library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9
  10 // TBD: Write log messages for the "view log" screen.
  11
  12
  13 require_once("Claim.class.php");
  14
  15 function gen_x12_837($pid, $encounter) {
  16
  17   $today = time();
  18   $out = '';
  19   $claim = new Claim($pid, $encounter);
  20   $edicount = 0;
  21
  22   $out .= "ISA" .
  23     "*00" .
  24     "*          " .
  25     "*00" .
  26     "*          " .
  27     "*ZZ" .
  28     "*" . strtoupper($claim->x12gssenderid()) .
  29     "*ZZ" .
  30     "*" . strtoupper($claim->x12gsreceiverid()) .
  31     "*030911" .
  32     "*1630" .
  33     "*U" .
  34     "*00401" .
  35     "*000000001" .
  36     "*0" .
  37     "*T" .
  38     "*:" .
  39     "~\n";
  40
  41   $out .= "GS" .
  42     "*HC" .
  43     "*" . strtoupper($claim->x12gssenderid()) .
  44     "*" . strtoupper($claim->x12gsreceiverid()) .
  45     "*" . date('Ymd', $today) .
  46     "*" . date('Hi', $today) .
  47     "*1" .
  48     "*X" .
  49     "*" . strtoupper($claim->x12gsversionstring()) .
  50     "~\n";
  51
  52   ++$edicount;
  53   $out .= "ST" .
  54     "*837" .
  55     "*0021" .
  56     "~\n";
  57
  58   ++$edicount;
  59   $out .= "BHT" .
  60     "*0019" .
  61     "*00" .
  62     "*0123" .
  63     "*" . date('Ymd', $today) .
  64     "*1023" .
  65     "*CH" .
  66     "~\n";
  67
  68   ++$edicount;
  69   $out .= "REF" .
  70     "*87" .
  71     "*" . strtoupper($claim->x12gsversionstring()) .
  72     "~\n";
  73
  74   ++$edicount;
  75   $out .= "NM1" .       // Loop 1000A Submitter
  76     "*41" .
  77     "*2" .
  78     "*" . strtoupper($claim->billingFacilityName()) .
  79     "*" .
  80     "*" .
  81     "*" .
  82     "*" .
  83     "*46" .
  84     "*" . strtoupper($claim->billingFacilityETIN()) .
  85     "~\n";
  86
  87   ++$edicount;
  88   $out .= "PER" .
  89     "*IC" .
  90     "*" . strtoupper($claim->billingContactName()) .
  91     "*TE" .
  92     "*" . $claim->billingContactPhone() .
  93     "~\n";
  94
  95   ++$edicount;
  96   $out .= "NM1" .       // Loop 1000B Receiver
  97     "*40" .
  98     "*2" .
  99     "*" . strtoupper($claim->clearingHouseName()) .
 100     "*" .
 101     "*" .
 102     "*" .
 103     "*" .
 104     "*46" .
 105     "*" . strtoupper($claim->clearingHouseETIN()) .
 106     "~\n";
 107
 108   $HLcount = 1;
 109
 110   ++$edicount;
 111   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 112     "*$HLcount" .
 113     "*" .
 114     "*20" .
 115     "*1" .
 116     "~\n";
 117
 118   $HLBillingPayToProvider = $HLcount++;
 119
 120   ++$edicount;
 121   $out .= "NM1" .       // Loop 2010AA Billing Provider
 122     "*85" .
 123     "*2" .
 124     "*" . strtoupper($claim->billingFacilityName()) .
 125     "*" .
 126     "*" .
 127     "*" .
 128     "*";
 129   if ($claim->billingFacilityNPI())
 130     $out .= "*XX*" . $claim->billingFacilityNPI();
 131   else
 132     $out .= "*24*" . $claim->billingFacilityETIN();
 133   $out .= "~\n";
 134
 135   ++$edicount;
 136   $out .= "N3" .
 137     "*" . strtoupper($claim->billingFacilityStreet()) .
 138     "~\n";
 139
 140   ++$edicount;
 141   $out .= "N4" .
 142     "*" . strtoupper($claim->billingFacilityCity()) .
 143     "*" . strtoupper($claim->billingFacilityState()) .
 144     "*" . strtoupper($claim->billingFacilityZip()) .
 145     "~\n";
 146
 147   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 148
 149   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 150     ++$edicount;
 151     $out .= "REF" .
 152       "*EI" .
 153       "*" . $claim->billingFacilityETIN() .
 154       "~\n";
 155   }
 156
 157   ++$edicount;
 158   $out .= "REF" .
 159     "*" . $claim->providerNumberType() .
 160     "*" . $claim->providerNumber() .
 161     "~\n";
 162
 163   ++$edicount;
 164   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 165     "*87" .
 166     "*2" .
 167     "*" . strtoupper($claim->billingFacilityName()) .
 168     "*" .
 169     "*" .
 170     "*" .
 171     "*";
 172   if ($claim->billingFacilityNPI())
 173     $out .= "*XX*" . $claim->billingFacilityNPI();
 174   else
 175     $out .= "*24*" . $claim->billingFacilityETIN();
 176   $out .= "~\n";
 177
 178   ++$edicount;
 179   $out .= "N3" .
 180     "*" . strtoupper($claim->billingFacilityStreet()) .
 181     "~\n";
 182
 183   ++$edicount;
 184   $out .= "N4" .
 185     "*" . strtoupper($claim->billingFacilityCity()) .
 186     "*" . strtoupper($claim->billingFacilityState()) .
 187     "*" . strtoupper($claim->billingFacilityZip()) .
 188     "~\n";
 189
 190   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 191     ++$edicount;
 192     $out .= "REF" .
 193       "*EI" .
 194       "*" . $claim->billingFacilityETIN() .
 195       "~\n";
 196   }
 197
 198   $PatientHL = 0;
 199
 200   ++$edicount;
 201   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 202     "*$HLcount" .
 203     "*$HLBillingPayToProvider" .
 204     "*22" .
 205     "*$PatientHL" .
 206     "~\n";
 207
 208   $HLSubscriber = $HLcount++;
 209
 210   ++$edicount;
 211   $out .= "SBR" .       // Subscriber Information
 212     "*" . strtoupper($claim->payerSequence()) .
 213     "*" . strtoupper($claim->insuredRelationship()) .
 214     "*" . strtoupper($claim->groupNumber()) .
 215     "*" . strtoupper($claim->groupName()) .
 216     "*" .
 217     "*" .
 218     "*" .
 219     "*" .
 220     "*" . $claim->claimType() .
 221     "~\n";
 222
 223   ++$edicount;
 224   $out .= "NM1" .       // Loop 2010BA Subscriber
 225     "*IL" .
 226     "*1" .
 227     "*" . strtoupper($claim->insuredLastName()) .
 228     "*" . strtoupper($claim->insuredFirstName()) .
 229     "*" . strtoupper($claim->insuredMiddleName()) .
 230     "*" .
 231     "*" .
 232     "*MI" .
 233     "*" . $claim->policyNumber() .
 234     "~\n";
 235
 236   ++$edicount;
 237   $out .= "N3" .
 238     "*" . strtoupper($claim->insuredStreet()) .
 239     "~\n";
 240
 241   ++$edicount;
 242   $out .= "N4" .
 243     "*" . strtoupper($claim->insuredCity()) .
 244     "*" . strtoupper($claim->insuredState()) .
 245     "*" . strtoupper($claim->insuredZip()) .
 246     "~\n";
 247
 248   ++$edicount;
 249   $out .= "DMG" .
 250     "*D8" .
 251     "*" . $claim->insuredDOB() .
 252     "*" . $claim->insuredSex() .
 253     "~\n";
 254
 255   ++$edicount;
 256   $out .= "NM1" .       // Loop 2010BB Payer
 257     "*PR" .
 258     "*2" .
 259     "*" . strtoupper($claim->payerName()) .
 260     "*" .
 261     "*" .
 262     "*" .
 263     "*" .
 264     "*PI" .
 265     "*" . $claim->payerID() .
 266     "~\n";
 267
 268   ++$edicount;
 269   $out .= "N3" .
 270     "*" . strtoupper($claim->payerStreet()) .
 271     "~\n";
 272
 273   ++$edicount;
 274   $out .= "N4" .
 275     "*" . strtoupper($claim->payerCity()) .
 276     "*" . strtoupper($claim->payerState()) .
 277     "*" . strtoupper($claim->payerZip()) .
 278     "~\n";
 279
 280   if (! $claim->isSelfOfInsured()) {
 281     ++$edicount;
 282     $out .= "HL" .        // Loop 2000C Patient Information
 283       "*$HLcount" .
 284       "*$HLSubscriber" .
 285       "*23" .
 286       "*0" .
 287       "~\n";
 288
 289     $HLcount++;
 290
 291     ++$edicount;
 292     $out .= "PAT" .
 293       "*" . $claim->insuredRelationship() .
 294       "~\n";
 295
 296     ++$edicount;
 297     $out .= "NM1" .       // Loop 2010CA Patient
 298       "*QC" .
 299       "*1" .
 300       "*" . strtoupper($claim->patientLastName()) .
 301       "*" . strtoupper($claim->patientFirstName()) .
 302       "*" . strtoupper($claim->patientMiddleName()) .
 303       "~\n";
 304
 305     ++$edicount;
 306     $out .= "N3" .
 307       "*" . strtoupper($claim->patientStreet()) .
 308       "~\n";
 309
 310     ++$edicount;
 311     $out .= "N4" .
 312       "*" . strtoupper($claim->patientCity()) .
 313       "*" . strtoupper($claim->patientState()) .
 314       "*" . strtoupper($claim->patientZip()) .
 315       "~\n";
 316
 317     ++$edicount;
 318     $out .= "DMG" .
 319       "*D8" .
 320       "*" . $claim->patientDOB() .
 321       "*" . $claim->patientSex() .
 322       "~\n";
 323   } // end of patient different from insured
 324
 325   $proccount = $claim->procCount();
 326
 327   $clm_total_charges = 0;
 328   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 329     $clm_total_charges += $claim->cptCharges($prockey);
 330   }
 331
 332   ++$edicount;
 333   $out .= "CLM" .       // Loop 2300 Claim
 334     "*$pid-$encounter" .
 335     "*" . sprintf("%.2f",$clm_total_charges) .
 336     "*" .
 337     "*" .
 338     "*" . $claim->facilityPOS() . "::1" .
 339     "*Y" .
 340     "*A" .
 341     "*Y" .
 342     "*Y" .
 343     "*C" .
 344     "~\n";
 345
 346   ++$edicount;
 347   $out .= "DTP" .       // Date of Onset
 348     "*431" .
 349     "*D8" .
 350     "*" . $claim->onsetDate() .
 351     "~\n";
 352
 353   if ($claim->facilityPOS() == '21') {
 354     ++$edicount;
 355     $out .= "DTP" .     // Date of Hospitalization
 356       "*435" .
 357       "*D8" .
 358       "*" . $claim->onsetDate() .
 359       "~\n";
 360   }
 361
 362   $patientpaid = $claim->patientPaidAmount();
 363   if ($patientpaid != 0) {
 364     ++$edicount;
 365     $out .= "AMT" .     // Patient paid amount. Page 220.
 366       "*F5" .
 367       "*" . $patientpaid .
 368       "~\n";
 369   }
 370
 371   if ($claim->priorAuth()) {
 372     ++$edicount;
 373     $out .= "REF" .     // Prior Authorization Number
 374       "*G1" .
 375       "*" . $claim->priorAuth() .
 376       "~\n";
 377   }
 378
 379   if ($claim->cliaCode()) {
 380     // Required by Medicare when in-house labs are done.
 381     ++$edicount;
 382     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 383       "*X4" .
 384       "*" . $claim->cliaCode() .
 385       "~\n";
 386   }
 387
 388   $da = $claim->diagArray();
 389   ++$edicount;
 390   $out .= "HI";         // Health Diagnosis Codes
 391   $diag_type_code = 'BK';
 392   foreach ($da as $diag) {
 393     $out .= "*$diag_type_code:" . $diag;
 394     $diag_type_code = 'BF';
 395   }
 396   $out .= "~\n";
 397
 398   if ($claim->referrerLastName()) {
 399     // Medicare requires referring provider's name and UPIN.
 400     ++$edicount;
 401     $out .= "NM1" .     // Loop 2310A Referring Provider
 402       "*DN" .
 403       "*1" .
 404       "*" . strtoupper($claim->referrerLastName()) .
 405       "*" . strtoupper($claim->referrerFirstName()) .
 406       "*" . strtoupper($claim->referrerMiddleName()) .
 407       "*" .
 408       "*";
 409     if ($claim->referrerNPI()) { $out .=
 410       "*XX" .
 411       "*" . $claim->referrerNPI();
 412     } else { $out .=
 413       "*34" .
 414       "*" . $claim->referrerSSN();
 415     }
 416     $out .= "~\n";
 417
 418     ++$edicount;
 419     $out .= "REF" .     // Referring Provider Secondary Identification
 420       "*1G" .
 421       "*" . strtoupper($claim->referrerUPIN()) .
 422       "~\n";
 423   }
 424
 425   ++$edicount;
 426   $out .= "NM1" .       // Loop 2310B Rendering Provider
 427     "*82" .
 428     "*1" .
 429     "*" . strtoupper($claim->providerLastName()) .
 430     "*" . strtoupper($claim->providerFirstName()) .
 431     "*" . strtoupper($claim->providerMiddleName()) .
 432     "*" .
 433     "*";
 434   if ($claim->providerNPI()) { $out .=
 435     "*XX" .
 436     "*" . $claim->providerNPI();
 437   } else { $out .=
 438     "*34" .
 439     "*" . $claim->providerSSN();
 440   }
 441   $out .= "~\n";
 442
 443   ++$edicount;
 444   $out .= "PRV" .       // Rendering Provider Information
 445     "*PE" .
 446     "*ZZ" .
 447     "*207Q00000X" .
 448     "~\n";
 449
 450   ++$edicount;
 451   $out .= "NM1" .       // Loop 2310B Service Location
 452     "*77" .
 453     "*2" .
 454     "*" . strtoupper($claim->facilityName()) .
 455     "*" .
 456     "*" .
 457     "*" .
 458     "*";
 459   if ($claim->facilityNPI()) { $out .=
 460     "*XX*" . $claim->facilityNPI();
 461   } else { $out .=
 462     "*24*" . $claim->facilityETIN();
 463   }
 464   $out .= "~\n";
 465
 466   ++$edicount;
 467   $out .= "N3" .
 468     "*" . strtoupper($claim->facilityStreet()) .
 469     "~\n";
 470
 471   ++$edicount;
 472   $out .= "N4" .
 473     "*" . strtoupper($claim->facilityCity()) .
 474     "*" . strtoupper($claim->facilityState()) .
 475     "*" . strtoupper($claim->facilityZip()) .
 476     "~\n";
 477
 478   // Loops 2320 and 2330*, other subscriber/payer information.
 479   //
 480   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 481
 482     ++$edicount;
 483     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 484       "*" . strtoupper($claim->payerSequence($ins)) .
 485       "*" . strtoupper($claim->insuredRelationship($ins)) .
 486       "*" . strtoupper($claim->groupNumber($ins)) .
 487       "*" . strtoupper($claim->groupName($ins)) .
 488       "*" .
 489       "*" .
 490       "*" .
 491       "*" .
 492       "*" . $claim->claimType($ins) .
 493       "~\n";
 494
 495     // Things that apply only to previous payers, not future payers.
 496     //
 497     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 498
 499       // Generate claim-level adjustments.
 500       $aarr = $claim->payerAdjustments($ins);
 501       foreach ($aarr as $a) {
 502         ++$edicount;
 503         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 504           "*" . $a[1] .
 505           "*" . $a[2] .
 506           "*" . $a[3] .
 507           "~\n";
 508       }
 509
 510       $payerpaid = $claim->payerPaidAmount($ins);
 511       ++$edicount;
 512       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 513         "*D" .
 514         "*" . $payerpaid .
 515         "~\n";
 516
 517       ++$edicount;
 518       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 519         "*F2" .
 520         "*" . sprintf('%.2f', $claim->invoiceTotal() - $payerpaid) .
 521         "~\n";
 522
 523     } // End of things that apply only to previous payers.
 524
 525     ++$edicount;
 526     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 527       "*" .
 528       "*" .
 529       "*Y" .
 530       "*B" .
 531       "*" .
 532       "*Y" .
 533       "~\n";
 534
 535     ++$edicount;
 536     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 537       "*IL" .
 538       "*1" .
 539       "*" . strtoupper($claim->insuredLastName($ins)) .
 540       "*" . strtoupper($claim->insuredFirstName($ins)) .
 541       "*" . strtoupper($claim->insuredMiddleName($ins)) .
 542       "*" .
 543       "*" .
 544       "*MI" .
 545       "*" . $claim->policyNumber($ins) .
 546       "~\n";
 547
 548     ++$edicount;
 549     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 550       "*PR" .
 551       "*2" .
 552       "*" . strtoupper($claim->payerName($ins)) .
 553       "*" .
 554       "*" .
 555       "*" .
 556       "*" .
 557       "*PI" .
 558       "*" . $claim->payerID($ins) .
 559       "~\n";
 560
 561   } // End loops 2320/2330*.
 562
 563   $loopcount = 0;
 564
 565   // Procedure loop starts here.
 566   //
 567   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 568     ++$loopcount;
 569
 570     ++$edicount;
 571     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 572       "*$loopcount" .
 573       "~\n";
 574
 575     ++$edicount;
 576     $out .= "SV1" .     // Professional Service. Page 400.
 577       "*HC:" . strtoupper($claim->cptCode($prockey));
 578     if ($claim->cptModifier($prockey)) { $out .=
 579       ":" . strtoupper($claim->cptModifier($prockey));
 580     }
 581     $out .=
 582       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 583       "*UN" .
 584       "*" . $claim->cptUnits($prockey) .
 585       "*" .
 586       "*" .
 587       "*" . $claim->diagIndex($prockey) .
 588       "~\n";
 589
 590     ++$edicount;
 591     $out .= "DTP" .     // Date of Service. Page 435.
 592       "*472" .
 593       "*D8" .
 594       "*" . $claim->serviceDate() .
 595       "~\n";
 596
 597     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 598     // with HCPCS codes.
 599     //
 600     if ($claim->cptNDCID($prockey))
 601       ++$edicount;
 602       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 603         "*4" .
 604         "*N4" .
 605         "*" . $claim->cptNDCID($prockey) .
 606         "~\n";
 607
 608       ++$edicount;
 609       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 610         "*" .
 611         "*" .
 612         "*0" . // dummy price, required by HIPAA
 613         "*" . $claim->cptNDCQuantity($prockey) .
 614         "*" . $claim->cptNDCUOM($prockey) .
 615         "~\n";
 616     }
 617
 618     // Loop 2430, adjudication by previous payers.
 619     //
 620     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 621       if ($claim->payerSequence($ins) > $claim->payerSequence())
 622         continue; // payer is future, not previous
 623
 624       ++$edicount;
 625       $out .= "SVD" . // Service line adjudication. Page 554.
 626         "*" . $claim->payerID($ins) .
 627         "*" . $claim->payerPaidAmount($ins, $claim->cptCode($prockey)) .
 628         "*HC:" . strtoupper($claim->cptCode($prockey));
 629       if ($claim->cptModifier($prockey)) $out .=
 630         ":" . strtoupper($claim->cptModifier($prockey));
 631       $out .=
 632         "*" .
 633         "*" . $claim->cptUnits($prockey) .
 634         "~\n";
 635
 636       $aarr = $claim->payerAdjustments($ins, $claim->cptCode($prockey));
 637       $tmpdate = '';
 638       foreach ($aarr as $a) {
 639         ++$edicount;
 640         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 641           "*" . $a[1] .
 642           "*" . $a[2] .
 643           "*" . $a[3] .
 644           "~\n";
 645         $tmpdate = $a[0];
 646       }
 647
 648       if ($tmpdate) {
 649         ++$edicount;
 650         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 651           "*573" .
 652           "*D8" .
 653           "*$tmpdate" .
 654           "~\n";
 655       }
 656     } // end loop 2430
 657   } // end this procedure
 658
 659   ++$edicount;
 660   $out .= "SE" .        // SE Trailer
 661     "*$edicount" .
 662     "*0021" .
 663     "~\n";
 664
 665   $out .= "GE" .        // GE Trailer
 666     "*1" .
 667     "*1" .
 668     "~\n";
 669
 670   $out .= "IEA" .       // IEA Trailer
 671     "*1" .
 672     "*000000001" .
 673     "~\n";
 674
 675   return $out;
 676 }
 677 ?>