library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007-2009 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 require_once("Claim.class.php");
  10
  11 function gen_x12_837($pid, $encounter, &$log, $encounter_claim=false) {
  12
  13   $today = time();
  14   $out = '';
  15   $claim = new Claim($pid, $encounter);
  16   $edicount = 0;
  17
  18   $log .= "Generating claim $pid-$encounter for " .
  19     $claim->patientFirstName()  . ' ' .
  20     $claim->patientMiddleName() . ' ' .
  21     $claim->patientLastName()   . ' on ' .
  22     date('Y-m-d H:i', $today) . ".\n";
  23
  24   $out .= "ISA" .
  25     "*00" .
  26     "*          " .
  27     "*00" .
  28     "*          " .
  29     "*" . $claim->x12gsisa05() .
  30     "*" . $claim->x12gssenderid() .
  31     "*" . $claim->x12gsisa07() .
  32     "*" . $claim->x12gsreceiverid() .
  33     "*030911" .
  34     "*1630" .
  35     "*U" .
  36     "*00401" .
  37     "*000000001" .
  38     "*" . $claim->x12gsisa14() .
  39     "*" . $claim->x12gsisa15() .
  40     "*:" .
  41     "~\n";
  42
  43   $out .= "GS" .
  44     "*HC" .
  45     "*" . $claim->x12gsgs02() .
  46     "*" . trim($claim->x12gsreceiverid()) .
  47     "*" . date('Ymd', $today) .
  48     "*" . date('Hi', $today) .
  49     "*1" .
  50     "*X" .
  51     "*" . $claim->x12gsversionstring() .
  52     "~\n";
  53
  54   ++$edicount;
  55   $out .= "ST" .
  56     "*837" .
  57     "*0021" .
  58     "~\n";
  59
  60   ++$edicount;
  61   $out .= "BHT" .
  62     "*0019" .
  63     "*00" .
  64     "*0123" .
  65     "*" . date('Ymd', $today) .
  66     "*1023" .
  67     ($encounter_claim ? "*RP" : "*CH") .
  68     "~\n";
  69
  70   ++$edicount;
  71   $out .= "REF" .
  72     "*87" .
  73     "*" . $claim->x12gsversionstring() .
  74     "~\n";
  75
  76   ++$edicount;
  77   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
  78   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
  79   $out .= "NM1" .       // Loop 1000A Submitter
  80     "*41" .
  81     "*2" .
  82     "*" . $billingFacilityName .
  83     "*" .
  84     "*" .
  85     "*" .
  86     "*" .
  87     "*46";
  88    if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
  89     $out  .=  "*" . $claim->clearingHouseETIN();
  90    } else {
  91     $out  .=  "*" . $claim->billingFacilityETIN();
  92    }
  93     $out .= "~\n";
  94
  95   ++$edicount;
  96   $out .= "PER" .
  97     "*IC" .
  98     "*" . $claim->billingContactName() .
  99     "*TE" .
 100     "*" . $claim->billingContactPhone();
 101   if ($claim->x12gsper06()) {
 102     $out .= "*ED*" . $claim->x12gsper06();
 103   }
 104   $out .= "~\n";
 105
 106   ++$edicount;
 107   $out .= "NM1" .       // Loop 1000B Receiver
 108     "*40" .
 109     "*2" .
 110     "*" . $claim->clearingHouseName() .
 111     "*" .
 112     "*" .
 113     "*" .
 114     "*" .
 115     "*46" .
 116     "*" . $claim->clearingHouseETIN() .
 117     "~\n";
 118
 119   $HLcount = 1;
 120
 121   ++$edicount;
 122   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 123     "*$HLcount" .
 124     "*" .
 125     "*20" .
 126     "*1" .
 127     "~\n";
 128
 129   $HLBillingPayToProvider = $HLcount++;
 130
 131   ++$edicount;
 132   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 133   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
 134   $out .= "NM1" .       // Loop 2010AA Billing Provider
 135     "*85" .
 136     "*2" .
 137     "*" . $billingFacilityName .
 138     "*" .
 139     "*" .
 140     "*" .
 141     "*";
 142   if ($claim->billingFacilityNPI()) {
 143     $out .= "*XX*" . $claim->billingFacilityNPI();
 144   } else {
 145     $log .= "*** Billing facility has no NPI.\n";
 146     $out .= "*24*" . $claim->billingFacilityETIN();
 147   }
 148   $out .= "~\n";
 149
 150   ++$edicount;
 151   $out .= "N3" .
 152     "*" . $claim->billingFacilityStreet() .
 153     "~\n";
 154
 155   ++$edicount;
 156   $out .= "N4" .
 157     "*" . $claim->billingFacilityCity() .
 158     "*" . $claim->billingFacilityState() .
 159     "*" . $claim->billingFacilityZip() .
 160     "~\n";
 161
 162   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 163   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 164     ++$edicount;
 165     $out .= "REF" ;
 166         if($claim->federalIdType()){
 167       $out .= "*" . $claim->federalIdType();
 168         }
 169         else{
 170           $out .= "*EI";//For dealing with the situation before adding selection for TaxId type In facility ie default to EIN.
 171         }
 172       $out .=  "*" . $claim->billingFacilityETIN() .
 173       "~\n";
 174   }
 175
 176   if ($claim->providerNumberType() && $claim->providerNumber()) {
 177     ++$edicount;
 178     $out .= "REF" .
 179       "*" . $claim->providerNumberType() .
 180       "*" . $claim->providerNumber() .
 181       "~\n";
 182   }
 183   else if ($claim->providerNumber()) {
 184     $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 185   }
 186
 187   ++$edicount;
 188   //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 189   $billingFacilityName=substr($claim->billingFacilityName(),0,35);
 190   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 191     "*87" .
 192     "*2" .
 193     "*" . $billingFacilityName .
 194     "*" .
 195     "*" .
 196     "*" .
 197     "*";
 198   if ($claim->billingFacilityNPI())
 199     $out .= "*XX*" . $claim->billingFacilityNPI();
 200   else
 201     $out .= "*24*" . $claim->billingFacilityETIN();
 202   $out .= "~\n";
 203
 204   ++$edicount;
 205   $out .= "N3" .
 206     "*" . $claim->billingFacilityStreet() .
 207     "~\n";
 208
 209   ++$edicount;
 210   $out .= "N4" .
 211     "*" . $claim->billingFacilityCity() .
 212     "*" . $claim->billingFacilityState() .
 213     "*" . $claim->billingFacilityZip() .
 214     "~\n";
 215
 216   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 217     ++$edicount;
 218     $out .= "REF" .
 219       "*EI" .
 220       "*" . $claim->billingFacilityETIN() .
 221       "~\n";
 222   }
 223
 224   $PatientHL = 0;
 225
 226   ++$edicount;
 227   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 228     "*$HLcount" .
 229     "*$HLBillingPayToProvider" .
 230     "*22" .
 231     "*$PatientHL" .
 232     "~\n";
 233
 234   $HLSubscriber = $HLcount++;
 235
 236   if (!$claim->payerSequence()) {
 237     $log .= "*** Error: Insurance information is missing!\n";
 238   }
 239   ++$edicount;
 240   $out .= "SBR" .       // Subscriber Information
 241     "*" . $claim->payerSequence() .
 242     "*" . $claim->insuredRelationship() .
 243     "*" . $claim->groupNumber() .
 244     "*" . $claim->groupName() .
 245     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 246     "*" .
 247     "*" .
 248     "*" .
 249     "*" . $claim->claimType() . // Zirmed replaces this
 250     "~\n";
 251
 252   ++$edicount;
 253   $out .= "NM1" .       // Loop 2010BA Subscriber
 254     "*IL" .
 255     "*1" .
 256     "*" . $claim->insuredLastName() .
 257     "*" . $claim->insuredFirstName() .
 258     "*" . $claim->insuredMiddleName() .
 259     "*" .
 260     "*" .
 261     "*MI" .
 262     "*" . $claim->policyNumber() .
 263     "~\n";
 264
 265   ++$edicount;
 266   $out .= "N3" .
 267     "*" . $claim->insuredStreet() .
 268     "~\n";
 269
 270   ++$edicount;
 271   $out .= "N4" .
 272     "*" . $claim->insuredCity() .
 273     "*" . $claim->insuredState() .
 274     "*" . $claim->insuredZip() .
 275     "~\n";
 276
 277   ++$edicount;
 278   $out .= "DMG" .
 279     "*D8" .
 280     "*" . $claim->insuredDOB() .
 281     "*" . $claim->insuredSex() .
 282     "~\n";
 283
 284   ++$edicount;
 285   //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 286   $payerName=substr($claim->payerName(),0,35);
 287   $out .= "NM1" .       // Loop 2010BB Payer
 288     "*PR" .
 289     "*2" .
 290     "*" . $payerName .
 291     "*" .
 292     "*" .
 293     "*" .
 294     "*" .
 295     "*PI" .
 296     // Zirmed ignores this if using payer name matching:
 297     "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 298     "~\n";
 299
 300   // if (!$claim->payerID()) {
 301   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 302   // }
 303
 304   ++$edicount;
 305   $out .= "N3" .
 306     "*" . $claim->payerStreet() .
 307     "~\n";
 308
 309   ++$edicount;
 310   $out .= "N4" .
 311     "*" . $claim->payerCity() .
 312     "*" . $claim->payerState() .
 313     "*" . $claim->payerZip() .
 314     "~\n";
 315
 316   if (! $claim->isSelfOfInsured()) {
 317     ++$edicount;
 318     $out .= "HL" .        // Loop 2000C Patient Information
 319       "*$HLcount" .
 320       "*$HLSubscriber" .
 321       "*23" .
 322       "*0" .
 323       "~\n";
 324
 325     $HLcount++;
 326
 327     ++$edicount;
 328     $out .= "PAT" .
 329       "*" . $claim->insuredRelationship() .
 330       "~\n";
 331
 332     ++$edicount;
 333     $out .= "NM1" .       // Loop 2010CA Patient
 334       "*QC" .
 335       "*1" .
 336       "*" . $claim->patientLastName() .
 337       "*" . $claim->patientFirstName() .
 338       "*" . $claim->patientMiddleName() .
 339       "~\n";
 340
 341     ++$edicount;
 342     $out .= "N3" .
 343       "*" . $claim->patientStreet() .
 344       "~\n";
 345
 346     ++$edicount;
 347     $out .= "N4" .
 348       "*" . $claim->patientCity() .
 349       "*" . $claim->patientState() .
 350       "*" . $claim->patientZip() .
 351       "~\n";
 352
 353     ++$edicount;
 354     $out .= "DMG" .
 355       "*D8" .
 356       "*" . $claim->patientDOB() .
 357       "*" . $claim->patientSex() .
 358       "~\n";
 359   } // end of patient different from insured
 360
 361   $proccount = $claim->procCount();
 362
 363   $clm_total_charges = 0;
 364   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 365     $clm_total_charges += $claim->cptCharges($prockey);
 366   }
 367
 368   if (!$clm_total_charges) {
 369     $log .= "*** This claim has no charges!\n";
 370   }
 371
 372
 373   ++$edicount;
 374   $out .= "CLM" .       // Loop 2300 Claim
 375     "*$pid-$encounter" .
 376     "*"  . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 377     "*"  .
 378     "*"  .
 379     "*" . sprintf('%02d', $claim->facilityPOS()) . "::" . $claim->frequencyTypeCode() . // Changed to correct single digit output
 380     "*Y" .
 381     "*A" .
 382     "*"  . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 383     "*Y" .
 384     "*C" .
 385     "~\n";
 386
 387   ++$edicount;
 388   $out .= "DTP" .       // Date of Onset
 389     "*431" .
 390     "*D8" .
 391     "*" . $claim->onsetDate() .
 392     "~\n";
 393
 394   if (strcmp($claim->facilityPOS(),'21') == 0) {
 395     ++$edicount;
 396     $out .= "DTP" .     // Date of Hospitalization
 397       "*435" .
 398       "*D8" .
 399       "*" . $claim->onsetDate() .
 400       "~\n";
 401   }
 402
 403   $patientpaid = $claim->patientPaidAmount();
 404   if ($patientpaid != 0) {
 405     ++$edicount;
 406     $out .= "AMT" .     // Patient paid amount. Page 220.
 407       "*F5" .
 408       "*" . $patientpaid .
 409       "~\n";
 410   }
 411
 412   if ($claim->priorAuth()) {
 413     ++$edicount;
 414     $out .= "REF" .     // Prior Authorization Number
 415       "*G1" .
 416       "*" . $claim->priorAuth() .
 417       "~\n";
 418   }
 419
 420   if ($claim->cliaCode() and $claim->claimType() === 'MB') {
 421     // Required by Medicare when in-house labs are done.
 422     ++$edicount;
 423     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 424       "*X4" .
 425       "*" . $claim->cliaCode() .
 426       "~\n";
 427   }
 428
 429   // Note: This would be the place to implement the NTE segment for loop 2300.
 430   if ($claim->additionalNotes()) {
 431     // Claim note.
 432     ++$edicount;
 433     $out .= "NTE" .     // comments box 19
 434       "*" .
 435       "*" . $claim->additionalNotes() .
 436       "~\n";
 437   }
 438
 439   // Diagnoses, up to 8 per HI segment.
 440   $da = $claim->diagArray();
 441   $diag_type_code = 'BK';
 442   $tmp = 0;
 443   foreach ($da as $diag) {
 444     if ($tmp % 8 == 0) {
 445       if ($tmp) $out .= "~\n";
 446       ++$edicount;
 447       $out .= "HI";         // Health Diagnosis Codes
 448     }
 449     $out .= "*$diag_type_code:" . $diag;
 450     $diag_type_code = 'BF';
 451     ++$tmp;
 452   }
 453   if ($tmp) $out .= "~\n";
 454
 455   if ($claim->referrerLastName()) {
 456     // Medicare requires referring provider's name and UPIN.
 457     ++$edicount;
 458     $out .= "NM1" .     // Loop 2310A Referring Provider
 459       "*DN" .
 460       "*1" .
 461       "*" . $claim->referrerLastName() .
 462       "*" . $claim->referrerFirstName() .
 463       "*" . $claim->referrerMiddleName() .
 464       "*" .
 465       "*";
 466     if ($claim->referrerNPI()) { $out .=
 467       "*XX" .
 468       "*" . $claim->referrerNPI();
 469     } else { $out .=
 470       "*34" .
 471       "*" . $claim->referrerSSN();
 472     }
 473     $out .= "~\n";
 474
 475     if ($claim->referrerTaxonomy()) {
 476       ++$edicount;
 477       $out .= "PRV" .
 478         "*RF" . // ReFerring provider
 479         "*ZZ" .
 480         "*" . $claim->referrerTaxonomy() .
 481         "~\n";
 482     }
 483
 484     if ($claim->referrerUPIN()) {
 485       ++$edicount;
 486       $out .= "REF" .   // Referring Provider Secondary Identification
 487         "*1G" .
 488         "*" . $claim->referrerUPIN() .
 489         "~\n";
 490     }
 491   }
 492
 493   ++$edicount;
 494   $out .= "NM1" .       // Loop 2310B Rendering Provider
 495     "*82" .
 496     "*1" .
 497     "*" . $claim->providerLastName() .
 498     "*" . $claim->providerFirstName() .
 499     "*" . $claim->providerMiddleName() .
 500     "*" .
 501     "*";
 502   if ($claim->providerNPI()) { $out .=
 503     "*XX" .
 504     "*" . $claim->providerNPI();
 505   } else { $out .=
 506     "*34" .
 507     "*" . $claim->providerSSN();
 508     $log .= "*** Rendering provider has no NPI.\n";
 509   }
 510   $out .= "~\n";
 511
 512   if ($claim->providerTaxonomy()) {
 513     ++$edicount;
 514     $out .= "PRV" .
 515       "*PE" . // PErforming provider
 516       "*ZZ" .
 517       "*" . $claim->providerTaxonomy() .
 518       "~\n";
 519   }
 520
 521   // REF*1C is required here for the Medicare provider number if NPI was
 522   // specified in NM109.  Not sure if other payers require anything here.
 523   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 524
 525    if (trim($claim->x12gsreceiverid()) != '470819582') { // if NOT ECLAIMS EDI
 526       if ($claim->providerNumber()) {
 527         ++$edicount;
 528         $out .= "REF" .
 529           "*" . $claim->providerNumberType() .
 530           "*" . $claim->providerNumber() .
 531           "~\n";
 532       }
 533    }
 534
 535   // Loop 2310D is omitted in the case of home visits (POS=12).
 536   if ($claim->facilityPOS() != 12) {
 537     ++$edicount;
 538     $out .= "NM1" .       // Loop 2310D Service Location
 539       "*77" .
 540       "*2";
 541    //Field length is limited to 35. See nucc dataset page 77 www.nucc.org
 542         $facilityName=substr($claim->facilityName(),0,35);
 543     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 544       "*" . $facilityName;
 545     }
 546     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 547       "*" .
 548       "*" .
 549       "*" .
 550       "*";
 551       if ($claim->facilityNPI()) { $out .=
 552         "*XX*" . $claim->facilityNPI();
 553       } else { $out .=
 554         "*24*" . $claim->facilityETIN();
 555         $log .= "*** Service location has no NPI.\n";
 556       }
 557     }
 558     $out .= "~\n";
 559     if ($claim->facilityStreet()) {
 560       ++$edicount;
 561       $out .= "N3" .
 562         "*" . $claim->facilityStreet() .
 563         "~\n";
 564     }
 565     if ($claim->facilityState()) {
 566       ++$edicount;
 567       $out .= "N4" .
 568         "*" . $claim->facilityCity() .
 569         "*" . $claim->facilityState() .
 570         "*" . $claim->facilityZip() .
 571         "~\n";
 572     }
 573   }
 574
 575   // Loop 2310E, Supervising Provider
 576   //
 577   if ($claim->supervisorLastName()) {
 578     ++$edicount;
 579     $out .= "NM1" .
 580       "*DQ" . // Supervising Physician
 581       "*1" .  // Person
 582       "*" . $claim->supervisorLastName() .
 583       "*" . $claim->supervisorFirstName() .
 584       "*" . $claim->supervisorMiddleName() .
 585       "*" .   // NM106 not used
 586       "*";    // Name Suffix
 587     if ($claim->supervisorNPI()) { $out .=
 588       "*XX" .
 589       "*" . $claim->supervisorNPI();
 590     } else { $out .=
 591       "*34" .
 592       "*" . $claim->supervisorSSN();
 593     }
 594     $out .= "~\n";
 595
 596     if ($claim->supervisorNumber()) {
 597       ++$edicount;
 598       $out .= "REF" .
 599         "*" . $claim->supervisorNumberType() .
 600         "*" . $claim->supervisorNumber() .
 601         "~\n";
 602     }
 603   }
 604
 605   $prev_pt_resp = $clm_total_charges; // for computation below
 606
 607   // Loops 2320 and 2330*, other subscriber/payer information.
 608   //
 609   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 610
 611     $tmp1 = $claim->claimType($ins);
 612     $tmp2 = 'C1'; // Here a kludge. See page 321.
 613     if ($tmp1 === 'CI') $tmp2 = 'C1';
 614     if ($tmp1 === 'AM') $tmp2 = 'AP';
 615     if ($tmp1 === 'HM') $tmp2 = 'HM';
 616     if ($tmp1 === 'MB') $tmp2 = 'MB';
 617     if ($tmp1 === 'MC') $tmp2 = 'MC';
 618     if ($tmp1 === '09') $tmp2 = 'PP';
 619     ++$edicount;
 620     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 621       "*" . $claim->payerSequence($ins) .
 622       "*" . $claim->insuredRelationship($ins) .
 623       "*" . $claim->groupNumber($ins) .
 624       "*" . $claim->groupName($ins) .
 625       "*" . $tmp2 .
 626       "*" .
 627       "*" .
 628       "*" .
 629       "*" . $claim->claimType($ins) .
 630       "~\n";
 631
 632     // Things that apply only to previous payers, not future payers.
 633     //
 634     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 635
 636       // Generate claim-level adjustments.
 637       $aarr = $claim->payerAdjustments($ins);
 638       foreach ($aarr as $a) {
 639         ++$edicount;
 640         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 641           "*" . $a[1] .
 642           "*" . $a[2] .
 643           "*" . $a[3] .
 644           "~\n";
 645       }
 646
 647       $payerpaid = $claim->payerTotals($ins);
 648       ++$edicount;
 649       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 650         "*D" .
 651         "*" . $payerpaid[1] .
 652         "~\n";
 653
 654       // Patient responsibility amount as of this previous payer.
 655       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 656       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 657
 658       ++$edicount;
 659       $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 660         "*B6" .
 661         "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 662         "~\n";
 663
 664       ++$edicount;
 665       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 666         "*F2" .
 667         "*" . sprintf('%.2f', $prev_pt_resp) .
 668         "~\n";
 669
 670     } // End of things that apply only to previous payers.
 671
 672     ++$edicount;
 673     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 674       "*D8" .
 675       "*" . $claim->insuredDOB($ins) .
 676       "*" . $claim->insuredSex($ins) .
 677       "~\n";
 678
 679     ++$edicount;
 680     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 681       "*" .
 682       "*" .
 683       "*Y" .
 684       "*B" .
 685       "*" .
 686       "*Y" .
 687       "~\n";
 688
 689     ++$edicount;
 690     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 691       "*IL" .
 692       "*1" .
 693       "*" . $claim->insuredLastName($ins) .
 694       "*" . $claim->insuredFirstName($ins) .
 695       "*" . $claim->insuredMiddleName($ins) .
 696       "*" .
 697       "*" .
 698       "*MI" .
 699       "*" . $claim->policyNumber($ins) .
 700       "~\n";
 701
 702     ++$edicount;
 703     $out .= "N3" .
 704       "*" . $claim->insuredStreet($ins) .
 705       "~\n";
 706
 707     ++$edicount;
 708     $out .= "N4" .
 709       "*" . $claim->insuredCity($ins) .
 710       "*" . $claim->insuredState($ins) .
 711       "*" . $claim->insuredZip($ins) .
 712       "~\n";
 713
 714     ++$edicount;
 715     //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 716     $payerName=substr($claim->payerName($ins),0,35);
 717     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 718       "*PR" .
 719       "*2" .
 720       "*" . $payerName .
 721       "*" .
 722       "*" .
 723       "*" .
 724       "*" .
 725       "*PI" .
 726       "*" . $claim->payerID($ins) .
 727       "~\n";
 728
 729     // if (!$claim->payerID($ins)) {
 730     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 731     // }
 732
 733     // Payer address (N3 and N4) are added below so that Gateway EDI can
 734     // auto-generate secondary claims.  These do NOT appear in my copy of
 735     // the spec!  -- Rod 2008-06-12
 736
 737     if (trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 738       ++$edicount;
 739       $out .= "N3" .
 740         "*" . $claim->payerStreet($ins) .
 741         "~\n";
 742       //
 743       ++$edicount;
 744       $out .= "N4" .
 745         "*" . $claim->payerCity($ins) .
 746         "*" . $claim->payerState($ins) .
 747         "*" . $claim->payerZip($ins) .
 748         "~\n";
 749     } // end Gateway EDI
 750
 751   } // End loops 2320/2330*.
 752
 753   $loopcount = 0;
 754
 755   // Procedure loop starts here.
 756   //
 757   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 758     ++$loopcount;
 759
 760     ++$edicount;
 761     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 762       "*$loopcount" .
 763       "~\n";
 764
 765     ++$edicount;
 766     $out .= "SV1" .     // Professional Service. Page 400.
 767       "*HC:" . $claim->cptKey($prockey) .
 768       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 769       "*UN" .
 770       "*" . $claim->cptUnits($prockey) .
 771       "*" .
 772       "*" .
 773       "*";
 774     $dia = $claim->diagIndexArray($prockey);
 775     $i = 0;
 776     foreach ($dia as $dindex) {
 777       if ($i) $out .= ':';
 778       $out .= $dindex;
 779       if (++$i >= 4) break;
 780     }
 781     $out .= "~\n";
 782
 783     if (!$claim->cptCharges($prockey)) {
 784       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 785     }
 786
 787     if (empty($dia)) {
 788       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 789     }
 790
 791     ++$edicount;
 792     $out .= "DTP" .     // Date of Service. Page 435.
 793       "*472" .
 794       "*D8" .
 795       "*" . $claim->serviceDate() .
 796       "~\n";
 797
 798     // AMT*AAE segment for Approved Amount from previous payer.
 799     // Medicare secondaries seem to require this.
 800     //
 801     for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
 802       if ($claim->payerSequence($ins) > $claim->payerSequence())
 803         continue; // payer is future, not previous
 804       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 805       ++$edicount;
 806       $out .= "AMT" . // Approved amount per previous payer. Page 485.
 807         "*AAE" .
 808         "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
 809         "~\n";
 810       break;
 811     }
 812
 813     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 814     // with HCPCS codes.
 815     //
 816     $ndc = $claim->cptNDCID($prockey);
 817     if ($ndc) {
 818       ++$edicount;
 819       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 820         "*" .         // Per addendum, LIN01 is not used.
 821         "*N4" .
 822         "*" . $ndc .
 823         "~\n";
 824
 825       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 826         $log .= "*** NDC code '$ndc' has invalid format!\n";
 827       }
 828
 829       ++$edicount;
 830       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 831       if (!$tmpunits) $tmpunits = 1;
 832       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 833         "*" .
 834         "*" .
 835         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 836         "*" . $claim->cptNDCQuantity($prockey) .
 837         "*" . $claim->cptNDCUOM($prockey) .
 838         "~\n";
 839     }
 840
 841     // Loop 2420A, Rendering Provider (service-specific).
 842     // Used if the rendering provider for this service line is different
 843     // from that in loop 2310B.
 844     //
 845     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
 846       ++$edicount;
 847       $out .= "NM1" .       // Loop 2310B Rendering Provider
 848         "*82" .
 849         "*1" .
 850         "*" . $claim->providerLastName($prockey) .
 851         "*" . $claim->providerFirstName($prockey) .
 852         "*" . $claim->providerMiddleName($prockey) .
 853         "*" .
 854         "*";
 855       if ($claim->providerNPI($prockey)) { $out .=
 856         "*XX" .
 857         "*" . $claim->providerNPI($prockey);
 858       } else { $out .=
 859         "*34" .
 860         "*" . $claim->providerSSN($prockey);
 861         $log .= "*** Rendering provider has no NPI.\n";
 862       }
 863       $out .= "~\n";
 864
 865       if ($claim->providerTaxonomy($prockey)) {
 866         ++$edicount;
 867         $out .= "PRV" .
 868           "*PE" . // PErforming provider
 869           "*ZZ" .
 870           "*" . $claim->providerTaxonomy($prockey) .
 871           "~\n";
 872       }
 873
 874       // REF*1C is required here for the Medicare provider number if NPI was
 875       // specified in NM109.  Not sure if other payers require anything here.
 876       if ($claim->providerNumber($prockey)) {
 877         ++$edicount;
 878         $out .= "REF" .
 879           "*" . $claim->providerNumberType($prockey) .
 880           "*" . $claim->providerNumber($prockey) .
 881           "~\n";
 882       }
 883     }
 884
 885     // Loop 2430, adjudication by previous payers.
 886     //
 887     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 888       if ($claim->payerSequence($ins) > $claim->payerSequence())
 889         continue; // payer is future, not previous
 890
 891       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 892       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 893
 894       if ($payerpaid[1] == 0 && !count($aarr)) {
 895         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 896           "' has no payments or adjustments from previous payer!\n";
 897         continue;
 898       }
 899
 900       ++$edicount;
 901       $out .= "SVD" . // Service line adjudication. Page 554.
 902         "*" . $claim->payerID($ins) .
 903         "*" . $payerpaid[1] .
 904         "*HC:" . $claim->cptKey($prockey) .
 905         "*" .
 906         "*" . $claim->cptUnits($prockey) .
 907         "~\n";
 908
 909       $tmpdate = $payerpaid[0];
 910       foreach ($aarr as $a) {
 911         ++$edicount;
 912         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 913           "*" . $a[1] .
 914           "*" . $a[2] .
 915           "*" . $a[3] .
 916           "~\n";
 917         if (!$tmpdate) $tmpdate = $a[0];
 918       }
 919
 920       if ($tmpdate) {
 921         ++$edicount;
 922         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 923           "*573" .
 924           "*D8" .
 925           "*$tmpdate" .
 926           "~\n";
 927       }
 928     } // end loop 2430
 929   } // end this procedure
 930
 931   ++$edicount;
 932   $out .= "SE" .        // SE Trailer
 933     "*$edicount" .
 934     "*0021" .
 935     "~\n";
 936
 937   $out .= "GE" .        // GE Trailer
 938     "*1" .
 939     "*1" .
 940     "~\n";
 941
 942   $out .= "IEA" .       // IEA Trailer
 943     "*1" .
 944     "*000000001" .
 945     "~\n";
 946
 947   $log .= "\n";
 948   return $out;
 949 }
 950 ?>