interface/billing/sl_eob_process.php

   1 <?php
   2         // Copyright (C) 2006 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         // This processes X12 835 remittances and produces a report.
  10
  11         // Caveats:
  12         // Currently we assume that all 835's come from primary insurance, and
  13         // that secondary claims always go out on paper.  This should be made
  14         // more general at some point.  So far we have only tested with a
  15         // family practice clinic using Zirmed.
  16
  17         // Buffer all output so we can archive it to a file.
  18         ob_start();
  19
  20         include_once("../globals.php");
  21         include_once("../../library/invoice_summary.inc.php");
  22         include_once("../../library/sl_eob.inc.php");
  23         include_once("../../library/parse_era.inc.php");
  24         include_once("claim_status_codes.php");
  25         include_once("adjustment_reason_codes.php");
  26         include_once("remark_codes.php");
  27
  28         $debug = $_GET['debug'] ? 1 : 0; // set to 1 for debugging mode
  29         $encount = 0;
  30
  31         $last_ptname = '';
  32         $last_invnumber = '';
  33         $last_code = '';
  34         $invoice_total = 0.00;
  35
  36 ///////////////////////// Assorted Functions /////////////////////////
  37
  38         function parse_date($date) {
  39                 $date = substr(trim($date), 0, 10);
  40                 if (preg_match('/^(\d\d\d\d)(\d\d)(\d\d)$/', $date, $matches)) {
  41                         return $matches[1] . '-' . $matches[2] . '-' . $matches[3];
  42                 }
  43                 return '';
  44         }
  45
  46         function writeMessageLine($bgcolor, $class, $description) {
  47                 $dline =
  48                         " <tr bgcolor='$bgcolor'>\n" .
  49                         "  <td class='$class' colspan='4'>&nbsp;</td>\n" .
  50                         "  <td class='$class'>$description</td>\n" .
  51                         "  <td class='$class' colspan='2'>&nbsp;</td>\n" .
  52                         " </tr>\n";
  53                 echo $dline;
  54         }
  55
  56         function writeDetailLine($bgcolor, $class, $ptname, $invnumber,
  57                 $code, $date, $description, $amount, $balance)
  58         {
  59                 global $last_ptname, $last_invnumber, $last_code;
  60                 if ($ptname == $last_ptname) $ptname = '&nbsp;';
  61                         else $last_ptname = $ptname;
  62                 if ($invnumber == $last_invnumber) $invnumber = '&nbsp;';
  63                         else $last_invnumber = $invnumber;
  64                 if ($code == $last_code) $code = '&nbsp;';
  65                         else $last_code = $code;
  66                 if ($amount ) $amount  = sprintf("%.2f", $amount );
  67                 if ($balance) $balance = sprintf("%.2f", $balance);
  68                 $dline =
  69                         " <tr bgcolor='$bgcolor'>\n" .
  70                         "  <td class='$class'>$ptname</td>\n" .
  71                         "  <td class='$class'>$invnumber</td>\n" .
  72                         "  <td class='$class'>$code</td>\n" .
  73                         "  <td class='$class'>$date</td>\n" .
  74                         "  <td class='$class'>$description</td>\n" .
  75                         "  <td class='$class' align='right'>$amount</td>\n" .
  76                         "  <td class='$class' align='right'>$balance</td>\n" .
  77                         " </tr>\n";
  78                 echo $dline;
  79         }
  80
  81         // This writes detail lines that were already in SQL-Ledger for a given
  82         // charge item.
  83         //
  84         function writeOldDetail(&$prev, $ptname, $invnumber, $dos, $code, $bgcolor) {
  85                 global $invoice_total;
  86                 // $prev['total'] = 0.00; // to accumulate total charges
  87                 ksort($prev['dtl']);
  88                 foreach ($prev['dtl'] as $dkey => $ddata) {
  89                         $ddate = substr($dkey, 0, 10);
  90                         $description = $ddata['src'] . $ddata['rsn'];
  91                         if ($ddate == '          ') { // this is the service item
  92                                 $ddate = $dos;
  93                                 $description = 'Service Item';
  94                         }
  95                         $amount = sprintf("%.2f", $ddata['chg'] - $ddata['pmt']);
  96                         $invoice_total = sprintf("%.2f", $invoice_total + $amount);
  97                         writeDetailLine($bgcolor, 'olddetail', $ptname, $invnumber,
  98                                 $code, $ddate, $description, $amount, $invoice_total);
  99                 }
 100         }
 101
 102         // This is called back by parse_era() once per claim.
 103         //
 104         function era_callback(&$out) {
 105                 global $encount, $debug, $claim_status_codes, $adjustment_reasons, $remark_codes;
 106                 global $invoice_total;
 107                 // print_r($out); // debugging
 108
 109                 // Some heading information.
 110                 if ($encount == 0) {
 111                         writeMessageLine('#ffffff', 'infdetail',
 112                                 "Payer: " . htmlentities($out['payer_name']));
 113                         if ($debug) {
 114                                 writeMessageLine('#ffffff', 'infdetail',
 115                                         "WITHOUT UPDATE is selected; no changes will be applied.");
 116                         }
 117                 }
 118
 119                 $invoice_total = 0.00;
 120                 $bgcolor = (++$encount & 1) ? "#ddddff" : "#ffdddd";
 121                 list($pid, $encounter, $invnumber) = slInvoiceNumber($out);
 122
 123                 // Get details, if we have them, for the invoice.
 124                 $inverror = true;
 125                 $codes = array();
 126                 if ($pid && $encounter) {
 127                         // Get invoice data into $arrow.
 128                         $arres = SLQuery("SELECT ar.id, ar.notes, ar.shipvia, customer.name " .
 129                                 "FROM ar, customer WHERE ar.invnumber = '$invnumber' AND " .
 130                                 "customer.id = ar.customer_id");
 131                         if ($sl_err) die($sl_err);
 132                         $arrow = SLGetRow($arres, 0);
 133                         if ($arrow) {
 134                                 $inverror = false;
 135                                 $codes = get_invoice_summary($arrow['id'], true);
 136                         } else { // oops, no such invoice
 137                                 $pid = $encounter = 0;
 138                                 $invnumber = $out['our_claim_id'];
 139                         }
 140                 }
 141
 142                 // Show the claim status.
 143                 $csc = $out['claim_status_code'];
 144                 writeMessageLine($bgcolor, 'infdetail',
 145                         "Claim status $csc: " . $claim_status_codes[$csc]);
 146
 147                 // Show an error message if the claim is missing or already posted.
 148                 if ($inverror) {
 149                         writeMessageLine($bgcolor, 'errdetail',
 150                                 "The following claim is not in our database");
 151                 }
 152                 else {
 153                         $insdone = strtolower($arrow['shipvia']);
 154                         if (strpos($insdone, 'ins1') !== false) {
 155                                 $inverror = true;
 156                                 writeMessageLine($bgcolor, 'errdetail',
 157                                         "Primary insurance EOB was already posted for the following claim");
 158                         }
 159                 }
 160
 161                 if ($out['warnings']) {
 162                         writeMessageLine($bgcolor, 'errdetail', nl2br(rtrim($out['warnings'])));
 163                 }
 164
 165                 // Simplify some claim attributes for cleaner code.
 166                 $service_date = parse_date($out['dos']);
 167                 $check_date = parse_date($out['check_date']);
 168                 $production_date = parse_date($out['production_date']);
 169                 $patient_name = $arrow['name'] ? $arrow['name'] :
 170                         ($out['patient_fname'] . ' ' . $out['patient_lname']);
 171
 172                 // This loops once for each service item in this claim.
 173                 foreach ($out['svc'] as $svc) {
 174                         $error = $inverror;
 175                         $prev = $codes[$svc['code']];
 176
 177                         // This reports detail lines already on file for this service item.
 178                         if ($prev) {
 179                                 writeOldDetail($prev, $patient_name, $invnumber, $service_date, $svc['code'], $bgcolor);
 180                                 // Check for sanity in amount charged.
 181                                 $prevchg = sprintf("%.2f", $prev['chg'] + $prev['adj']);
 182                                 if ($prevchg != $svc['chg']) {
 183                                         writeMessageLine($bgcolor, 'errdetail',
 184                                                 "EOB charge amount " . $svc['chg'] . " for this code does not match our invoice");
 185                                         $error = true;
 186                                 }
 187                                 // Check for duplicate payment.  Should not happen.
 188                                 foreach ($prev['dtl'] as $dkey => $ddata) {
 189                                         if (! $ddata['pmt']) continue;
 190                                         $ddate = parse_date($dkey);
 191                                         if ($ddate == $check_date && $ddata['pmt'] == $svc['paid']) {
 192                                                 writeMessageLine($bgcolor, 'errdetail',
 193                                                         "This payment dated $check_date seems to be already posted!");
 194                                                 $error = true;
 195                                         }
 196                                 }
 197                                 unset($codes[$svc['code']]);
 198                         }
 199
 200                         // Or if the service item is not in our database, show it in red for
 201                         // manual resolution.  Probably what happened is that the billing was
 202                         // "corrected" in OpenEMR after the claim was generated... not good!
 203                         else {
 204                                 writeDetailLine($bgcolor, 'errdetail', $patient_name, $invnumber,
 205                                         $svc['code'], $service_date, '*** UNMATCHED SERVICE ITEM ***',
 206                                         $svc['chg'], '');
 207                                 $error = true;
 208                         }
 209
 210                         $class = $error ? 'errdetail' : 'newdetail';
 211
 212                         // Report Allowed Amount.
 213                         if ($svc['allowed']) {
 214                                 // A problem here is that some payers will include an adjustment
 215                                 // reflecting the allowed amount, others not.  So here we need to
 216                                 // check if the adjustment exists, and if not then create it.  We
 217                                 // assume that any nonzero CO (Contractual Obligation) adjustment
 218                                 // is good enough.
 219                                 $contract_adj = sprintf("%.2f", $svc['chg'] - $svc['allowed']);
 220                                 foreach ($svc['adj'] as $adj) {
 221                                         if ($adj['group_code'] == 'CO' && $adj['amount'] != 0)
 222                                                 $contract_adj = 0;
 223                                 }
 224                                 if ($contract_adj > 0) {
 225                                         $svc['adj'][] = array('group_code' => 'CO', 'reason_code' => 'A2',
 226                                                 'amount' => $contract_adj);
 227                                 }
 228                                 writeMessageLine($bgcolor, 'infdetail',
 229                                         'Allowed amount is ' . sprintf("%.2f", $svc['allowed']));
 230                         }
 231
 232                         // Report miscellaneous remarks.
 233                         if ($svc['remark']) {
 234                                 $rmk = $svc['remark'];
 235                                 writeMessageLine($bgcolor, 'infdetail', "$rmk: " . $remark_codes[$rmk]);
 236                         }
 237
 238                         // Post and report the payment for this service item from the ERA.
 239                         if ($svc['paid']) {
 240                                 if (!$error && !$debug) {
 241                                         slPostPayment($arrow['id'], $svc['paid'], $check_date,
 242                                                 'Ins1/' . $out['check_number'], $svc['code'], $prev['ins'], $debug);
 243                                         $invoice_total -= $svc['paid'];
 244                                 }
 245                                 writeDetailLine($bgcolor, $class, $patient_name, $invnumber,
 246                                         $svc['code'], $check_date, 'Ins1/' . $out['check_number'] . ' payment',
 247                                         0 - $svc['paid'], ($error ? '' : $invoice_total));
 248                         }
 249
 250                         // Post and report adjustments from this ERA.  Posted adjustment reasons
 251                         // must be 25 characters or less in order to fit on patient statements.
 252                         foreach ($svc['adj'] as $adj) {
 253                                 $description = $adj['reason_code'] . ': ' . $adjustment_reasons[$adj['reason_code']];
 254                                 // Group code PR is Patient Responsibility.  Enter these as zero
 255                                 // adjustments to retain the note without crediting the claim.
 256                                 if ($adj['group_code'] == 'PR') {
 257                                         $reason = 'Pt resp: '; // Reasons should be 25 chars or less.
 258                                         if ($adj['reason_code'] == '1') $reason = 'To deductible: ';
 259                                         else if ($adj['reason_code'] == '2') $reason = 'Coinsurance: ';
 260                                         else if ($adj['reason_code'] == '3') $reason = 'Co-pay: ';
 261                                         $reason .= sprintf("%.2f", $adj['amount']);
 262                                         if (!$error && !$debug) {
 263                                                 slPostAdjustment($arrow['id'], 0, $production_date,
 264                                                         $out['check_number'], $svc['code'], $prev['ins'],
 265                                                         $reason, $debug);
 266                                         }
 267                                         writeMessageLine($bgcolor, $class, $description . ' ' .
 268                                                 sprintf("%.2f", $adj['amount']));
 269                                 }
 270                                 // Other group codes are real adjustments.
 271                                 else {
 272                                         if (!$error && !$debug) {
 273                                                 slPostAdjustment($arrow['id'], $adj['amount'], $production_date,
 274                                                         $out['check_number'], $svc['code'], $prev['ins'],
 275                                                         'Ins1 adjust code ' . $adj['reason_code'], $debug);
 276                                                 $invoice_total -= $adj['amount'];
 277                                         }
 278                                         writeDetailLine($bgcolor, $class, $patient_name, $invnumber,
 279                                                 $svc['code'], $production_date, $description,
 280                                                 0 - $adj['amount'], ($error ? '' : $invoice_total));
 281                                 }
 282                         }
 283
 284                 } // End of service item
 285
 286                 // Report any existing service items not mentioned in the ERA.
 287                 foreach ($codes as $code => $prev) {
 288                         writeOldDetail($prev, $arrow['name'], $invnumber, $service_date, $code, $bgcolor);
 289                 }
 290
 291                 // Cleanup: If all is well, mark Ins1 done and check for secondary billing.
 292                 if (!$error && !$debug) {
 293                         // Mark Ins1 done.
 294                         $query = "UPDATE ar SET shipvia = 'Done: Ins1' WHERE id = " . $arrow['id'];
 295                         SLQuery($query);
 296                         if ($sl_err) die($sl_err);
 297                         // Check for secondary insurance.
 298                         $insgot = strtolower($arrow['notes']);
 299                         if (strpos($insgot, 'ins2') !== false) {
 300                                 slSetupSecondary($arrow['id'], $debug);
 301                                 writeMessageLine($bgcolor, 'infdetail',
 302                                         'This claim is now re-queued for secondary paper billing');
 303                         }
 304                 }
 305
 306         }
 307
 308 /////////////////////////// End Functions ////////////////////////////
 309
 310         $info_msg = "";
 311
 312         $eraname = $_GET['eraname'];
 313         if (! $eraname) die(xl("You cannot access this page directly."));
 314
 315         // Open the output file early so that in case it fails, we do not post a
 316         // bunch of stuff without saving the report.  Also be sure to retain any old
 317         // report files.  Do not save the report if this is a no-update situation.
 318         //
 319         if (!$debug) {
 320                 $nameprefix = "$webserver_root/era/$eraname";
 321                 $namesuffix = '';
 322                 for ($i = 1; is_file("$nameprefix$namesuffix.html"); ++$i) {
 323                         $namesuffix = "_$i";
 324                 }
 325                 $fnreport = "$nameprefix$namesuffix.html";
 326                 $fhreport = fopen($fnreport, 'w');
 327                 if (!$fhreport) die(xl("Cannot create") . " '$fnreport'");
 328         }
 329
 330         slInitialize();
 331 ?>
 332 <html>
 333 <head>
 334 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
 335 <style type="text/css">
 336  body       { font-family:sans-serif; font-size:8pt; font-weight:normal }
 337  .dehead    { color:#000000; font-family:sans-serif; font-size:9pt; font-weight:bold }
 338  .olddetail { color:#000000; font-family:sans-serif; font-size:9pt; font-weight:normal }
 339  .newdetail { color:#00dd00; font-family:sans-serif; font-size:9pt; font-weight:normal }
 340  .errdetail { color:#dd0000; font-family:sans-serif; font-size:9pt; font-weight:normal }
 341  .infdetail { color:#0000ff; font-family:sans-serif; font-size:9pt; font-weight:normal }
 342 </style>
 343 <title><?xl('EOB Posting - Electronic Remittances','e')?></title>
 344 <script language="JavaScript">
 345 </script>
 346 </head>
 347 <body leftmargin='0' topmargin='0' marginwidth='0' marginheight='0'>
 348 <center>
 349
 350 <table border='0' cellpadding='2' cellspacing='0' width='100%'>
 351
 352  <tr bgcolor="#cccccc">
 353   <td class="dehead">
 354    <?php xl('Patient','e') ?>
 355   </td>
 356   <td class="dehead">
 357    <?php xl('Invoice','e') ?>
 358   </td>
 359   <td class="dehead">
 360    <?php xl('Code','e') ?>
 361   </td>
 362   <td class="dehead">
 363    <?php xl('Date','e') ?>
 364   </td>
 365   <td class="dehead">
 366    <?php xl('Description','e') ?>
 367   </td>
 368   <td class="dehead" align="right">
 369    <?php xl('Amount','e') ?>&nbsp;
 370   </td>
 371   <td class="dehead" align="right">
 372    <?php xl('Balance','e') ?>&nbsp;
 373   </td>
 374  </tr>
 375
 376 <?php
 377   $alertmsg = parse_era("$webserver_root/era/$eraname.edi", 'era_callback');
 378   slTerminate();
 379 ?>
 380 </table>
 381 </center>
 382 <script language="JavaScript">
 383 <?php
 384         if ($alertmsg) echo " alert('" . htmlentities($alertmsg) . "');\n";
 385 ?>
 386 </script>
 387 </body>
 388 </html>
 389 <?php
 390         // Save all of this script's output to a report file.
 391         if (!$debug) {
 392                 fwrite($fhreport, ob_get_contents());
 393                 fclose($fhreport);
 394         }
 395         ob_end_flush();
 396 ?>