName() ."," . $claim->providerFirstName() . " has invalid NPI.\n";
 661     }
 662     /* Skipping this segment because the providerNPI and the billingFacilityNPI are identical
 663      * is a normal condition, so no need to warn.
 664      */
 665
 666   }
 667
 668   // 4010: REF*1C is required here for the Medicare provider number if NPI was
 669   // specified in NM109.  Not sure if other payers require anything here.
 670   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 671   //
 672   // 5010 spec says nothing here if NPI was specified.
 673   //
 674   if (($CMS_5010 && !$claim->providerNPI() && in_array($claim->providerNumberType(), array('0B','1G','G2','LU')))
 675       || (!$CMS_5010 && trim($claim->x12gsreceiverid()) != '470819582')) // if NOT ECLAIMS EDI
 676   {
 677     if ($claim->providerNumber()) {
 678       ++$edicount;
 679       $out .= "REF" .
 680         "*" . $claim->providerNumberType() .
 681         "*" . $claim->providerNumber() .
 682         "~\n";
 683     }
 684   }
 685
 686   // Loop 2310D is omitted in the case of home visits (POS=12).
 687   if ($claim->facilityPOS() != 12 &&
 688       (!$CMS_5010 || $claim->facilityNPI() != $claim->billingFacilityNPI()))
 689     {
 690     ++$edicount;
 691     $out .= "NM1" .       // Loop 2310D Service Location
 692       "*77" .
 693       "*2";
 694     //Field length is limited to 35. See nucc dataset page 77 www.nucc.org
 695     $facilityName = substr($claim->facilityName(), 0, $CMS_5010 ? 60 : 35);
 696     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 697       "*" . $facilityName;
 698     }
 699     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 700       "*" .
 701       "*" .
 702       "*" .
 703       "*";
 704       if ($CMS_5010 || $claim->facilityNPI()) { $out .=
 705         "*XX*" . $claim->facilityNPI();
 706       } else { $out .=
 707         "*24*" . $claim->facilityETIN();
 708       }
 709       if (!$claim->facilityNPI()) {
 710         $log .= "*** Service location has no NPI.\n";
 711       }
 712     }
 713     $out .= "~\n";
 714     if ($claim->facilityStreet()) {
 715       ++$edicount;
 716       $out .= "N3" .
 717         "*" . $claim->facilityStreet() .
 718         "~\n";
 719     }
 720     if ($claim->facilityState()) {
 721       ++$edicount;
 722       $out .= "N4" .
 723         "*" . $claim->facilityCity() .
 724         "*" . $claim->facilityState() .
 725         "*" . stripZipCode($claim->facilityZip()) .
 726         "~\n";
 727     }
 728   }
 729
 730   // Segment REF (Service Facility Location Secondary Identification) omitted.
 731   // Segment PER (Service Facility Contact Information) omitted.
 732
 733   // Loop 2310E, Supervising Provider
 734   //
 735   if ($claim->supervisorLastName()) {
 736     ++$edicount;
 737     $out .= "NM1" .
 738       "*DQ" . // Supervising Physician
 739       "*1" .  // Person
 740       "*" . $claim->supervisorLastName() .
 741       "*" . $claim->supervisorFirstName() .
 742       "*" . $claim->supervisorMiddleName() .
 743       "*" .   // NM106 not used
 744       "*";    // Name Suffix
 745     if ($CMS_5010 || $claim->supervisorNPI()) { $out .=
 746       "*XX" .
 747       "*" . $claim->supervisorNPI();
 748     } else { $out .=
 749       "*34" .
 750       "*" . $claim->supervisorSSN();
 751     }
 752     if (!$claim->supervisorNPI()) {
 753       $log .= "*** Supervising Provider has no NPI.\n";
 754     }
 755     $out .= "~\n";
 756
 757     if ($claim->supervisorNumber()) {
 758       ++$edicount;
 759       $out .= "REF" .
 760         "*" . $claim->supervisorNumberType() .
 761         "*" . $claim->supervisorNumber() .
 762         "~\n";
 763     }
 764   }
 765
 766   // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
 767   // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
 768
 769   $prev_pt_resp = $clm_total_charges; // for computation below
 770
 771   // Loops 2320 and 2330*, other subscriber/payer information.
 772   // Remember that insurance index 0 is always for the payer being billed
 773   // by this claim, and 1 and above are always for the "other" payers.
 774   //
 775   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 776
 777     $tmp1 = $claim->claimType($ins);
 778     $tmp2 = 'C1'; // Here a kludge. See page 321.
 779     if ($tmp1 === 'CI') $tmp2 = 'C1';
 780     if ($tmp1 === 'AM') $tmp2 = 'AP';
 781     if ($tmp1 === 'HM') $tmp2 = 'HM';
 782     if ($tmp1 === 'MB') $tmp2 = 'MB';
 783     if ($tmp1 === 'MC') $tmp2 = 'MC';
 784     if ($tmp1 === '09') $tmp2 = 'PP';
 785     ++$edicount;
 786     $out .= "SBR" . // Loop 2320, Subscriber Information - page 297/318
 787       "*" . $claim->payerSequence($ins) .
 788       "*" . $claim->insuredRelationship($ins) .
 789       "*" . $claim->groupNumber($ins) .
 790       "*" . (($CMS_5010 && $claim->groupNumber($ins)) ? '' : $claim->groupName($ins)) .
 791       "*" . ($CMS_5010 ? $claim->insuredTypeCode($ins) : $tmp2) .
 792       "*" .
 793       "*" .
 794       "*" .
 795       "*" . $claim->claimType($ins) .
 796       "~\n";
 797
 798     // Things that apply only to previous payers, not future payers.
 799     //
 800     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 801
 802       // Generate claim-level adjustments.
 803       $aarr = $claim->payerAdjustments($ins);
 804       foreach ($aarr as $a) {
 805         ++$edicount;
 806         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 301/323.
 807           "*" . $a[1] .
 808           "*" . $a[2] .
 809           "*" . $a[3] .
 810           "~\n";
 811       }
 812
 813       $payerpaid = $claim->payerTotals($ins);
 814       ++$edicount;
 815       $out .= "AMT" . // Previous payer's paid amount. Page 307/332.
 816         "*D" .
 817         "*" . $payerpaid[1] .
 818         "~\n";
 819
 820       // Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
 821       // Segment AMT*EAF (Remaining Patient Liability) omitted.
 822
 823       if (!$CMS_5010) {
 824         // Patient responsibility amount as of this previous payer.
 825         $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 826         $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 827
 828         ++$edicount;
 829         $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 830           "*B6" .
 831           "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 832           "~\n";
 833
 834         ++$edicount;
 835         $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 836           "*F2" .
 837           "*" . sprintf('%.2f', $prev_pt_resp) .
 838           "~\n";
 839       }
 840     } // End of things that apply only to previous payers.
 841
 842     if (!$CMS_5010) {
 843       ++$edicount;
 844       $out .= "DMG" . // Other subscriber demographic information. Page 342.
 845         "*D8" .
 846         "*" . $claim->insuredDOB($ins) .
 847         "*" . $claim->insuredSex($ins) .
 848         "~\n";
 849     }
 850
 851     ++$edicount;
 852     $out .= "OI" .  // Other Insurance Coverage Information. Page 310/344.
 853       "*" .
 854       "*" .
 855       "*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
 856       // For this next item, the 5010 example in the spec does not match its
 857       // description.  So this might be wrong.
 858       "*" . ($CMS_5010 ? '' : 'B') .
 859       "*" .
 860       "*Y" .
 861       "~\n";
 862
 863     // Segment MOA (Medicare Outpatient Adjudication) omitted.
 864
 865     ++$edicount;
 866     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
 867       "*IL" .
 868       "*1" .
 869       "*" . $claim->insuredLastName($ins) .
 870       "*" . $claim->insuredFirstName($ins) .
 871       "*" . $claim->insuredMiddleName($ins) .
 872       "*" .
 873       "*" .
 874       "*MI" .
 875       "*" . $claim->policyNumber($ins) .
 876       "~\n";
 877
 878     ++$edicount;
 879     $out .= "N3" .
 880       "*" . $claim->insuredStreet($ins) .
 881       "~\n";
 882
 883     ++$edicount;
 884     $out .= "N4" .
 885       "*" . $claim->insuredCity($ins) .
 886       "*" . $claim->insuredState($ins) .
 887       "*" . stripZipCode($claim->insuredZip($ins)) .
 888       "~\n";
 889
 890     // Segment REF (Other Subscriber Secondary Identification) omitted.
 891
 892     ++$edicount;
 893     //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 894     $payerName = substr($claim->payerName($ins), 0, $CMS_5010 ? 60 : 35);
 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     // Payer address (N3 and N4) are added below so that Gateway EDI can
 912     // auto-generate secondary claims.  These do NOT appear in my copy of
 913     // the spec!  -- Rod 2008-06-12
 914
 915     if ($CMS_5010 || trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 916       ++$edicount;
 917       $out .= "N3" .
 918         "*" . $claim->payerStreet($ins) .
 919         "~\n";
 920       //
 921       ++$edicount;
 922       $out .= "N4" .
 923         "*" . $claim->payerCity($ins) .
 924         "*" . $claim->payerState($ins) .
 925         "*" . stripZipCode($claim->payerZip($ins)) .
 926         "~\n";
 927     } // end Gateway EDI
 928
 929     // Segment DTP*573 (Claim Check or Remittance Date) omitted.
 930     // Segment REF (Other Payer Secondary Identifier) omitted.
 931     // Segment REF*G1 (Other Payer Prior Authorization Number) omitted.
 932     // Segment REF*9F (Other Payer Referral Number) omitted.
 933     // Segment REF*T4 (Other Payer Claim Adjustment Indicator) omitted.
 934     // Segment REF*F8 (Other Payer Claim Control Number) omitted.
 935     // Segment NM1 (Other Payer Referring Provider) omitted.
 936     // Segment REF (Other Payer Referring Provider Secondary Identification) omitted.
 937     // Segment NM1 (Other Payer Rendering Provider) omitted.
 938     // Segment REF (Other Payer Rendering Provider Secondary Identification) omitted.
 939     // Segment NM1 (Other Payer Service Facility Location) omitted.
 940     // Segment REF (Other Payer Service Facility Location Secondary Identification) omitted.
 941     // Segment NM1 (Other Payer Supervising Provider) omitted.
 942     // Segment REF (Other Payer Supervising Provider Secondary Identification) omitted.
 943     // Segment NM1 (Other Payer Billing Provider) omitted.
 944     // Segment REF (Other Payer Billing Provider Secondary Identification) omitted.
 945
 946   } // End loops 2320/2330*.
 947
 948   $loopcount = 0;
 949
 950   // Procedure loop starts here.
 951   //
 952   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 953     ++$loopcount;
 954
 955     ++$edicount;
 956     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 957       "*$loopcount" .
 958       "~\n";
 959
 960     ++$edicount;
 961     $out .= "SV1" .     // Professional Service. Page 400.
 962       "*HC:" . $claim->cptKey($prockey) .
 963       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 964       "*UN" .
 965       "*" . $claim->cptUnits($prockey) .
 966       "*" .
 967       "*" .
 968       "*";
 969     $dia = $claim->diagIndexArray($prockey);
 970     $i = 0;
 971     foreach ($dia as $dindex) {
 972       if ($i) $out .= ':';
 973       $out .= $dindex;
 974       if (++$i >= 4) break;
 975     }
 976     $out .= "~\n";
 977
 978     if (!$claim->cptCharges($prockey)) {
 979       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 980     }
 981
 982     if (empty($dia)) {
 983       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 984     }
 985
 986     // Segment SV5 (Durable Medical Equipment Service) omitted.
 987     // Segment PWK (Line Supplemental Information) omitted.
 988     // Segment PWK (Durable Medical Equipment Certificate of Medical Necessity Indicator) omitted.
 989     // Segment CR1 (Ambulance Transport Information) omitted.
 990     // Segment CR3 (Durable Medical Equipment Certification) omitted.
 991     // Segment CRC (Ambulance Certification) omitted.
 992     // Segment CRC (Hospice Employee Indicator) omitted.
 993     // Segment CRC (Condition Indicator / Durable Medical Equipment) omitted.
 994
 995     ++$edicount;
 996     $out .= "DTP" .     // Date of Service. Page 435.
 997       "*472" .
 998       "*D8" .
 999       "*" . $claim->serviceDate() .
1000       "~\n";
1001
1002     $testnote = rtrim($claim->cptNotecodes($prockey));
1003     if (!empty($testnote)) {
1004       ++$edicount;
1005       $out .= "NTE" .     // Explain Unusual Circumstances.
1006         "*ADD" .
1007         "*" . $claim->cptNotecodes($prockey) .
1008         "~\n";
1009     }
1010
1011     // Segment DTP*471 (Prescription Date) omitted.
1012     // Segment DTP*607 (Revision/Recertification Date) omitted.
1013     // Segment DTP*463 (Begin Therapy Date) omitted.
1014     // Segment DTP*461 (Last Certification Date) omitted.
1015     // Segment DTP*304 (Last Seen Date) omitted.
1016     // Segment DTP (Test Date) omitted.
1017     // Segment DTP*011 (Shipped Date) omitted.
1018     // Segment DTP*455 (Last X-Ray Date) omitted.
1019     // Segment DTP*454 (Initial Treatment Date) omitted.
1020     // Segment QTY (Ambulance Patient Count) omitted.
1021     // Segment QTY (Obstetric Anesthesia Additional Units) omitted.
1022     // Segment MEA (Test Result) omitted.
1023     // Segment CN1 (Contract Information) omitted.
1024     // Segment REF*9B (Repriced Line Item Reference Number) omitted.
1025     // Segment REF*9D (Adjusted Repriced Line Item Reference Number) omitted.
1026     // Segment REF*G1 (Prior Authorization) omitted.
1027     // Segment REF*6R (Line Item Control Number) omitted.
1028     //   (Really oughta have this for robust 835 posting!)
1029     // Segment REF*EW (Mammography Certification Number) omitted.
1030     // Segment REF*X4 (CLIA Number) omitted.
1031     // Segment REF*F4 (Referring CLIA Facility Identification) omitted.
1032     // Segment REF*BT (Immunization Batch Number) omitted.
1033     // Segment REF*9F (Referral Number) omitted.
1034     // Segment AMT*T (Sales Tax Amount) omitted.
1035     // Segment AMT*F4 (Postage Claimed Amount) omitted.
1036     // Segment K3 (File Information) omitted.
1037     // Segment NTE (Line Note) omitted.
1038     // Segment NTE (Third Party Organization Notes) omitted.
1039     // Segment PS1 (Purchased Service Information) omitted.
1040     // Segment HCP (Line Pricing/Repricing Information) omitted.
1041
1042     if (!$CMS_5010) {
1043       // This segment was deleted for 5010.
1044       //
1045       // AMT*AAE segment for Approved Amount from previous payer.
1046       // Medicare secondaries seem to require this.
1047       //
1048       for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
1049         if ($claim->payerSequence($ins) > $claim->payerSequence())
1050           continue; // payer is future, not previous
1051         $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1052         ++$edicount;
1053         $out .= "AMT" . // Approved amount per previous payer. Page 485.
1054           "*AAE" .
1055           "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
1056           "~\n";
1057         break;
1058       }
1059     }
1060
1061     // Loop 2410, Drug Information. Medicaid insurers seem to want this
1062     // with HCPCS codes.
1063     //
1064     $ndc = $claim->cptNDCID($prockey);
1065     if ($ndc) {
1066       ++$edicount;
1067       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
1068         "*" .         // Per addendum, LIN01 is not used.
1069         "*N4" .
1070         "*" . $ndc .
1071         "~\n";
1072
1073       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp) && !preg_match('/^\d{11}$/', $ndc)) {
1074         $log .= "*** NDC code '$ndc' has invalid format!\n";
1075       }
1076
1077       ++$edicount;
1078       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
1079       if (!$tmpunits) $tmpunits = 1;
1080       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
1081         "*" .
1082         "*" .
1083         "*" . ($CMS_5010 ? '' : sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits)) .
1084         "*" . $claim->cptNDCQuantity($prockey) .
1085         "*" . $claim->cptNDCUOM($prockey) .
1086         // Note: 5010 documents "ME" (Milligrams) as an additional unit of measure.
1087         "~\n";
1088     }
1089
1090     // Segment REF (Prescription or Compound Drug Association Number) omitted.
1091
1092     // Loop 2420A, Rendering Provider (service-specific).
1093     // Used if the rendering provider for this service line is different
1094     // from that in loop 2310B.
1095     //
1096     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
1097       ++$edicount;
1098       $out .= "NM1" .       // Loop 2310B Rendering Provider
1099         "*82" .
1100         "*1" .
1101         "*" . $claim->providerLastName($prockey) .
1102         "*" . $claim->providerFirstName($prockey) .
1103         "*" . $claim->providerMiddleName($prockey) .
1104         "*" .
1105         "*";
1106       if ($CMS_5010 || $claim->providerNPI($prockey)) { $out .=
1107         "*XX" .
1108         "*" . $claim->providerNPI($prockey);
1109       } else { $out .=
1110         "*34" .                         // Not allowed for 5010
1111         "*" . $claim->providerSSN($prockey);
1112       }
1113       if (!$claim->providerNPI($prockey)) {
1114         $log .= "*** Rendering provider has no NPI.\n";
1115       }
1116       $out .= "~\n";
1117
1118       if ($claim->providerTaxonomy($prockey)) {
1119         ++$edicount;
1120         $out .= "PRV" .
1121           "*PE" . // PErforming provider
1122           "*" . ($CMS_5010 ? "PXC" : "ZZ") .
1123           "*" . $claim->providerTaxonomy($prockey) .
1124           "~\n";
1125       }
1126
1127       // Segment PRV*PE (Rendering Provider Specialty Information) omitted.
1128       // Segment REF (Rendering Provider Secondary Identification) omitted.
1129       // Segment NM1 (Purchased Service Provider Name) omitted.
1130       // Segment REF (Purchased Service Provider Secondary Identification) omitted.
1131       // Segment NM1,N3,N4 (Service Facility Location) omitted.
1132       // Segment REF (Service Facility Location Secondary Identification) omitted.
1133       // Segment NM1 (Supervising Provider Name) omitted.
1134       // Segment REF (Supervising Provider Secondary Identification) omitted.
1135       // Segment NM1,N3,N4 (Ordering Provider) omitted.
1136       // Segment REF (Ordering Provider Secondary Identification) omitted.
1137       // Segment PER (Ordering Provider Contact Information) omitted.
1138       // Segment NM1 (Referring Provider Name) omitted.
1139       // Segment REF (Referring Provider Secondary Identification) omitted.
1140       // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
1141       // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
1142
1143       // REF*1C is required here for the Medicare provider number if NPI was
1144       // specified in NM109.  Not sure if other payers require anything here.
1145       if (!$CMS_5010 && $claim->providerNumber($prockey)) {
1146         ++$edicount;
1147         $out .= "REF" .
1148           "*" . $claim->providerNumberType($prockey) .
1149           // Note: 5010 documents that type 1D (Medicaid) is changed to G2.
1150           "*" . $claim->providerNumber($prockey) .
1151           "~\n";
1152       }
1153     }
1154
1155     // Loop 2430, adjudication by previous payers.
1156     //
1157     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
1158       if ($claim->payerSequence($ins) > $claim->payerSequence())
1159         continue; // payer is future, not previous
1160
1161       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1162       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
1163
1164       if ($payerpaid[1] == 0 && !count($aarr)) {
1165         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
1166           "' has no payments or adjustments from previous payer!\n";
1167         continue;
1168       }
1169
1170       ++$edicount;
1171       $out .= "SVD" . // Service line adjudication. Page 554.
1172         "*" . $claim->payerID($ins) .
1173         "*" . $payerpaid[1] .
1174         "*HC:" . $claim->cptKey($prockey) .
1175         "*" .
1176         "*" . $claim->cptUnits($prockey) .
1177         "~\n";
1178
1179       $tmpdate = $payerpaid[0];
1180       foreach ($aarr as $a) {
1181         ++$edicount;
1182         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
1183           "*" . $a[1] .
1184           "*" . $a[2] .
1185           "*" . $a[3] .
1186           "~\n";
1187         if (!$tmpdate) $tmpdate = $a[0];
1188
1189         // WTH is this??
1190         /*************************************************************
1191         if ( isset($a[4]) &&
1192                 $a[4] != null ) {
1193                 $out .= "CAS02" . // Previous payer's adjustment reason
1194                   "*" . $a[4] .
1195                   "~\n";
1196         }
1197         *************************************************************/
1198       }
1199
1200       if ($tmpdate) {
1201         ++$edicount;
1202         $out .= "DTP" . // Previous payer's line adjustment date. Page 493/566.
1203           "*573" .
1204           "*D8" .
1205           "*$tmpdate" .
1206           "~\n";
1207       }
1208
1209       // Segment AMT*EAF (Remaining Patient Liability) omitted.
1210       // Segment LQ (Form Identification Code) omitted.
1211       // Segment FRM (Supporting Documentation) omitted.
1212
1213     } // end loop 2430
1214   } // end this procedure
1215
1216   ++$edicount;
1217   $out .= "SE" .        // SE Trailer
1218     "*$edicount" .
1219     "*0021" .
1220     "~\n";
1221
1222   $out .= "GE" .        // GE Trailer
1223     "*1" .
1224     "*1" .
1225     "~\n";
1226
1227   $out .= "IEA" .       // IEA Trailer
1228     "*1" .
1229     "*000000001" .
1230     "~\n";
1231
1232   // Remove any trailing empty fields (delimiters) from each segment.
1233   $out = preg_replace('/\*+~/', '~', $out);
1234
1235   $log .= "\n";
1236   return $out;
1237 }
1238 ?>