library/parse_era.inc.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 function parse_era_2100(&$out, $cb)
  10 {
  11     if ($out['loopid'] == '2110' || $out['loopid'] == '2100') {
  12
  13         // Production date is posted with adjustments, so make sure it exists.
  14         if (!$out['production_date']) $out['production_date'] = $out['check_date'];
  15
  16         // Force the sum of service payments to equal the claim payment
  17         // amount, and the sum of service adjustments to equal the CLP's
  18         // (charged amount - paid amount - patient responsibility amount).
  19         // This may result from claim-level adjustments, and in this case the
  20         // first SVC item that we stored was a 'Claim' type.  It also may result
  21         // from poorly reported payment reversals, in which case we may need to
  22         // create the 'Claim' service type here.
  23         //
  24         $paytotal = $out['amount_approved'];
  25         $adjtotal = $out['amount_charged'] - $out['amount_approved'] - $out['amount_patient'];
  26         foreach ($out['svc'] as $svc) {
  27             $paytotal -= $svc['paid'];
  28             foreach ($svc['adj'] as $adj) {
  29                 if ($adj['group_code'] != 'PR') $adjtotal -= $adj['amount'];
  30             }
  31         }
  32         $paytotal = round($paytotal, 2);
  33         $adjtotal = round($adjtotal, 2);
  34         if ($paytotal != 0 || $adjtotal != 0) {
  35             if ($out['svc'][0]['code'] != 'Claim') {
  36                 array_unshift($out['svc'], array());
  37                 $out['svc'][0]['code'] = 'Claim';
  38                 $out['svc'][0]['mod']  = '';
  39                 $out['svc'][0]['chg']  = '0';
  40                 $out['svc'][0]['paid'] = '0';
  41                 $out['svc'][0]['adj']  = array();
  42                 $out['warnings'] .= "Procedure 'Claim' is inserted artificially to " .
  43                     "force claim balancing.\n";
  44             }
  45             $out['svc'][0]['paid'] += $paytotal;
  46             if ($adjtotal) {
  47                 $j = count($out['svc'][0]['adj']);
  48                 $out['svc'][0]['adj'][$j] = array();
  49                 $out['svc'][0]['adj'][$j]['group_code']  = 'CR'; // presuming a correction or reversal
  50                 $out['svc'][0]['adj'][$j]['reason_code'] = 'Balancing';
  51                 $out['svc'][0]['adj'][$j]['amount'] = $adjtotal;
  52             }
  53             // if ($out['svc'][0]['code'] != 'Claim') {
  54             //   $out['warnings'] .= "First service item payment amount " .
  55             //   "adjusted by $paytotal due to payment imbalance. " .
  56             //   "This should not happen!\n";
  57             // }
  58         }
  59
  60         $cb($out);
  61     }
  62 }
  63
  64 function parse_era($filename, $cb)
  65 {
  66     $delimiter1 = '~';
  67     $delimiter2 = '|';
  68     $delimiter3 = '^';
  69
  70     $infh = fopen($filename, 'r');
  71     if (! $infh) return "ERA input file open failed";
  72
  73     $out = array();
  74     $out['loopid'] = '';
  75     $out['st_segment_count'] = 0;
  76     $buffer = '';
  77     $segid = '';
  78
  79     while (true) {
  80         if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
  81         $tpos = strpos($buffer, $delimiter1);
  82         if ($tpos === false) break;
  83         $inline = substr($buffer, 0, $tpos);
  84         $buffer = substr($buffer, $tpos + 1);
  85
  86     // If this is the ISA segment then figure out what the delimiters are.
  87         if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
  88               $delimiter2 = substr($inline, 3, 1);
  89               $delimiter3 = substr($inline, -1);
  90         }
  91
  92         $seg = explode($delimiter2, $inline);
  93         $segid = $seg[0];
  94
  95         if ($segid == 'ISA') {
  96             if ($out['loopid']) return 'Unexpected ISA segment';
  97             $out['isa_sender_id']      = trim($seg[6]);
  98             $out['isa_receiver_id']    = trim($seg[8]);
  99             $out['isa_control_number'] = trim($seg[13]);
 100             // TBD: clear some stuff if we allow multiple transmission files.
 101         }
 102         else if ($segid == 'GS') {
 103             if ($out['loopid']) return 'Unexpected GS segment';
 104             $out['gs_date'] = trim($seg[4]);
 105             $out['gs_time'] = trim($seg[5]);
 106             $out['gs_control_number'] = trim($seg[6]);
 107         }
 108         else if ($segid == 'ST') {
 109             parse_era_2100($out, $cb);
 110             $out['loopid'] = '';
 111             $out['st_control_number'] = trim($seg[2]);
 112             $out['st_segment_count'] = 0;
 113         }
 114         else if ($segid == 'BPR') {
 115             if ($out['loopid']) return 'Unexpected BPR segment';
 116             $out['check_amount'] = trim($seg[2]);
 117             $out['check_date'] = trim($seg[16]); // yyyymmdd
 118             // TBD: BPR04 is a payment method code.
 119         }
 120         else if ($segid == 'TRN') {
 121             if ($out['loopid']) return 'Unexpected TRN segment';
 122             $out['check_number'] = trim($seg[2]);
 123             $out['payer_tax_id'] = substr($seg[3], 1); // 9 digits
 124             $out['payer_id'] = trim($seg[4]);
 125             // Note: TRN04 further qualifies the paying entity within the
 126             // organization identified by TRN03.
 127         }
 128         else if ($segid == 'REF' && $seg[1] == 'EV') {
 129             if ($out['loopid']) return 'Unexpected REF|EV segment';
 130         }
 131         else if ($segid == 'CUR' && ! $out['loopid']) {
 132             if ($seg[3] && $seg[3] != 1.0) {
 133                 return("We cannot handle foreign currencies!");
 134             }
 135         }
 136         else if ($segid == 'REF' && ! $out['loopid']) {
 137             // ignore
 138         }
 139         else if ($segid == 'DTM' && $seg[1] == '405') {
 140             if ($out['loopid']) return 'Unexpected DTM|405 segment';
 141             $out['production_date'] = trim($seg[2]); // yyyymmdd
 142         }
 143         //
 144         // Loop 1000A is Payer Information.
 145         //
 146         else if ($segid == 'N1' && $seg[1] == 'PR') {
 147             if ($out['loopid']) return 'Unexpected N1|PR segment';
 148             $out['loopid'] = '1000A';
 149             $out['payer_name'] = trim($seg[2]);
 150         }
 151         else if ($segid == 'N3' && $out['loopid'] == '1000A') {
 152             $out['payer_street'] = trim($seg[1]);
 153             // TBD: N302 may exist as an additional address line.
 154         }
 155         else if ($segid == 'N4' && $out['loopid'] == '1000A') {
 156             $out['payer_city']  = trim($seg[1]);
 157             $out['payer_state'] = trim($seg[2]);
 158             $out['payer_zip']   = trim($seg[3]);
 159         }
 160         else if ($segid == 'REF' && $out['loopid'] == '1000A') {
 161             // Other types of REFs may be given to identify the payer, but we
 162             // ignore them.
 163         }
 164         else if ($segid == 'PER' && $out['loopid'] == '1000A') {
 165             // TBD: Report payer contact information as a note.
 166         }
 167         //
 168         // Loop 1000B is Payee Identification.
 169         //
 170         else if ($segid == 'N1' && $seg[1] == 'PE') {
 171             if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 172             $out['loopid'] = '1000B';
 173             $out['payee_name']   = trim($seg[2]);
 174             $out['payee_tax_id'] = trim($seg[4]);
 175         }
 176         else if ($segid == 'N3' && $out['loopid'] == '1000B') {
 177             $out['payee_street'] = trim($seg[1]);
 178         }
 179         else if ($segid == 'N4' && $out['loopid'] == '1000B') {
 180             $out['payee_city']  = trim($seg[1]);
 181             $out['payee_state'] = trim($seg[2]);
 182             $out['payee_zip']   = trim($seg[3]);
 183         }
 184         else if ($segid == 'REF' && $out['loopid'] == '1000B') {
 185             // Used to report additional ID numbers.  Ignored.
 186         }
 187         //
 188         // Loop 2000 provides for logical grouping of claim payment information.
 189         // LX is required if any CLPs are present, but so far we do not care
 190         // about loop 2000 content.
 191         //
 192         else if ($segid == 'LX') {
 193             if (! $out['loopid']) return 'Unexpected LX segment';
 194             parse_era_2100($out, $cb);
 195             $out['loopid'] = '2000';
 196         }
 197         else if ($segid == 'TS2' && $out['loopid'] == '2000') {
 198             // ignore
 199         }
 200         else if ($segid == 'TS3' && $out['loopid'] == '2000') {
 201             // ignore
 202         }
 203         //
 204         // Loop 2100 is Claim Payment Information. The good stuff begins here.
 205         //
 206         else if ($segid == 'CLP') {
 207             if (! $out['loopid']) return 'Unexpected CLP segment';
 208             parse_era_2100($out, $cb);
 209             $out['loopid'] = '2100';
 210             $out['warnings'] = '';
 211             // Clear some stuff to start the new claim:
 212             $out['subscriber_lname']     = '';
 213             $out['subscriber_fname']     = '';
 214             $out['subscriber_mname']     = '';
 215             $out['subscriber_member_id'] = '';
 216             $out['crossover']=0;
 217             $out['svc'] = array();
 218             //
 219             // This is the poorly-named "Patient Account Number".  For 837p
 220             // it comes from CLM01 which we populated as pid-diagid-procid,
 221             // where diagid and procid are id values from the billing table.
 222             // For HCFA 1500 claims it comes from field 26 which we
 223             // populated with our familiar pid-encounter billing key.
 224             //
 225             // The 835 spec calls this the "provider-assigned claim control
 226             // number" and notes that it is specifically intended for
 227             // identifying the claim in the provider's database.
 228             $out['our_claim_id']      = trim($seg[1]);
 229             //
 230             $out['claim_status_code'] = trim($seg[2]);
 231             $out['amount_charged']    = trim($seg[3]);
 232             $out['amount_approved']   = trim($seg[4]);
 233             $out['amount_patient']    = trim($seg[5]); // pt responsibility, copay + deductible
 234             $out['payer_claim_id']    = trim($seg[7]); // payer's claim number
 235         }
 236         else if ($segid == 'CAS' && $out['loopid'] == '2100') {
 237             // This is a claim-level adjustment and should be unusual.
 238             // Handle it by creating a dummy zero-charge service item and
 239             // then populating the adjustments into it.  See also code in
 240             // parse_era_2100() which will later plug in a payment reversal
 241             // amount that offsets these adjustments.
 242             $i = 0; // if present, the dummy service item will be first.
 243             if (!$out['svc'][$i]) {
 244                 $out['svc'][$i] = array();
 245                 $out['svc'][$i]['code'] = 'Claim';
 246                 $out['svc'][$i]['mod']  = '';
 247                 $out['svc'][$i]['chg']  = '0';
 248                 $out['svc'][$i]['paid'] = '0';
 249                 $out['svc'][$i]['adj']  = array();
 250             }
 251             for ($k = 2; $k < 20; $k += 3) {
 252                 if (!$seg[$k]) break;
 253                 $j = count($out['svc'][$i]['adj']);
 254                 $out['svc'][$i]['adj'][$j] = array();
 255                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 256                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 257                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 258             }
 259         }
 260         // QC = Patient
 261         else if ($segid == 'NM1' && $seg[1] == 'QC' && $out['loopid'] == '2100') {
 262             $out['patient_lname']     = trim($seg[3]);
 263             $out['patient_fname']     = trim($seg[4]);
 264             $out['patient_mname']     = trim($seg[5]);
 265             $out['patient_member_id'] = trim($seg[9]);
 266         }
 267         // IL = Insured or Subscriber
 268         else if ($segid == 'NM1' && $seg[1] == 'IL' && $out['loopid'] == '2100') {
 269             $out['subscriber_lname']     = trim($seg[3]);
 270             $out['subscriber_fname']     = trim($seg[4]);
 271             $out['subscriber_mname']     = trim($seg[5]);
 272             $out['subscriber_member_id'] = trim($seg[9]);
 273         }
 274         // 82 = Rendering Provider
 275         else if ($segid == 'NM1' && $seg[1] == '82' && $out['loopid'] == '2100') {
 276             $out['provider_lname']     = trim($seg[3]);
 277             $out['provider_fname']     = trim($seg[4]);
 278             $out['provider_mname']     = trim($seg[5]);
 279             $out['provider_member_id'] = trim($seg[9]);
 280         }
 281         else if ($segid == 'NM1' && $seg[1] == 'TT' && $out['loopid'] == '2100') {
 282             $out['crossover']     = 1;//Claim automatic forward case.
 283
 284         }
 285         // 74 = Corrected Insured
 286         // TT = Crossover Carrier (Transfer To another payer)
 287         // PR = Corrected Payer
 288         else if ($segid == 'NM1' && $out['loopid'] == '2100') {
 289             // $out['warnings'] .= "NM1 segment at claim level ignored.\n";
 290         }
 291         else if ($segid == 'MOA' && $out['loopid'] == '2100') {
 292             $out['warnings'] .= "MOA segment at claim level ignored.\n";
 293         }
 294         // REF segments may provide various identifying numbers, where REF02
 295         // indicates the type of number.
 296         else if ($segid == 'REF' && $seg[1] == '1W' && $out['loopid'] == '2100') {
 297             $out['claim_comment'] = trim($seg[2]);
 298         }
 299         else if ($segid == 'REF' && $out['loopid'] == '2100') {
 300             // ignore
 301         }
 302         else if ($segid == 'DTM' && $seg[1] == '050' && $out['loopid'] == '2100') {
 303             $out['claim_date'] = trim($seg[2]); // yyyymmdd
 304         }
 305         // 036 = expiration date of coverage
 306         // 050 = date claim received by payer
 307         // 232 = claim statement period start
 308         // 233 = claim statement period end
 309         else if ($segid == 'DTM' && $out['loopid'] == '2100') {
 310             // ignore?
 311         }
 312         else if ($segid == 'PER' && $out['loopid'] == '2100') {
 313
 314             $out['payer_insurance']  = trim($seg[2]);
 315             $out['warnings'] .= 'Claim contact information: ' .
 316                 $seg[4] . "\n";
 317         }
 318         // For AMT01 see the Amount Qualifier Codes on pages 135-135 of the
 319         // Implementation Guide.  AMT is only good for comments and is not
 320         // part of claim balancing.
 321         else if ($segid == 'AMT' && $out['loopid'] == '2100') {
 322             $out['warnings'] .= "AMT segment at claim level ignored.\n";
 323         }
 324         // For QTY01 see the Quantity Qualifier Codes on pages 137-138 of the
 325         // Implementation Guide.  QTY is only good for comments and is not
 326         // part of claim balancing.
 327         else if ($segid == 'QTY' && $out['loopid'] == '2100') {
 328             $out['warnings'] .= "QTY segment at claim level ignored.\n";
 329         }
 330         //
 331         // Loop 2110 is Service Payment Information.
 332         //
 333         else if ($segid == 'SVC') {
 334             if (! $out['loopid']) return 'Unexpected SVC segment';
 335             $out['loopid'] = '2110';
 336             if ($seg[6]) {
 337                 // SVC06 if present is our original procedure code that they are changing.
 338                 // We will not put their crap in our invoice, but rather log a note and
 339                 // treat it as adjustments to our originally submitted coding.
 340                 $svc = explode($delimiter3, $seg[6]);
 341                 $tmp = explode($delimiter3, $seg[1]);
 342                 $out['warnings'] .= "Payer is restating our procedure " . $svc[1] .
 343                     " as " . $tmp[1] . ".\n";
 344             } else {
 345                 $svc = explode($delimiter3, $seg[1]);
 346             }
 347             if ($svc[0] != 'HC') return 'SVC segment has unexpected qualifier';
 348             // TBD: Other qualifiers are possible; see IG pages 140-141.
 349             $i = count($out['svc']);
 350             $out['svc'][$i] = array();
 351       // It seems some payers append the modifier with no separator!
 352             if (strlen($svc[1]) == 7 && empty($svc[2])) {
 353                     $out['svc'][$i]['code'] = substr($svc[1], 0, 5);
 354                     $out['svc'][$i]['mod']  = substr($svc[1], 5);
 355             } else {
 356                     $out['svc'][$i]['code'] = $svc[1];
 357                     $out['svc'][$i]['mod']  = $svc[2] ? $svc[2] . ':' : '';
 358                     $out['svc'][$i]['mod']  .= $svc[3] ? $svc[3] . ':' : '';
 359                     $out['svc'][$i]['mod']  .= $svc[4] ? $svc[4] . ':' : '';
 360                     $out['svc'][$i]['mod']  .= $svc[5] ? $svc[5] . ':' : '';
 361                     $out['svc'][$i]['mod'] = preg_replace('/:$/','',$out['svc'][$i]['mod']);
 362             }
 363             $out['svc'][$i]['chg']  = $seg[2];
 364             $out['svc'][$i]['paid'] = $seg[3];
 365             $out['svc'][$i]['adj']  = array();
 366             // Note: SVC05, if present, indicates the paid units of service.
 367             // It defaults to 1.
 368         }
 369         // DTM01 identifies the type of service date:
 370         // 472 = a single date of service
 371         // 150 = service period start
 372         // 151 = service period end
 373         else if ($segid == 'DTM' && $out['loopid'] == '2110') {
 374             $out['dos'] = trim($seg[2]); // yyyymmdd
 375         }
 376         else if ($segid == 'CAS' && $out['loopid'] == '2110') {
 377             $i = count($out['svc']) - 1;
 378             for ($k = 2; $k < 20; $k += 3) {
 379                 if (!$seg[$k]) break;
 380                 if ($seg[1] == 'CO' && $seg[$k+1] < 0) {
 381                           $out['warnings'] .= "Negative Contractual Obligation adjustment " .
 382                     "seems wrong. Inverting, but should be checked!\n";
 383                           $seg[$k+1] = 0 - $seg[$k+1];
 384                 }
 385                 $j = count($out['svc'][$i]['adj']);
 386                 $out['svc'][$i]['adj'][$j] = array();
 387                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 388                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 389                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 390                 // Note: $seg[$k+2] is "quantity".  A value here indicates a change to
 391                 // the number of units of service.  We're ignoring that for now.
 392             }
 393         }
 394         else if ($segid == 'REF' && $out['loopid'] == '2110') {
 395             // ignore
 396         }
 397         else if ($segid == 'AMT' && $seg[1] == 'B6' && $out['loopid'] == '2110') {
 398             $i = count($out['svc']) - 1;
 399             $out['svc'][$i]['allowed'] = $seg[2]; // report this amount as a note
 400         }
 401         else if ($segid == 'AMT' && $out['loopid'] == '2110') {
 402               $out['warnings'] .= "$inline at service level ignored.\n";
 403         }
 404         else if ($segid == 'LQ' && $seg[1] == 'HE' && $out['loopid'] == '2110') {
 405             $i = count($out['svc']) - 1;
 406             $out['svc'][$i]['remark'] = $seg[2];
 407         }
 408         else if ($segid == 'QTY' && $out['loopid'] == '2110') {
 409             $out['warnings'] .= "QTY segment at service level ignored.\n";
 410         }
 411         else if ($segid == 'PLB') {
 412             // Provider-level adjustments are a General Ledger thing and should not
 413             // alter the A/R for the claim, so we just report them as notes.
 414             for ($k = 3; $k < 15; $k += 2) {
 415                 if (!$seg[$k]) break;
 416                 $out['warnings'] .= 'PROVIDER LEVEL ADJUSTMENT (not claim-specific): $' .
 417                     sprintf('%.2f', $seg[$k+1]) . " with reason code " . $seg[$k] . "\n";
 418                 // Note: For PLB adjustment reason codes see IG pages 165-170.
 419             }
 420         }
 421         else if ($segid == 'SE') {
 422             parse_era_2100($out, $cb);
 423             $out['loopid'] = '';
 424             if ($out['st_control_number'] != trim($seg[2])) {
 425                 return 'Ending transaction set control number mismatch';
 426             }
 427             if (($out['st_segment_count'] + 1) != trim($seg[1])) {
 428                 return 'Ending transaction set segment count mismatch';
 429             }
 430         }
 431         else if ($segid == 'GE') {
 432             if ($out['loopid']) return 'Unexpected GE segment';
 433             if ($out['gs_control_number'] != trim($seg[2])) {
 434                 return 'Ending functional group control number mismatch';
 435             }
 436         }
 437         else if ($segid == 'IEA') {
 438             if ($out['loopid']) return 'Unexpected IEA segment';
 439             if ($out['isa_control_number'] != trim($seg[2])) {
 440                 return 'Ending interchange control number mismatch';
 441             }
 442         }
 443         else {
 444             return "Unknown or unexpected segment ID $segid";
 445         }
 446
 447         ++$out['st_segment_count'];
 448     }
 449
 450     if ($segid != 'IEA') return 'Premature end of ERA file';
 451     return '';
 452 }
 453 //for getting the check details and provider details
 454 function parse_era_for_check($filename)
 455 {
 456     $delimiter1 = '~';
 457     $delimiter2 = '|';
 458     $delimiter3 = '^';
 459
 460     $infh = fopen($filename, 'r');
 461     if (! $infh) return "ERA input file open failed";
 462
 463     $out = array();
 464     $out['loopid'] = '';
 465     $out['st_segment_count'] = 0;
 466     $buffer = '';
 467     $segid = '';
 468     $check_count=0;
 469     while (true) {
 470
 471         if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
 472         $tpos = strpos($buffer, $delimiter1);
 473         if ($tpos === false) break;
 474         $inline = substr($buffer, 0, $tpos);
 475         $buffer = substr($buffer, $tpos + 1);
 476
 477     // If this is the ISA segment then figure out what the delimiters are.
 478         if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
 479               $delimiter2 = substr($inline, 3, 1);
 480               $delimiter3 = substr($inline, -1);
 481         }
 482
 483         $seg = explode($delimiter2, $inline);
 484         $segid = $seg[0];
 485
 486         if ($segid == 'ISA') {
 487
 488         }
 489         else if ($segid == 'BPR') {
 490             ++$check_count;
 491             //if ($out['loopid']) return 'Unexpected BPR segment';
 492             $out['check_amount'.$check_count] = trim($seg[2]);
 493             $out['check_date'.$check_count] = trim($seg[16]); // yyyymmdd
 494             // TBD: BPR04 is a payment method code.
 495
 496         }
 497         else if ($segid == 'N1' && $seg[1] == 'PE') {
 498             //if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 499             $out['loopid'] = '1000B';
 500             $out['payee_name'.$check_count]   = trim($seg[2]);
 501             $out['payee_tax_id'.$check_count] = trim($seg[4]);
 502
 503         }
 504         else if ($segid == 'TRN') {
 505             //if ($out['loopid']) return 'Unexpected TRN segment';
 506             $out['check_number'.$check_count] = trim($seg[2]);
 507             $out['payer_tax_id'.$check_count] = substr($seg[3], 1); // 9 digits
 508             $out['payer_id'.$check_count] = trim($seg[4]);
 509             // Note: TRN04 further qualifies the paying entity within the
 510             // organization identified by TRN03.
 511         }
 512
 513
 514
 515
 516         ++$out['st_segment_count'];
 517     }
 518     $out['check_count']=$check_count;
 519     era_callback_check($out);
 520
 521     if ($segid != 'IEA') return 'Premature end of ERA file';
 522     return '';
 523 }
 524 ?>