interface/billing/sl_eob_invoice.php

   1 <?php
   2 /**
   3  * This provides for manual posting of EOBs.  It is invoked from
   4  * sl_eob_search.php.  For automated (X12 835) remittance posting
   5  * see sl_eob_process.php.
   6  *
   7  * Copyright (C) 2005-2016 Rod Roark <rod@sunsetsystems.com>
   8  *
   9  * LICENSE: This program is free software; you can redistribute it and/or
  10  * modify it under the terms of the GNU General Public License
  11  * as published by the Free Software Foundation; either version 2
  12  * of the License, or (at your option) any later version.
  13  * This program is distributed in the hope that it will be useful,
  14  * but WITHOUT ANY WARRANTY; without even the implied warranty of
  15  * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
  16  * GNU General Public License for more details.
  17  * You should have received a copy of the GNU General Public License
  18  * along with this program. If not, see <http://opensource.org/licenses/gpl-license.php>;.
  19  *
  20  * @package OpenEMR
  21  * @author  Rod Roark <rod@sunsetsystems.com>
  22  * @author  Roberto Vasquez <robertogagliotta@gmail.com>
  23  * @author  Terry Hill <terry@lillysystems.com>
  24  * @author  Jerry Padgett <sjpadgett@gmail.com>
  25  * @link    http://www.open-emr.org
  26  */
  27
  28
  29 require_once("../globals.php");
  30 require_once("$srcdir/log.inc");
  31 require_once("$srcdir/patient.inc");
  32 require_once("$srcdir/forms.inc");
  33 require_once("$srcdir/sl_eob.inc.php");
  34 require_once("$srcdir/invoice_summary.inc.php");
  35 require_once("../../custom/code_types.inc.php");
  36
  37 use OpenEMR\Core\Header;
  38
  39 $debug = 0; // set to 1 for debugging mode
  40 $save_stay = $_REQUEST['form_save'] == '1' ? true : false;
  41
  42 // If we permit deletion of transactions.  Might change this later.
  43 $ALLOW_DELETE = true;
  44
  45 $info_msg = "";
  46
  47 // Format money for display.
  48 //
  49 function bucks($amount)
  50 {
  51     if ($amount) {
  52         return sprintf("%.2f", $amount);
  53     }
  54 }
  55
  56 // Delete rows, with logging, for the specified table using the
  57 // specified WHERE clause.  Borrowed from deleter.php.
  58 //
  59 function row_delete($table, $where)
  60 {
  61     $tres = sqlStatement("SELECT * FROM $table WHERE $where");
  62     $count = 0;
  63     while ($trow = sqlFetchArray($tres)) {
  64         $logstring = "";
  65         foreach ($trow as $key => $value) {
  66             if (!$value || $value == '0000-00-00 00:00:00') {
  67                 continue;
  68             }
  69
  70             if ($logstring) {
  71                 $logstring .= " ";
  72             }
  73
  74             $logstring .= $key . "='" . addslashes($value) . "'";
  75         }
  76
  77         newEvent("delete", $_SESSION['authUser'], $_SESSION['authProvider'], 1, "$table: $logstring");
  78         ++$count;
  79     }
  80
  81     if ($count) { // Lets not echo the query for stay and save
  82         $query = "DELETE FROM $table WHERE $where";
  83         sqlStatement($query);
  84     }
  85 }
  86
  87 ?>
  88 <html>
  89 <head>
  90     <?php Header::setupHeader(['datetime-picker']); ?>
  91     <title><?php echo xlt('EOB Posting - Invoice') ?></title>
  92     <script language="JavaScript">
  93     var adjDisable = opener.document.forms[0].posting_adj_disable.checked;
  94
  95         // An insurance radio button is selected.
  96         function setins(istr) {
  97             return true;
  98         }
  99
 100         function refreshOpener() {
 101             opener.location.reload();
 102             window.close();
 103         }
 104
 105         // Compute an adjustment that writes off the balance:
 106         function writeoff(code) {
 107             var f = document.forms[0];
 108             var belement = f['form_line[' + code + '][bal]'];
 109             var pelement = f['form_line[' + code + '][pay]'];
 110             var aelement = f['form_line[' + code + '][adj]'];
 111             var relement = f['form_line[' + code + '][reason]'];
 112             var tmp = belement.value - pelement.value;
 113             aelement.value = Number(tmp).toFixed(2);
 114             if (aelement.value && !relement.value) relement.selectedIndex = 1;
 115             return false;
 116         }
 117
 118         // Onsubmit handler.  A good excuse to write some JavaScript.
 119         function validate(f) {
 120             let delcount = 0;
 121             let allempty = true;
 122             adjDisable = opener.document.forms[0].posting_adj_disable.checked;
 123
 124             for (var i = 0; i < f.elements.length; ++i) {
 125                 let ename = f.elements[i].name;
 126 // Count deletes.
 127                 if (ename.substring(0, 9) == 'form_del[') {
 128                     if (f.elements[i].checked) ++delcount;
 129                     continue;
 130                 }
 131                 let pfxlen = ename.indexOf('[pay]');
 132                 if (pfxlen < 0) continue;
 133                 let pfx = ename.substring(0, pfxlen);
 134                 let code = pfx.substring(pfx.indexOf('[') + 1, pfxlen - 1);
 135                 let cPay = parseFloat(f[pfx + '[pay]'].value).toFixed(2);
 136                 let cAdjust = parseFloat(f[pfx + '[adj]'].value).toFixed(2);
 137
 138                 if ((cPay != 0) || cAdjust != 0) {
 139                     allempty = false;
 140                 }
 141                 if(adjDisable) {
 142                     if ((cAdjust == 0 && f[pfx + '[reason]'].value)) {
 143                         allempty = false;
 144                     }
 145                 }
 146                 if ((cPay != 0) && isNaN(parseFloat(f[pfx + '[pay]'].value))) {
 147                     alert('<?php echo xls('Payment value for code ') ?>' + code + '<?php echo xls(' is not a number') ?>');
 148                     return false;
 149                 }
 150                 if ((cAdjust != 0) && isNaN(parseFloat(f[pfx + '[adj]'].value))) {
 151                     alert('<?php echo xls('Adjustment value for code ') ?>' + code + '<?php echo xls(' is not a number') ?>');
 152                     return false;
 153                 }
 154                 if ((cAdjust != 0) && !f[pfx + '[reason]'].value) {
 155                     alert('<?php echo xls('Please select an adjustment reason for code ') ?>' + code);
 156                     return false;
 157                 }
 158 // TBD: validate the date format
 159             }
 160 // Check if save is clicked with nothing to post.
 161             if (allempty && delcount === 0) {
 162                 alert('<?php echo xls('Nothing to Post! Please review entries or use Cancel to exit transaction')?>');
 163                 return false;
 164             }
 165 // Demand confirmation if deleting anything.
 166             if (delcount > 0) {
 167                 if (!confirm('<?php echo xls('Really delete'); ?> ' + delcount +
 168                     ' <?php echo xls('transactions'); ?>?' +
 169                     ' <?php echo xls('This action will be logged'); ?>!')
 170                 ) return false;
 171             }
 172             return true;
 173         }
 174
 175         <!-- Get current date -->
 176
 177         function getFormattedToday() {
 178             let today = new Date();
 179             let dd = today.getDate();
 180             let mm = today.getMonth() + 1; //January is 0!
 181             let yyyy = today.getFullYear();
 182             if (dd < 10) {
 183                 dd = '0' + dd
 184             }
 185             if (mm < 10) {
 186                 mm = '0' + mm
 187             }
 188
 189             return (yyyy + '-' + mm + '-' + dd);
 190         }
 191
 192         <!-- Update Payment Fields -->
 193
 194         function updateFields(payField, adjField, balField, coPayField, isFirstProcCode) {
 195             let payAmount = 0.0;
 196             let adjAmount = 0.0;
 197             let balAmount = 0.0;
 198             let coPayAmount = 0.0;
 199
 200 // coPayFiled will be null if there is no co-pay entry in the fee sheet
 201             if (coPayField)
 202                 coPayAmount = coPayField.value;
 203
 204 // if balance field is 0.00, its value comes back as null, so check for nul-ness first
 205             if (balField)
 206                 balAmount = (balField.value) ? balField.value : 0;
 207             if (payField)
 208                 payAmount = (payField.value) ? payField.value : 0;
 209
 210 //alert('balance = >' + balAmount +'<  payAmount = ' + payAmount + '  copay = ' + coPayAmount + '  isFirstProcCode = ' + isFirstProcCode);
 211
 212 // subtract the co-pay only from the first procedure code
 213             if (isFirstProcCode == 1)
 214                 balAmount = parseFloat(balAmount) + parseFloat(coPayAmount);
 215             let adjDisable = opener.document.forms[0].posting_adj_disable.checked;
 216             if (adjDisable) return;
 217
 218             adjAmount = balAmount - payAmount;
 219 // Assign rounded adjustment value back to TextField
 220             adjField.value = adjAmount = Math.round(adjAmount * 100) / 100;
 221         }
 222
 223         $(document).ready(function () {
 224             $('.datepicker').datetimepicker({
 225                 <?php $datetimepicker_timepicker = false; ?>
 226                 <?php $datetimepicker_showseconds = false; ?>
 227                 <?php $datetimepicker_formatInput = false; ?>
 228                 <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 229                 <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 230             });
 231         });
 232
 233     </script>
 234     <style>
 235         @media only screen and (max-width: 768px) {
 236             [class*="col-"] {
 237                 width: 100%;
 238                 text-align: left !Important;
 239             }
 240         }
 241
 242         .table {
 243             margin: auto;
 244             width: 99%;
 245         }
 246
 247         .table > tbody > tr > td {
 248             border-top: none;
 249         }
 250
 251         .last_detail {
 252             border-bottom: 1px black solid;
 253             margin-top: 2px;
 254         }
 255
 256         @media (min-width: 992px) {
 257             .modal-lg {
 258                 width: 1000px !Important;
 259             }
 260         }
 261
 262         /*.modalclass {
 263         overflow-x: hidden !Important;
 264         }
 265         .oe-ckbox-label{
 266         padding-left: 30px;
 267         font-weight: 500;
 268         }*/
 269     </style>
 270 </head>
 271 <body>
 272 <?php
 273 $trans_id = 0 + $_GET['id'];
 274 if (!$trans_id) {
 275     die(xlt("You cannot access this page directly."));
 276 }
 277
 278 // A/R case, $trans_id matches form_encounter.id.
 279 $ferow = sqlQuery("SELECT e.*, p.fname, p.mname, p.lname FROM form_encounter AS e, patient_data AS p WHERE e.id = ? AND p.pid = e.pid", array($trans_id));
 280 if (empty($ferow)) {
 281     die("There is no encounter with form_encounter.id = '" . text($trans_id) . "'.");
 282 }
 283 $patient_id = 0 + $ferow['pid'];
 284 $encounter_id = 0 + $ferow['encounter'];
 285 $svcdate = substr($ferow['date'], 0, 10);
 286 $form_payer_id = 0 + $_POST['form_payer_id'];
 287 $form_reference = $_POST['form_reference'];
 288 $form_check_date = fixDate($_POST['form_check_date'], date('Y-m-d'));
 289 $form_deposit_date = fixDate($_POST['form_deposit_date'], $form_check_date);
 290 $form_pay_total = 0 + $_POST['form_pay_total'];
 291
 292 $payer_type = 0;
 293 if (preg_match('/^Ins(\d)/i', $_POST['form_insurance'], $matches)) {
 294     $payer_type = $matches[1];
 295 }
 296
 297 if (($_POST['form_save'] || $_POST['form_cancel'])) {
 298     if ($_POST['form_save']) {
 299         if (!verifyCsrfToken($_POST["csrf_token_form"])) {
 300             die(xlt('Authentication Error'));
 301         }
 302
 303         if ($debug) {
 304             echo "<p><b>" . xlt("This module is in test mode. The database will not be changed.") . "</b><p>\n";
 305         }
 306
 307         $session_id = arGetSession($form_payer_id, $form_reference, $form_check_date, $form_deposit_date, $form_pay_total);
 308 // The sl_eob_search page needs its invoice links modified to invoke
 309 // javascript to load form parms for all the above and submit.
 310 // At the same time that page would be modified to work off the
 311 // openemr database exclusively.
 312 // And back to the sl_eob_invoice page, I think we may want to move
 313 // the source input fields from row level to header level.
 314
 315 // Handle deletes. row_delete() is borrowed from deleter.php.
 316         if ($ALLOW_DELETE && !$debug) {
 317             if (is_array($_POST['form_del'])) {
 318                 foreach ($_POST['form_del'] as $arseq => $dummy) {
 319                     row_delete("ar_activity", "pid = '" . add_escape_custom($patient_id) . "' AND " . "encounter = '" . add_escape_custom($encounter_id) . "' AND sequence_no = '" . add_escape_custom($arseq) . "'");
 320                 }
 321             }
 322         }
 323
 324         $paytotal = 0;
 325         foreach ($_POST['form_line'] as $code => $cdata) {
 326             $thispay = trim($cdata['pay']);
 327             $thisadj = trim($cdata['adj']);
 328             $thisins = trim($cdata['ins']);
 329             $thiscodetype = trim($cdata['code_type']);
 330             $reason = $cdata['reason'];
 331
 332 // Get the adjustment reason type.  Possible values are:
 333 // 1 = Charge adjustment
 334 // 2 = Coinsurance
 335 // 3 = Deductible
 336 // 4 = Other pt resp
 337 // 5 = Comment
 338             $reason_type = '1';
 339             if ($reason) {
 340                 $tmp = sqlQuery("SELECT option_value FROM list_options WHERE list_id = 'adjreason' AND activity = 1 AND option_id = ?", array($reason));
 341                 if (empty($tmp['option_value'])) {
 342 // This should not happen but if it does, apply old logic.
 343                     if (preg_match("/To copay/", $reason)) {
 344                         $reason_type = 2;
 345                     } elseif (preg_match("/To ded'ble/", $reason)) {
 346                         $reason_type = 3;
 347                     }
 348                     $info_msg .= xl("No adjustment reason type found for") . " \"$reason\". ";
 349                 } else {
 350                     $reason_type = $tmp['option_value'];
 351                 }
 352             }
 353
 354             if (!$thisins) {
 355                 $thisins = 0;
 356             }
 357
 358             if (0.0 + $thispay) {
 359                 arPostPayment($patient_id, $encounter_id, $session_id, $thispay, $code, $payer_type, '', $debug, '', $thiscodetype);
 360                 $paytotal += $thispay;
 361             }
 362
 363 // Be sure to record adjustment reasons, even for zero adjustments if
 364 // they happen to be comments.
 365             if ((0.0 + $thisadj) ||
 366                 ($reason && $reason_type == 5) ||
 367                 ($reason && ($reason_type > 1 && $reason_type < 6))) {
 368 // "To copay" and "To ded'ble" need to become a comment in a zero
 369 // adjustment, formatted just like sl_eob_process.php.
 370                 if ($reason_type == '2') {
 371                     $reason = $_POST['form_insurance'] . " coins: $thisadj";
 372                     $thisadj = 0;
 373                 } elseif ($reason_type == '3') {
 374                     $reason = $_POST['form_insurance'] . " dedbl: $thisadj";
 375                     $thisadj = 0;
 376                 } elseif ($reason_type == '4') {
 377                     $reason = $_POST['form_insurance'] . " ptresp: $thisadj $reason";
 378                     $thisadj = 0;
 379                 } elseif ($reason_type == '5') {
 380                     $reason = $_POST['form_insurance'] . " note: $thisadj $reason";
 381                     $thisadj = 0;
 382                 } else {
 383 // An adjustment reason including "Ins" is assumed to be assigned by
 384 // insurance, and in that case we identify which one by appending
 385 // Ins1, Ins2 or Ins3.
 386                     if (strpos(strtolower($reason), 'ins') != false) {
 387                         $reason .= ' ' . $_POST['form_insurance'];
 388                     }
 389                 }
 390                 arPostAdjustment($patient_id, $encounter_id, $session_id, $thisadj, $code, $payer_type, $reason, $debug, '', $thiscodetype);
 391             }
 392         }
 393
 394 // Maintain which insurances are marked as finished.
 395
 396         $form_done = 0 + $_POST['form_done'];
 397         $form_stmt_count = 0 + $_POST['form_stmt_count'];
 398         sqlStatement("UPDATE form_encounter SET last_level_closed = ?, stmt_count = ? WHERE pid = ? AND encounter = ?", array($form_done, $form_stmt_count, $patient_id, $encounter_id));
 399
 400         if ($_POST['form_secondary']) {
 401             arSetupSecondary($patient_id, $encounter_id, $debug);
 402         }
 403         echo "<script language='JavaScript'>\n";
 404         echo " if (opener.document.forms[0] != undefined) {\n";
 405         echo "   if (opener.document.forms[0].form_amount) {\n";
 406         echo "     var tmp = opener.document.forms[0].form_amount.value - " . attr($paytotal) . ";\n";
 407         echo "     opener.document.forms[0].form_amount.value = Number(tmp).toFixed(2);\n";
 408         echo "   }\n";
 409         echo " }\n";
 410     } else {
 411         echo "<script language='JavaScript'>\n";
 412     }
 413     if ($info_msg) {
 414         echo " alert('" . addslashes($info_msg) . "');\n";
 415     }
 416     echo "opener.location.reload();";
 417     if (!$debug && !$save_stay) {
 418         echo " window.close();\n";
 419     } else {
 420         $reload_url = "sl_eob_invoice.php?id=" . attr(urlencode($trans_id));
 421         echo "window.location.assign('" . $reload_url . "')";
 422     }
 423     echo "</script></body></html>\n";
 424     if (!$save_stay) {
 425         exit();
 426     }
 427 }
 428
 429 // Get invoice charge details.
 430 $codes = ar_get_invoice_summary($patient_id, $encounter_id, true);
 431 $pdrow = sqlQuery("select billing_note from patient_data where pid = ? limit 1", array($patient_id));
 432 ?>
 433
 434 <div class="container">
 435     <div class="row">
 436         <div class="page-header">
 437             <h2><?php echo xlt('EOB Invoice'); ?></h2>
 438         </div>
 439     </div>
 440     <div class="row">
 441         <form action='sl_eob_invoice.php?id=<?php echo attr(urlencode($trans_id)); ?>' method='post'
 442               onsubmit='return validate(this)'>
 443             <input type="hidden" name="csrf_token_form" value="<?php echo attr(collectCsrfToken()); ?>"/>
 444             <fieldset>
 445                 <legend><?php echo xlt('Invoice Actions'); ?></legend>
 446                 <div class="col-xs-12 oe-custom-line">
 447                     <div class="col-xs-3">
 448                         <label class="control-label" for="form_name"><?php echo xlt('Patient'); ?>:</label>
 449                         <input type="text" class="form-control" class="form-control" class="form-control" id='form_name'
 450                                name='form_name'
 451                                value="<?php echo attr($ferow['fname']) . ' ' . attr($ferow['mname']) . ' ' . attr($ferow['lname']); ?>"
 452                                disabled>
 453                     </div>
 454                     <div class="col-xs-3">
 455                         <label class="control-label" for="form_provider"><?php echo xlt('Provider'); ?>:</label>
 456                         <?php
 457                         $tmp = sqlQuery("SELECT fname, mname, lname " .
 458                             "FROM users WHERE id = ?", array($ferow['provider_id']));
 459                         $provider = text($tmp['fname']) . ' ' . text($tmp['mname']) . ' ' . text($tmp['lname']);
 460                         $tmp = sqlQuery("SELECT bill_date FROM billing WHERE " .
 461                             "pid = ? AND encounter = ? AND " .
 462                             "activity = 1 ORDER BY fee DESC, id ASC LIMIT 1", array($patient_id, $encounter_id));
 463                         $billdate = substr(($tmp['bill_date'] . "Not Billed"), 0, 10);
 464                         ?>
 465                         <input type="text" class="form-control" class="form-control" id='form_provider'
 466                                name='form_provider' value="<?php echo attr($provider); ?>" disabled>
 467                     </div>
 468                     <div class="col-xs-2">
 469                         <label class="control-label" for="form_invoice"><?php echo xlt('Invoice'); ?>:</label>
 470                         <input type="text" class="form-control" class="form-control" id='form_provider'
 471                                name='form_provider' value='<?php echo attr($patient_id) . "." . attr($encounter_id); ?>'
 472                                disabled>
 473                     </div>
 474                     <div class="col-xs-2">
 475                         <label class="control-label" for="svc_date"><?php echo xlt('Svc Date'); ?>:</label>
 476                         <input type="text" class="form-control" class="form-control" id='svc_date' name='form_provider'
 477                                value='<?php echo attr($svcdate); ?>' disabled>
 478                     </div>
 479                     <div class="col-xs-2">
 480                         <label class="control-label" for="insurance_name"><?php echo xlt('Insurance'); ?>:</label>
 481                         <?php
 482                         for ($i = 1; $i <= 3; ++$i) {
 483                             $payerid = arGetPayerID($patient_id, $svcdate, $i);
 484                             if ($payerid) {
 485                                 $tmp = sqlQuery("SELECT name FROM insurance_companies WHERE id = ?", array($payerid));
 486                                 $insurance .= "$i: " . $tmp['name'] . "\n";
 487                             }
 488                         }
 489                         ?>
 490                         <textarea name="insurance_name" id="insurance_name" class="form-control" cols="5" rows="2"
 491                                   readonly><?php echo attr($insurance); ?></textarea>
 492                     </div>
 493                 </div>
 494                 <div class="col-xs-12 oe-custom-line">
 495                     <div class="col-xs-3">
 496                         <label class="control-label" for="form_stmt_count"><?php echo xlt('Statements Sent'); ?>
 497                             :</label>
 498                         <input type='text' name='form_stmt_count' id='form_stmt_count' class="form-control"
 499                                value='<?php echo attr((0 + $ferow['stmt_count'])); ?>'/>
 500                     </div>
 501                     <div class="col-xs-3">
 502                         <label class="control-label" for="form_reference"><?php echo xlt('Check/EOB No.'); ?>:</label>
 503                         <input type='text' name='form_reference' id='form_reference' class="form-control" value=''/>
 504                     </div>
 505                     <div class="col-xs-2">
 506                         <label class="control-label" for="form_check_date"><?php echo xlt('Check/EOB Date'); ?>:</label>
 507                         <input type='text' name='form_check_date' class='form-control datepicker' value=''/>
 508                     </div>
 509                     <div class="col-xs-2">
 510                         <label class="control-label" for="form_deposit_date"><?php echo xlt('Deposit Date'); ?>:</label>
 511                         <input type='text' name='form_deposit_date' id='form_deposit_date'
 512                                class='form-control datepicker' value=''/>
 513                         <input type='hidden' name='form_payer_id' value=''/>
 514                         <input type='hidden' name='form_orig_reference' value=''/>
 515                         <input type='hidden' name='form_orig_check_date' value=''/>
 516                         <input type='hidden' name='form_orig_deposit_date' value=''/>
 517                         <input type='hidden' name='form_pay_total' value=''/>
 518                     </div>
 519                 </div>
 520                 <div class="col-xs-12 oe-custom-line">
 521                     <div class="col-xs-4">
 522                         <label class="control-label" for="type_code"><?php echo xlt('Now posting for'); ?>:</label>
 523                         <div style="padding-left:15px">
 524                             <?php
 525                             // TBD: check the first not-done-with insurance, not always Ins1!
 526                             ?>
 527                             <label class="radio-inline">
 528                                 <input checked name='form_insurance' onclick='setins("Ins1")' type='radio'
 529                                        value='Ins1'><?php echo xlt('Ins1') ?>
 530                             </label>
 531                             <label class="radio-inline">
 532                                 <input name='form_insurance' onclick='setins("Ins2")' type='radio'
 533                                        value='Ins2'><?php echo xlt('Ins2') ?>
 534                             </label>
 535                             <label class="radio-inline">
 536                                 <input name='form_insurance' onclick='setins("Ins3")' type='radio'
 537                                        value='Ins3'><?php echo xlt('Ins3') ?>
 538                             </label>
 539                             <label class="radio-inline">
 540                                 <input name='form_insurance' onclick='setins("Pt")' type='radio'
 541                                        value='Pt'><?php echo xlt('Patient') ?>
 542                             </label>
 543                             <?php
 544                             // TBD: I think the following is unused and can be removed.
 545                             ?>
 546                             <input name='form_eobs' type='hidden' value='<?php echo attr($arrow['shipvia']) ?>'/>
 547                         </div>
 548                     </div>
 549                     <div class="col-xs-4">
 550                         <label class="control-label" for=""><?php echo xlt('Done with'); ?>:</label>
 551                         <div style="padding-left:15px">
 552                             <?php
 553                             // Write a checkbox for each insurance.  It is to be checked when
 554                             // we no longer expect any payments from that company for the claim.
 555                             $last_level_closed = 0 + $ferow['last_level_closed'];
 556                             foreach (array(0 => 'None', 1 => 'Ins1', 2 => 'Ins2', 3 => 'Ins3') as $key => $value) {
 557                                 if ($key && !arGetPayerID($patient_id, $svcdate, $key)) {
 558                                     continue;
 559                                 }
 560                                 $checked = ($last_level_closed == $key) ? " checked" : "";
 561                                 echo "<label class='radio-inline'>";
 562                                 echo "<input type='radio' name='form_done' value='" . attr($key) . "'$checked />" . text($value);
 563                                 echo "</label>";
 564                             }
 565                             ?>
 566                         </div>
 567                     </div>
 568                     <div class="col-xs-4">
 569                         <label class="control-label" for=""><?php echo xlt('Secondary billing'); ?>:</label>
 570                         <div style="padding-left:15px">
 571                             <label class="checkbox-inline">
 572                                 <input name="form_secondary" type="checkbox"
 573                                        value="1"><?php echo xlt('Needs secondary billing') ?>
 574                             </label>
 575                         </div>
 576                     </div>
 577                 </div>
 578
 579             </fieldset>
 580             <fieldset>
 581                 <legend><?php echo xlt('Invoice Details'); ?></legend>
 582                 <div class="table-responsive">
 583                     <table class="table table-condensed">
 584                         <thead>
 585                         <tr>
 586                             <th><?php echo xlt('Code') ?></th>
 587                             <th align="right"><?php echo xlt('Charge') ?></th>
 588                             <th align="right"><?php echo xlt('Balance') ?>&nbsp;</th>
 589                             <th><?php echo xlt('By/Source') ?></th>
 590                             <th><?php echo xlt('Date') ?></th>
 591                             <th><?php echo xlt('Pay') ?></th>
 592                             <th><?php echo xlt('Adjust') ?></th>
 593                             <th>&nbsp;</th>
 594                             <th><?php echo xlt('Reason') ?></th>
 595                             <?php
 596                             if ($ALLOW_DELETE) { ?>
 597                                 <th><?php echo xlt('Del') ?></th>
 598                                 <?php
 599                             } ?>
 600                         </tr>
 601                         </thead>
 602                         <?php
 603                         $firstProcCodeIndex = -1;
 604                         $encount = 0;
 605                         foreach ($codes as $code => $cdata) {
 606                             ++$encount;
 607                             $dispcode = $code;
 608
 609                             // remember the index of the first entry whose code is not "CO-PAY", i.e. it's a legitimate proc code
 610                             if ($firstProcCodeIndex == -1 && strcmp($code, "CO-PAY") != 0) {
 611                                 $firstProcCodeIndex = $encount;
 612                             }
 613
 614                             // this sorts the details more or less chronologically:
 615                             ksort($cdata['dtl']);
 616                             foreach ($cdata['dtl'] as $dkey => $ddata) {
 617                                 $ddate = substr($dkey, 0, 10);
 618                                 if (preg_match('/^(\d\d\d\d)(\d\d)(\d\d)\s*$/', $ddate, $matches)) {
 619                                     $ddate = $matches[1] . '-' . $matches[2] . '-' . $matches[3];
 620                                 }
 621                                 $tmpchg = "";
 622                                 $tmpadj = "";
 623                                 if ($ddata['chg'] != 0) {
 624                                     if (isset($ddata['rsn'])) {
 625                                         $tmpadj = 0 - $ddata['chg'];
 626                                     } else {
 627                                         $tmpchg = $ddata['chg'];
 628                                     }
 629                                 }
 630                                 ?>
 631                                 <tr>
 632                                     <td class="detail"
 633                                         style="background:<?php echo $dispcode ? 'lightyellow' : ''; ?>"><?php echo text($dispcode);
 634                                         $dispcode = "" ?></td>
 635                                     <td class="detail" class="detail"><?php echo text(bucks($tmpchg)); ?></td>
 636                                     <td class="detail" class="detail">&nbsp;</td>
 637                                     <td class="detail">
 638                                         <?php
 639                                         if (isset($ddata['plv'])) {
 640                                             if (!$ddata['plv']) {
 641                                                 echo 'Pt/';
 642                                             } else {
 643                                                 echo 'Ins' . text($ddata['plv']) . '/';
 644                                             }
 645                                         }
 646                                         echo text($ddata['src']);
 647                                         ?>
 648                                     </td>
 649                                     <td class="detail"><?php echo text($ddate); ?></td>
 650                                     <td class="detail"><?php echo text(bucks($ddata['pmt'])); ?></td>
 651                                     <td class="detail"><?php echo text(bucks($tmpadj)); ?></td>
 652                                     <td class="detail">&nbsp;</td>
 653                                     <td class="detail"><?php echo text($ddata['rsn']); ?></td>
 654                                     <?php
 655                                     if ($ALLOW_DELETE) { ?>
 656                                         <td class="detail">
 657                                             <?php
 658                                             if (!empty($ddata['arseq'])) { ?>
 659                                                 <input name="form_del[<?php echo attr($ddata['arseq']); ?>]"
 660                                                        type="checkbox">
 661                                                 <?php
 662                                             } else {
 663                                                 ?> &nbsp;
 664                                                 <?php
 665                                             } ?>
 666                                         </td>
 667                                     <?php } ?>
 668                                 </tr>
 669                             <?php } // end of prior detail line ?>
 670                             <tr>
 671                                 <td class="last_detail"><?php echo text($dispcode);
 672                                     $dispcode = "" ?></td>
 673                                 <td class="last_detail">&nbsp;</td>
 674                                 <td class="last_detail">
 675                                     <input name="form_line[<?php echo attr($code); ?>][bal]" type="hidden"
 676                                            value="<?php echo attr(bucks($cdata['bal'])); ?>">
 677                                     <input name="form_line[<?php echo attr($code); ?>][ins]" type="hidden"
 678                                            value="<?php echo attr($cdata['ins']); ?>">
 679                                     <input name="form_line[<?php echo attr($code); ?>][code_type]" type="hidden"
 680                                            value="<?php echo attr($cdata['code_type']); ?>"> <?php echo text(sprintf("%.2f", $cdata['bal'])); ?>
 681                                     &nbsp;
 682                                 </td>
 683                                 <td class="last_detail"></td>
 684                                 <td class="last_detail"></td>
 685                                 <td class="last_detail">
 686                                     <input name="form_line[<?php echo attr($code); ?>][pay]"
 687                                            onkeyup="updateFields(document.forms[0]['form_line[<?php echo attr(addslashes($code)); ?>][pay]'], document.forms[0]['form_line[<?php echo attr(addslashes($code)); ?>][adj]'], document.forms[0]['form_line[<?php echo attr(addslashes($code)); ?>][bal]'], document.forms[0]['form_line[CO-PAY][bal]'], <?php echo ($firstProcCodeIndex == $encount) ? 1 : 0 ?>)"
 688                                            onclick="this.select()" autofocus size="10" type="text" class="form-control"
 689                                            value="0.00"></td>
 690                                 <td class="last_detail">
 691                                     <input name="form_line[<?php echo attr($code); ?>][adj]" size="10" type="text"
 692                                            class="form-control"
 693                                            value='<?php echo attr($totalAdjAmount ? $totalAdjAmount : '0.00'); ?>'
 694                                            onclick="this.select()">
 695                                 </td>
 696                                 <td class="last_detail" align="center"><a href=""
 697                                                                           onclick="return writeoff('<?php echo attr(addslashes($code)); ?>')">WO</a>
 698                                 </td>
 699                                 <td class="last_detail">
 700                                     <select class="form-control" name="form_line[<?php echo attr($code); ?>][reason]">
 701                                         <?php
 702                                         // Adjustment reasons are now taken from the list_options table.
 703                                         echo "    <option value=''></option>\n";
 704                                         $ores = sqlStatement("SELECT option_id, title, is_default FROM list_options " .
 705                                             "WHERE list_id = 'adjreason' AND activity = 1 ORDER BY seq, title");
 706                                         while ($orow = sqlFetchArray($ores)) {
 707                                             echo "    <option value='" . attr($orow['option_id']) . "'";
 708                                             if ($orow['is_default']) {
 709                                                 echo " selected";
 710                                             }
 711                                             echo ">" . text($orow['title']) . "</option>\n";
 712                                         }
 713                                         ?>
 714                                     </select>
 715                                     <?php
 716                                     // TBD: Maybe a comment field would be good here, for appending
 717                                     // to the reason.
 718                                     ?>
 719                                 </td>
 720                                 <?php if ($ALLOW_DELETE) { ?>
 721                                     <td class="last_detail">&nbsp;</td>
 722                                 <?php } ?>
 723                             </tr>
 724                         <?php } // end of code ?>
 725                     </table>
 726                 </div>
 727             </fieldset>
 728             <?php //can change position of buttons by creating a class 'position-override' and adding rule text-align:center or right as the case may be in individual stylesheets ?>
 729             <div class="form-group clearfix">
 730                 <div class="col-sm-12 text-left position-override" id="search-btn">
 731                     <div class="btn-group" role="group">
 732                         <button type='submit' class="btn btn-default btn-save" name='form_save' id="btn-save-stay"
 733                                 onclick="this.value='1';"><?php echo xlt("Save & Stay"); ?></button>
 734                         <button type='submit' class="btn btn-default btn-save" name='form_save' id="btn-save"
 735                                 onclick="this.value='2';"><?php echo xlt("Save & Exit"); ?></button>
 736                         <button type='submit' class="btn btn-link btn-cancel btn-separate-left" name='form_cancel'
 737                                 id="btn-cancel" onclick='refreshOpener()'><?php echo xlt("Close"); ?></button>
 738                     </div>
 739                 </div>
 740             </div>
 741         </form>
 742     </div>
 743 </div><!--End of container div-->
 744 <script language="JavaScript">
 745     var f1 = opener.document.forms[0];
 746     var f2 = document.forms[0];
 747     if (f1.form_source) {
 748         <?php
 749         // These support creation and lookup of ar_session table entries:
 750         echo "  f2.form_reference.value         = f1.form_source.value;\n";
 751         echo "  f2.form_check_date.value        = f1.form_paydate.value;\n";
 752         echo "  //f2.form_deposit_date.value      = f1.form_deposit_date.value;\n";
 753         echo "  if (f1.form_deposit_date.value != '')\n";
 754         echo "     f2.form_deposit_date.value      = f1.form_deposit_date.value;\n";
 755         echo "  else\n";
 756         echo "     f2.form_deposit_date.value      = getFormattedToday();\n";
 757         echo "  f2.form_payer_id.value          = f1.form_payer_id.value;\n";
 758         echo "  f2.form_pay_total.value         = f1.form_amount.value;\n";
 759         echo "  f2.form_orig_reference.value    = f1.form_source.value;\n";
 760         echo "  f2.form_orig_check_date.value   = f1.form_paydate.value;\n";
 761         echo "  f2.form_orig_deposit_date.value = f1.form_deposit_date.value;\n";
 762
 763         // While I'm thinking about it, some notes about eob sessions.
 764         // If they do not have all of the session key fields in the search
 765         // page, then show a warning at the top of the invoice page.
 766         // Also when they go to save the invoice page and a session key
 767         // field has changed, alert them to that and allow a cancel.
 768
 769         // Another point... when posting EOBs, the incoming payer ID might
 770         // not match the payer ID for the patient's insurance.  This is
 771         // because the same payer might be entered more than once into the
 772         // insurance_companies table.  I don't think it matters much.
 773         ?>
 774     }
 775     setins("Ins1");
 776 </script>
 777 </body>
 778 </html>