library/gen_hcfa_1500.inc.php

   1 <?php
   2 /*
   3  * This program creates the HCFA 1500 claim form.
   4  *
   5  * @package OpenEMR
   6  * @author Rod Roark <rod@sunsetsystems.com>
   7  * @author Stephen Waite <stephen.waite@cmsvt.com>
   8  * @copyright Copyright (c) 2011 Rod Roark <rod@sunsetsystems.com>
   9  * @copyright Copyright (C) 2017 Stephen Waite <stephen.waite@cmsvt.com>
  10  * @link http://www.open-emr.org
  11  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once("Claim.class.php");
  15 require_once("gen_hcfa_1500_02_12.inc.php");
  16
  17 $hcfa_curr_line = 1;
  18 $hcfa_curr_col = 1;
  19 $hcfa_data = '';
  20 $hcfa_proc_index = 0;
  21
  22
  23 /**
  24  * take the data element and place it at the correct coordinates on the page
  25  *
  26  * @global int $hcfa_curr_line
  27  * @global type $hcfa_curr_col
  28  * @global type $hcfa_data
  29  * @param type $line
  30  * @param type $col
  31  * @param type $maxlen
  32  * @param type $data
  33  * @param type $strip   regular expression for what to strip from the data. period and has are the defaults
  34  *                      02/12 version needs to include periods in the diagnoses hence the need to override
  35  */
  36 function put_hcfa($line, $col, $maxlen, $data, $strip = '/[.#]/')
  37 {
  38     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  39     if ($line < $hcfa_curr_line) {
  40         die("Data item at ($line, $col) precedes current line.");
  41     }
  42
  43     while ($hcfa_curr_line < $line) {
  44         $hcfa_data .= "\n";
  45         ++$hcfa_curr_line;
  46         $hcfa_curr_col = 1;
  47     }
  48
  49     if ($col < $hcfa_curr_col) {
  50         die("Data item at ($line, $col) precedes current column.");
  51     }
  52
  53     while ($hcfa_curr_col < $col) {
  54         $hcfa_data .= " ";
  55         ++$hcfa_curr_col;
  56     }
  57
  58     $data = preg_replace($strip, '', strtoupper($data));
  59     $len = min(strlen($data), $maxlen);
  60     $hcfa_data .= substr($data, 0, $len);
  61     $hcfa_curr_col += $len;
  62 }
  63
  64 function gen_hcfa_1500($pid, $encounter, &$log)
  65 {
  66     global $hcfa_data, $hcfa_proc_index;
  67
  68     $hcfa_data = '';
  69     $hcfa_proc_index = 0;
  70
  71     $today = time();
  72     $claim = new Claim($pid, $encounter);
  73
  74     $log .= "Generating HCFA claim $pid-$encounter for " .
  75     $claim->patientFirstName()  . ' ' .
  76     $claim->patientMiddleName() . ' ' .
  77     $claim->patientLastName()   . ' on ' .
  78     date('Y-m-d H:i', $today) . ".\n";
  79
  80     while ($hcfa_proc_index < $claim->procCount()) {
  81         if ($hcfa_proc_index) {
  82             $hcfa_data .= "\014"; // append form feed for new page
  83         }
  84
  85         gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  86     }
  87
  88     $log .= "\n";
  89     return $hcfa_data;
  90 }
  91
  92 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim)
  93 {
  94     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  95
  96     $hcfa_curr_line = 1;
  97     $hcfa_curr_col = 1;
  98
  99   // According to:
 100   // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
 101   // Medicare interprets sections 9 and 11 of the claim form in its own
 102   // special way.  This flag tells us to do that.  However I'm not 100%
 103   // sure that it applies nationwide, and if you find that it is not right
 104   // for you then set it to false.  -- Rod 2009-03-26
 105     $new_medicare_logic = $claim->claimType() == 'MB';
 106
 107   // Payer name, attn, street.
 108     put_hcfa(2, 41, 31, $claim->payerName());
 109     put_hcfa(3, 41, 31, $claim->payerAttn());
 110     put_hcfa(4, 41, 31, $claim->payerStreet());
 111
 112   // Payer city, state, zip.
 113     $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
 114     put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
 115
 116   // Box 1. Insurance Type
 117   // claimTypeRaw() gets the integer value from insurance_companies.ins_type_code.
 118   // Previous version of this code called claimType() which maps ins_type_code to
 119   // a 2-character code and that was not specific enough.
 120     $ct = $claim->claimTypeRaw();
 121     $tmpcol = 45;                    // Other
 122     if ($ct == 2) {
 123         $tmpcol =  1; // Medicare
 124     } else if ($ct == 3) {
 125         $tmpcol =  8; // Medicaid
 126     } else if ($ct == 5) {
 127         $tmpcol = 15; // TriCare (formerly CHAMPUS)
 128     } else if ($ct == 4) {
 129         $tmpcol = 24; // Champus VA
 130     } else if ($ct == 6) {
 131         $tmpcol = 31; // Group Health Plan (only BCBS?)
 132     } else if ($ct == 7) {
 133         $tmpcol = 39; // FECA
 134     }
 135
 136     put_hcfa(8, $tmpcol, 1, 'X');
 137
 138   // Box 1a. Insured's ID Number
 139     put_hcfa(8, 50, 17, $claim->policyNumber());
 140
 141   // Box 2. Patient's Name
 142     $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 143     if ($claim->patientMiddleName()) {
 144         $tmp .= ', ' . substr($claim->patientMiddleName(), 0, 1);
 145     }
 146
 147     put_hcfa(10, 1, 28, $tmp);
 148
 149   // Box 3. Patient's Birth Date and Sex
 150     $tmp = $claim->patientDOB();
 151     put_hcfa(10, 31, 2, substr($tmp, 4, 2));
 152     put_hcfa(10, 34, 2, substr($tmp, 6, 2));
 153     put_hcfa(10, 37, 4, substr($tmp, 0, 4));
 154     put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 155
 156   // Box 4. Insured's Name
 157     $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 158     if ($claim->insuredMiddleName()) {
 159         $tmp .= ', ' . substr($claim->insuredMiddleName(), 0, 1);
 160     }
 161
 162     put_hcfa(10, 50, 28, $tmp);
 163
 164   // Box 5. Patient's Address
 165     put_hcfa(12, 1, 28, $claim->patientStreet());
 166
 167   // Box 6. Patient Relationship to Insured
 168     $tmp = $claim->insuredRelationship();
 169     $tmpcol = 47;                         // Other
 170     if ($tmp === '18') {
 171         $tmpcol = 33; // self
 172     } else if ($tmp === '01') {
 173         $tmpcol = 38; // spouse
 174     } else if ($tmp === '19') {
 175         $tmpcol = 42; // child
 176     }
 177
 178     put_hcfa(12, $tmpcol, 1, 'X');
 179
 180   // Box 7. Insured's Address
 181     put_hcfa(12, 50, 28, $claim->insuredStreet());
 182
 183   // Box 5 continued. Patient's City and State
 184     put_hcfa(14, 1, 20, $claim->patientCity());
 185     put_hcfa(14, 26, 2, $claim->patientState());
 186
 187   // Box 8. Patient (Marital) Status
 188     if (!hcfa_1500_version_02_12()) {  // Box 8 Reserved for NUCC Use in 02/12
 189         $tmp = $claim->patientStatus();
 190         $tmpcol = 47;                        // Other
 191         if ($tmp === 'S') {
 192             $tmpcol = 35; // Single
 193         } else if ($tmp === 'M') {
 194             $tmpcol = 41; // Married
 195         }
 196
 197         put_hcfa(14, $tmpcol, 1, 'X');
 198     }
 199
 200   // Box 7 continued. Insured's City and State
 201     put_hcfa(14, 50, 20, $claim->insuredCity());
 202     put_hcfa(14, 74, 2, $claim->insuredState());
 203
 204   // Box 5 continued. Patient's Zip Code and Telephone
 205     put_hcfa(16, 1, 10, $claim->patientZip());
 206     $tmp = $claim->patientPhone();
 207     put_hcfa(16, 15, 3, substr($tmp, 0, 3));
 208     put_hcfa(16, 19, 7, substr($tmp, 3));
 209
 210   // Box 8 continued. Patient (Employment) Status
 211     if (!hcfa_1500_version_02_12()) {  // Box 8 Reserved for NUCC Use in 02/12
 212         $tmp = $claim->patientOccupation();
 213         if ($tmp === 'STUDENT') {
 214             put_hcfa(16, 41, 1, 'X');
 215         } else if ($tmp === 'PT STUDENT') {
 216             put_hcfa(16, 47, 1, 'X');
 217         } else if ($tmp !== 'UNEMPLOYED') {
 218             put_hcfa(16, 35, 1, 'X');
 219         }
 220     }
 221
 222   // Box 7 continued. Insured's Zip Code and Telephone
 223     put_hcfa(16, 50, 10, $claim->insuredZip());
 224     $tmp = $claim->insuredPhone();
 225     put_hcfa(16, 65, 3, substr($tmp, 0, 3));
 226     put_hcfa(16, 69, 7, substr($tmp, 3));
 227
 228   // Box 9. Other Insured's Name
 229     if ($new_medicare_logic) {
 230         // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 231     } else {
 232         if ($claim->payerCount() > 1) {
 233             $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 234             if ($claim->insuredMiddleName(1)) {
 235                 $tmp .= ', ' . substr($claim->insuredMiddleName(1), 0, 1);
 236             }
 237
 238             put_hcfa(18, 1, 28, $tmp);
 239         }
 240     }
 241
 242   // Box 11. Insured's Group Number
 243     if ($new_medicare_logic) {
 244         // If this is Medicare secondary then we need the primary's policy number
 245         // here, otherwise the word "NONE".
 246         $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 247     } else {
 248         $tmp = $claim->groupNumber();
 249     }
 250
 251     put_hcfa(18, 50, 30, $tmp);
 252
 253   // Box 9a. Other Insured's Policy or Group Number
 254     if ($new_medicare_logic) {
 255         // TBD: Medigap stuff?
 256     } else {
 257         if ($claim->payerCount() > 1) {
 258             put_hcfa(20, 1, 28, $claim->policyNumber(1));
 259         }
 260     }
 261
 262   // Box 10a. Employment Related
 263     put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 264
 265   // Box 11a. Insured's Birth Date and Sex
 266     if ($new_medicare_logic) {
 267         $tmpdob = $tmpsex = '';
 268         if ($claim->payerSequence() != 'P') {
 269             $tmpdob = $claim->insuredDOB(1);
 270             $tmpsex = $claim->insuredSex(1);
 271         }
 272     } else {
 273         $tmpdob = $claim->insuredDOB();
 274         $tmpsex = $claim->insuredSex();
 275     }
 276
 277     if ($tmpdob) {
 278         put_hcfa(20, 53, 2, substr($tmpdob, 4, 2));
 279         put_hcfa(20, 56, 2, substr($tmpdob, 6, 2));
 280         put_hcfa(20, 59, 4, substr($tmpdob, 0, 4));
 281     }
 282
 283     if ($tmpsex) {
 284         put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 285     }
 286
 287   // Box 9b. Other Insured's Birth Date and Sex
 288     if (!hcfa_1500_version_02_12()) {  // Box 9b Reserved for NUCC Use in 02/12
 289         if ($new_medicare_logic) {
 290             // TBD: Medigap stuff?
 291         } else {
 292             if ($claim->payerCount() > 1) {
 293                 $tmp = $claim->insuredDOB(1);
 294                 put_hcfa(22, 2, 2, substr($tmp, 4, 2));
 295                 put_hcfa(22, 5, 2, substr($tmp, 6, 2));
 296                 put_hcfa(22, 8, 4, substr($tmp, 0, 4));
 297                 put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 298             }
 299         }
 300     }
 301
 302   // Box 10b. Auto Accident
 303     put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 304     if ($claim->isRelatedAuto()) {
 305         put_hcfa(22, 45, 2, $claim->autoAccidentState());
 306     }
 307
 308   // Box 11b. Insured's Employer/School Name
 309     if ($new_medicare_logic) {
 310         $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 311     } else {
 312         $tmp = $claim->groupName();
 313     }
 314
 315     put_hcfa(22, 50, 30, $tmp);
 316
 317   // Box 9c. Other Insured's Employer/School Name
 318     if (!hcfa_1500_version_02_12()) {  // Box 9c Reserved for NUCC Use in 02/12
 319         if ($new_medicare_logic) {
 320             // TBD: Medigap stuff?
 321         } else {
 322             if ($claim->payerCount() > 1) {
 323                 put_hcfa(24, 1, 28, $claim->groupName(1));
 324             }
 325         }
 326     }
 327
 328   // Box 10c. Other Accident
 329     put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 330
 331   // Box 11c. Insurance Plan Name or Program Name
 332     if ($new_medicare_logic) {
 333         $tmp = '';
 334         if ($claim->payerSequence() != 'P') {
 335             $tmp = $claim->planName(1);
 336             if (!$tmp) {
 337                 $tmp = $claim->payerName(1);
 338             }
 339         }
 340     } else {
 341         $tmp = $claim->planName();
 342     }
 343
 344     put_hcfa(24, 50, 30, $tmp);
 345
 346   // Box 9d. Other Insurance Plan Name or Program Name
 347     if ($new_medicare_logic) {
 348         // TBD: Medigap stuff?
 349     } else {
 350         if ($claim->payerCount() > 1) {
 351             put_hcfa(26, 1, 28, $claim->planName(1));
 352         }
 353     }
 354
 355   // Box 10d. Claim Codes  medicaid_referral_code
 356
 357     if ($claim->epsdtFlag()) {
 358         put_hcfa(26, 34, 2, $claim->medicaidReferralCode());
 359     }
 360
 361   // Box 11d. Is There Another Health Benefit Plan
 362
 363     if (!$new_medicare_logic) {
 364         put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 365     }
 366
 367   // Box 12. Patient's or Authorized Person's Signature
 368     put_hcfa(29, 7, 17, 'Signature on File');
 369   // Note: Date does not apply unless the person physically signs the form.
 370
 371   // Box 13. Insured's or Authorized Person's Signature
 372     put_hcfa(29, 55, 17, 'Signature on File');
 373
 374   // Box 14. Date of Current Illness/Injury/Pregnancy
 375     $tmp = $claim->miscOnsetDate();
 376     put_hcfa(32, 2, 2, substr($tmp, 4, 2));
 377     put_hcfa(32, 5, 2, substr($tmp, 6, 2));
 378     put_hcfa(32, 8, 4, substr($tmp, 0, 4));
 379
 380     if (hcfa_1500_version_02_12() && !empty($tmp)) {
 381         // Only include the Box 14 qualifier if using version 02/12 and there is a Box 14 date.
 382         put_hcfa(32, 16, 3, $claim->box14Qualifier());
 383     }
 384
 385   // Box 15. First Date of Same or Similar Illness, if applicable
 386     $tmp = $claim->dateInitialTreatment();
 387     if (hcfa_1500_version_02_12() && !empty($tmp)) {
 388         // Only include the Box 15 qualifier if using version 02/12 and there is a Box 15 date.
 389         put_hcfa(32, 31, 3, $claim->box15Qualifier());
 390     }
 391
 392     put_hcfa(32, 37, 2, substr($tmp, 4, 2));
 393     put_hcfa(32, 40, 2, substr($tmp, 6, 2));
 394     put_hcfa(32, 43, 4, substr($tmp, 0, 4));
 395
 396   // Box 16. Dates Patient Unable to Work in Current Occupation
 397     if ($claim->isUnableToWork()) {
 398         $tmp = $claim->offWorkFrom();
 399         put_hcfa(32, 54, 2, substr($tmp, 4, 2));
 400         put_hcfa(32, 57, 2, substr($tmp, 6, 2));
 401         put_hcfa(32, 60, 4, substr($tmp, 0, 4));
 402         $tmp = $claim->offWorkTo();
 403         put_hcfa(32, 68, 2, substr($tmp, 4, 2));
 404         put_hcfa(32, 71, 2, substr($tmp, 6, 2));
 405         put_hcfa(32, 74, 4, substr($tmp, 0, 4));
 406     }
 407
 408   // Referring provider stuff.  Reports are that for primary care doctors,
 409   // Medicare forbids an entry here and other payers require one.
 410   // There is still confusion over this.
 411   //
 412     if ($claim->referrerLastName() || $claim->billingProviderLastName() &&
 413     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB')) {
 414         // Box 17a. Referring Provider Alternate Identifier
 415         // Commented this out because UPINs are obsolete, leaving the code as an
 416         // example in case some other identifier needs to be supported.
 417         /*****************************************************************
 418       if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 419         put_hcfa(33, 30,  2, '1G');
 420         put_hcfa(33, 33, 15, $claim->referrerUPIN());
 421       }
 422         *****************************************************************/
 423         if ($claim->claimType() == 'MC') {
 424             put_hcfa(33, 30, 2, 'ZZ');
 425             put_hcfa(33, 33, 14, $claim->referrerTaxonomy());
 426         }
 427
 428         // Box 17. Name of Referring Provider or Other Source leave it like it is just check if there is info in misc_billing the use it provider_qualifier_code
 429         # Changed to look first at the misc hcfa billing form to complete this box if nothing on misc hcfa form use referrer
 430         if (strlen($claim->billingProviderLastName()) !=0) {
 431             $tmp2 = $claim->billingProviderLastName() . ', ' . $claim->billingProviderFirstName();
 432             if ($claim->billingProviderMiddleName()) {
 433                 $tmp2 .= ', ' . substr($claim->billingProviderMiddleName(), 0, 1);
 434             }
 435
 436             put_hcfa(34, 1, 3, $claim->billing_options['provider_qualifier_code']);
 437             put_hcfa(34, 4, 25, $tmp2);
 438             if ($claim->billingProviderNPI()) {
 439                 put_hcfa(34, 33, 15, $claim->billingProviderNPI());
 440             }
 441         } else {
 442             $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 443             if ($claim->referrerMiddleName()) {
 444                 $tmp .= ', ' . substr($claim->referrerMiddleName(), 0, 1);
 445             }
 446
 447             put_hcfa(34, 1, 3, 'DN');
 448             put_hcfa(34, 4, 25, $tmp);
 449             if ($claim->referrerNPI()) {
 450                 put_hcfa(34, 33, 15, $claim->referrerNPI());
 451             }
 452         }
 453     }
 454
 455   // Box 18. Hospitalization Dates Related to Current Services
 456     if ($claim->isHospitalized()) {
 457         $tmp = $claim->hospitalizedFrom();
 458         put_hcfa(34, 54, 2, substr($tmp, 4, 2));
 459         put_hcfa(34, 57, 2, substr($tmp, 6, 2));
 460         put_hcfa(34, 60, 4, substr($tmp, 0, 4));
 461         $tmp = $claim->hospitalizedTo();
 462         put_hcfa(34, 68, 2, substr($tmp, 4, 2));
 463         put_hcfa(34, 71, 2, substr($tmp, 6, 2));
 464         put_hcfa(34, 74, 4, substr($tmp, 0, 4));
 465     }
 466
 467   // Box 19. Reserved for Local Use
 468     put_hcfa(36, 1, 48, $claim->additionalNotes());
 469
 470   // Box 20. Outside Lab
 471     put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 472     if ($claim->isOutsideLab()) {
 473         // Note here that put_hcfa strips the decimal point, as required.
 474         // We right-justify this amount (ending in col. 69).
 475         put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 476     }
 477
 478     if (hcfa_1500_version_02_12()) {
 479         process_diagnoses_02_12($claim, $log);
 480     } else {
 481         // Box 21. Diagnoses
 482         $tmp = $claim->diagArray();
 483         $diags = array();
 484         foreach ($tmp as $diag) {
 485             $diags[] = $diag;
 486         }
 487
 488         if (!empty($diags[0])) {
 489             put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 490             put_hcfa(38, 7, 2, substr($diags[0], 3));
 491         }
 492
 493         if (!empty($diags[2])) {
 494             put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 495             put_hcfa(38, 34, 2, substr($diags[2], 3));
 496         }
 497
 498         // Box 22. Medicaid Resubmission Code and Original Ref. No.
 499         put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 500         put_hcfa(38, 62, 15, $claim->medicaidOriginalReference());
 501
 502         // Box 21 continued. Diagnoses
 503         if (!empty($diags[1])) {
 504             put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 505             put_hcfa(40, 7, 2, substr($diags[1], 3));
 506         }
 507
 508         if (!empty($diags[3])) {
 509             put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 510             put_hcfa(40, 34, 2, substr($diags[3], 3));
 511         }
 512
 513         // Box 23. Prior Authorization Number
 514         put_hcfa(40, 50, 28, $claim->priorAuth());
 515     }
 516
 517     $proccount = $claim->procCount(); // number of procedures
 518
 519   // Charges, adjustments and payments are accumulated by line item so that
 520   // each page of a multi-page claim will stand alone.  Payments include the
 521   // co-pay for the first page only.
 522     $clm_total_charges = 0;
 523     $clm_amount_adjusted = 0;
 524     $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 525
 526   // Procedure loop starts here.
 527   //
 528     for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 529         $dia = $claim->diagIndexArray($hcfa_proc_index);
 530
 531         if (!$claim->cptCharges($hcfa_proc_index)) {
 532             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 533             "' has no charges!\n";
 534         }
 535
 536         if (empty($dia)) {
 537             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 538             "' is not justified!\n";
 539         }
 540
 541         $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 542
 543         // Compute prior payments and "hard" adjustments.
 544         for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 545             if ($claim->payerSequence($ins) > $claim->payerSequence()) {
 546                 continue; // skip future payers
 547             }
 548
 549             $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 550             $clm_amount_paid += $payerpaid[1];
 551             $clm_amount_adjusted += $payerpaid[2];
 552         }
 553
 554         ++$svccount;
 555         $lino = $svccount * 2 + 41;
 556
 557         // Drug Information. Medicaid insurers want this with HCPCS codes.
 558         //
 559         $ndc = $claim->cptNDCID($hcfa_proc_index);
 560         if ($ndc) {
 561             if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 562                 $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 563             } else if (preg_match('/^\d{11}$/', $ndc)) {
 564             } else {
 565                 $log .= "*** NDC code '$ndc' has invalid format!\n";
 566             }
 567
 568             put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 569             $claim->cptNDCQuantity($hcfa_proc_index));
 570         }
 571
 572         //Note Codes.
 573         put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 574
 575         // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 576         if ($claim->supervisorNumber()) {
 577             // If there is a supervising provider and that person has a
 578             // payer-specific provider number, then we assume that the SP
 579             // must be identified on the claim and this is how we do it
 580             // (but the NPI of the actual rendering provider appears below).
 581             // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 582             put_hcfa($lino, 65, 2, $claim->supervisorNumberType());
 583             put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 584         } else if ($claim->providerNumber($hcfa_proc_index)) {
 585             put_hcfa($lino, 65, 2, $claim->providerNumberType($hcfa_proc_index));
 586             put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 587         } else if ($claim->claimType() == 'MC') {
 588             put_hcfa($lino, 65, 2, 'ZZ');
 589             put_hcfa($lino, 68, 14, $claim->providerTaxonomy());
 590         }
 591
 592         ++$lino;
 593
 594         // 24a. Date of Service
 595         $tmp = $claim->serviceDate();
 596         put_hcfa($lino, 1, 2, substr($tmp, 4, 2));
 597         put_hcfa($lino, 4, 2, substr($tmp, 6, 2));
 598         put_hcfa($lino, 7, 2, substr($tmp, 2, 2));
 599         put_hcfa($lino, 10, 2, substr($tmp, 4, 2));
 600         put_hcfa($lino, 13, 2, substr($tmp, 6, 2));
 601         put_hcfa($lino, 16, 2, substr($tmp, 2, 2));
 602
 603         // 24b. Place of Service
 604         put_hcfa($lino, 19, 2, $claim->facilityPOS());
 605
 606         // 24c. EMG
 607         // Not currently supported.
 608
 609         // 24d. Procedures, Services or Supplies
 610         put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 611         // replace colon with space for printing
 612         put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 613
 614         // 24e. Diagnosis Pointer
 615         $tmp = '';
 616         foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) {
 617             if (hcfa_1500_version_02_12()) {// For 02/12 Version convert number to letter.
 618             // ASCII A is 65, since diagIndexArray is ones based, this will make 1->A, 2->B...
 619                 $value=chr($value+64);
 620             }
 621
 622             $tmp .= $value;
 623         }
 624
 625         put_hcfa($lino, 45, 4, $tmp);
 626
 627         // 24f. Charges
 628         put_hcfa($lino, 50, 8, str_replace(
 629             '.',
 630             ' ',
 631             sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))
 632         ));
 633
 634         // 24g. Days or Units
 635         put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 636
 637         // 24h. EPSDT Family Plan
 638         //
 639         if ($claim->epsdtFlag()) {
 640               put_hcfa($lino, 63, 2, '03');
 641         }
 642
 643         // 24j. Rendering Provider NPI
 644         put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 645     }
 646
 647   // 25. Federal Tax ID Number
 648   // FrreB hard coded EIN. Changed it to included SSN as well.
 649     put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 650     if ($claim->federalIdType()=='SY') {
 651         put_hcfa(56, 17, 1, 'X'); // The SSN checkbox
 652     } else {
 653         put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 654     }
 655
 656   // 26. Patient's Account No.
 657   // Instructions say hyphens are not allowed.
 658     put_hcfa(56, 23, 15, "$pid-$encounter");
 659
 660   // 27. Accept Assignment
 661     put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 662
 663   // 28. Total Charge
 664     put_hcfa(56, 52, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_total_charges)));
 665     if (!$clm_total_charges) {
 666         $log .= "*** This claim has no charges!\n";
 667     }
 668
 669   // 29. Amount Paid
 670     put_hcfa(56, 62, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_amount_paid)));
 671
 672   // 30. Balance Due
 673   // For secondary payers this reflects primary "contracted rate" adjustments,
 674   // so in general box 30 will not equal box 28 minus box 29.
 675     if (!hcfa_1500_version_02_12()) {  // Box 30 Reserved for NUCC Use in 02/12
 676         put_hcfa(56, 71, 8, str_replace('.', ' ', sprintf(
 677             '%8.2f',
 678             $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted
 679         )));
 680     }
 681
 682   // 33. Billing Provider: Phone Number
 683     $tmp = $claim->billingContactPhone();
 684     put_hcfa(57, 66, 3, substr($tmp, 0, 3));
 685     put_hcfa(57, 70, 3, substr($tmp, 3)); // slight adjustment for better look smw 030315
 686     put_hcfa(57, 73, 1, '-');
 687     put_hcfa(57, 74, 4, substr($tmp, 6));
 688
 689   // 32. Service Facility Location Information: Name
 690     put_hcfa(58, 23, 25, $claim->facilityName());
 691
 692   // 33. Billing Provider: Name
 693     if ($claim->federalIdType()=='SY') {
 694         $tempName = $claim->billingFacilityName();
 695         $partsName = explode(' ', $tempName);// entity == person
 696         $num_parts = count($partsName);
 697         switch ($num_parts) {
 698             case "2":
 699                 $firstName = $partsName[0];
 700                 $lastName = $partsName[1];
 701                 $billingProviderName = $lastName . ", " . $firstName;
 702                 break;
 703             case "3":
 704                 $firstName = $partsName[0];
 705                 $middleName = $partsName[1];
 706                 $lastName = $partsName[2];
 707                 $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName;
 708                 break;
 709             case "4":
 710                 $firstName = $partsName[0];
 711                 $middleName = $partsName[1];
 712                 $lastName = $partsName[2];
 713                 $suffixName = $partsName[3];
 714                 $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 715                 break;
 716             default:
 717                 $log .= "*** individual name has more than 4 parts and may not be desirable on the claim form\n";
 718                 $firstName = $partsName[0];
 719                 $middleName = $partsName[1];
 720                 $lastName = $partsName[2];
 721                 $suffixName = $partsName[3];
 722                 $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 723         }
 724
 725         put_hcfa(58, 50, 25, $billingProviderName);
 726     } else {
 727         put_hcfa(58, 50, 25, $claim->billingFacilityName());
 728     }
 729
 730   // 32. Service Facility Location Information: Street
 731     put_hcfa(59, 23, 25, $claim->facilityStreet());
 732
 733   // 33. Billing Provider: Name
 734     put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 735
 736   // 31. Signature of Physician or Supplier
 737
 738     if ($GLOBALS['cms_1500_box_31_format']==0) {
 739         put_hcfa(60, 1, 20, 'Signature on File');
 740     } else if ($GLOBALS['cms_1500_box_31_format']==1) {
 741         put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 742     }
 743
 744   //
 745   // $tmp = $claim->providerFirstName();
 746   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 747   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 748
 749   // 32. Service Facility Location Information: City State Zip
 750     $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 751     put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 752     $claim->facilityZip());
 753
 754   // 33. Billing Provider: City State Zip
 755     $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 756     put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 757     $claim->billingFacilityZip());
 758
 759   // 31. Signature of Physician or Supplier: Date
 760     if ($GLOBALS['cms_1500_box_31_date']>0) {
 761         if ($GLOBALS['cms_1500_box_31_date']==1) {
 762             $date_of_service= $claim->serviceDate();
 763             $MDY=substr($date_of_service, 4, 2)." ".substr($date_of_service, 6, 2)." ".substr($date_of_service, 2, 2);
 764         } else if ($GLOBALS['cms_1500_box_31_date']==2) {
 765             $MDY=date("m/d/y");
 766         }
 767
 768         put_hcfa(61, 6, 10, $MDY);
 769     }
 770
 771   // 32a. Service Facility NPI
 772     put_hcfa(61, 23, 10, $claim->facilityNPI());
 773
 774   // 32b. Service Facility Other ID
 775   // Note that Medicare does NOT want this any more.
 776     if ($claim->providerGroupNumber()) {
 777         put_hcfa(61, 36, 2, $claim->providerNumberType());
 778         put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 779     }
 780
 781   // 33a. Billing Facility NPI
 782     put_hcfa(61, 50, 10, $claim->billingFacilityNPI());
 783
 784   // 33b. Billing Facility Other ID
 785   // Note that Medicare does NOT want this any more.
 786     if ($claim->claimType() == 'MC') {
 787         put_hcfa(61, 63, 2, 'ZZ');
 788         put_hcfa(61, 65, 14, $claim->providerTaxonomy());
 789     } elseif ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 790         put_hcfa(61, 63, 2, $claim->providerNumberType());
 791         put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 792     }
 793
 794   // Put an extra line here for compatibility with old hcfa text generated form
 795     put_hcfa(62, 1, 1, ' ');
 796   // put a couple more in so that multiple claims correctly print through the text file download
 797     put_hcfa(63, 1, 1, ' ');
 798     put_hcfa(64, 1, 1, ' ');
 799     return;
 800 }