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