library/gen_hcfa_1500.inc.php

   1 <?php
   2 // Copyright (C) 2008-2011 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 $hcfa_curr_line = 1;
  12 $hcfa_curr_col = 1;
  13 $hcfa_data = '';
  14 $hcfa_proc_index = 0;
  15
  16 function put_hcfa($line, $col, $maxlen, $data) {
  17   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  18   if ($line < $hcfa_curr_line)
  19     die("Data item at ($line, $col) precedes current line.");
  20   while ($hcfa_curr_line < $line) {
  21     $hcfa_data .= "\n";
  22     ++$hcfa_curr_line;
  23     $hcfa_curr_col = 1;
  24   }
  25   if ($col < $hcfa_curr_col)
  26     die("Data item at ($line, $col) precedes current column.");
  27   while ($hcfa_curr_col < $col) {
  28     $hcfa_data .= " ";
  29     ++$hcfa_curr_col;
  30   }
  31   $data = preg_replace('/[.#]/', '', strtoupper($data));
  32   $len = min(strlen($data), $maxlen);
  33   $hcfa_data .= substr($data, 0, $len);
  34   $hcfa_curr_col += $len;
  35 }
  36
  37 function gen_hcfa_1500($pid, $encounter, &$log) {
  38   global $hcfa_data, $hcfa_proc_index;
  39
  40   $hcfa_data = '';
  41   $hcfa_proc_index = 0;
  42
  43   $today = time();
  44   $claim = new Claim($pid, $encounter);
  45
  46   $log .= "Generating HCFA claim $pid-$encounter for " .
  47     $claim->patientFirstName()  . ' ' .
  48     $claim->patientMiddleName() . ' ' .
  49     $claim->patientLastName()   . ' on ' .
  50     date('Y-m-d H:i', $today) . ".\n";
  51
  52   while ($hcfa_proc_index < $claim->procCount()) {
  53     if ($hcfa_proc_index) $hcfa_data .= "\014"; // append form feed for new page
  54     gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  55   }
  56
  57   $log .= "\n";
  58   return $hcfa_data;
  59 }
  60
  61 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim) {
  62   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  63
  64   $hcfa_curr_line = 1;
  65   $hcfa_curr_col = 1;
  66
  67   // According to:
  68   // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
  69   // Medicare interprets sections 9 and 11 of the claim form in its own
  70   // special way.  This flag tells us to do that.  However I'm not 100%
  71   // sure that it applies nationwide, and if you find that it is not right
  72   // for you then set it to false.  -- Rod 2009-03-26
  73   $new_medicare_logic = $claim->claimType() == 'MB';
  74
  75   // Payer name, attn, street.
  76   put_hcfa(2, 41, 31, $claim->payerName());
  77   put_hcfa(3, 41, 31, $claim->payerAttn());
  78   put_hcfa(4, 41, 31, $claim->payerStreet());
  79
  80   // Payer city, state, zip.
  81   $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
  82   put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
  83
  84   // Box 1. Insurance Type
  85   $ct = $claim->claimType();
  86   $tmpcol = 45;                        // Other
  87   if      ($ct === 'MB') $tmpcol =  1; // Medicare
  88   else if ($ct === 'MC') $tmpcol =  8; // Medicaid
  89   else if ($ct === 'CH') $tmpcol = 15; // Champus
  90   else if ($ct === 'CH') $tmpcol = 24; // Champus VA (why same code?)
  91   else if ($ct === 'BL') $tmpcol = 31; // Group Health Plan (only BCBS?)
  92   else if ($ct === '16') $tmpcol = 39; // FECA
  93   put_hcfa(8, $tmpcol, 1, 'X');
  94
  95   // Box 1a. Insured's ID Number
  96   put_hcfa(8, 50, 17, $claim->policyNumber());
  97
  98   // Box 2. Patient's Name
  99   $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 100   if ($claim->patientMiddleName())
 101     $tmp .= ', ' . substr($claim->patientMiddleName(),0,1);
 102   put_hcfa(10, 1, 28, $tmp);
 103
 104   // Box 3. Patient's Birth Date and Sex
 105   $tmp = $claim->patientDOB();
 106   put_hcfa(10, 31, 2, substr($tmp,4,2));
 107   put_hcfa(10, 34, 2, substr($tmp,6,2));
 108   put_hcfa(10, 37, 4, substr($tmp,0,4));
 109   put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 110
 111   // Box 4. Insured's Name
 112   $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 113   if ($claim->insuredMiddleName())
 114     $tmp .= ', ' . substr($claim->insuredMiddleName(),0,1);
 115   put_hcfa(10, 50, 28, $tmp);
 116
 117   // Box 5. Patient's Address
 118   put_hcfa(12, 1, 28, $claim->patientStreet());
 119
 120   // Box 6. Patient Relationship to Insured
 121   $tmp = $claim->insuredRelationship();
 122   $tmpcol = 47;                         // Other
 123   if      ($tmp === '18') $tmpcol = 33; // self
 124   else if ($tmp === '01') $tmpcol = 38; // spouse
 125   else if ($tmp === '19') $tmpcol = 42; // child
 126   put_hcfa(12, $tmpcol, 1, 'X');
 127
 128   // Box 7. Insured's Address
 129   put_hcfa(12, 50, 28, $claim->insuredStreet());
 130
 131   // Box 5 continued. Patient's City and State
 132   put_hcfa(14,  1, 20, $claim->patientCity());
 133   put_hcfa(14, 26,  2, $claim->patientState());
 134
 135   // Box 8. Patient (Marital) Status
 136   $tmp = $claim->patientStatus();
 137   $tmpcol = 47;                        // Other
 138   if      ($tmp === 'S') $tmpcol = 35; // Single
 139   else if ($tmp === 'M') $tmpcol = 41; // Married
 140   put_hcfa(14, $tmpcol, 1, 'X');
 141
 142   // Box 7 continued. Insured's City and State
 143   put_hcfa(14, 50, 20, $claim->insuredCity());
 144   put_hcfa(14, 74,  2, $claim->insuredState());
 145
 146   // Box 5 continued. Patient's Zip Code and Telephone
 147   put_hcfa(16,  1, 10, $claim->patientZip());
 148   $tmp = $claim->patientPhone();
 149   put_hcfa(16, 15,  3, substr($tmp,0,3));
 150   put_hcfa(16, 19,  7, substr($tmp,3));
 151
 152   // Box 8 continued. Patient (Employment) Status
 153   $tmp = $claim->patientOccupation();
 154   if      ($tmp === 'STUDENT'   ) put_hcfa(16, 41, 1, 'X');
 155   else if ($tmp === 'PT STUDENT') put_hcfa(16, 47, 1, 'X');
 156   else if ($tmp !== 'UNEMPLOYED') put_hcfa(16, 35, 1, 'X');
 157
 158   // Box 7 continued. Insured's Zip Code and Telephone
 159   put_hcfa(16, 50, 10, $claim->insuredZip());
 160   $tmp = $claim->insuredPhone();
 161   put_hcfa(16, 65,  3, substr($tmp,0,3));
 162   put_hcfa(16, 69,  7, substr($tmp,3));
 163
 164   // Box 9. Other Insured's Name
 165   if ($new_medicare_logic) {
 166     // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 167   }
 168   else {
 169     if ($claim->payerCount() > 1) {
 170       $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 171       if ($claim->insuredMiddleName(1))
 172         $tmp .= ', ' . substr($claim->insuredMiddleName(1),0,1);
 173       put_hcfa(18, 1, 28, $tmp);
 174     }
 175   }
 176
 177   // Box 11. Insured's Group Number
 178   if ($new_medicare_logic) {
 179     // If this is Medicare secondary then we need the primary's policy number
 180     // here, otherwise the word "NONE".
 181     $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 182   }
 183   else {
 184     $tmp = $claim->groupNumber();
 185   }
 186   put_hcfa(18, 50, 30, $tmp);
 187
 188   // Box 9a. Other Insured's Policy or Group Number
 189   if ($new_medicare_logic) {
 190     // TBD: Medigap stuff?
 191   }
 192   else {
 193     if ($claim->payerCount() > 1) {
 194       put_hcfa(20, 1, 28, $claim->policyNumber(1));
 195     }
 196   }
 197
 198   // Box 10a. Employment Related
 199   put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 200
 201   // Box 11a. Insured's Birth Date and Sex
 202   if ($new_medicare_logic) {
 203     $tmpdob = $tmpsex = '';
 204     if ($claim->payerSequence() != 'P') {
 205       $tmpdob = $claim->insuredDOB(1);
 206       $tmpsex = $claim->insuredSex(1);
 207     }
 208    }
 209   else {
 210     $tmpdob = $claim->insuredDOB();
 211     $tmpsex = $claim->insuredSex();
 212   }
 213   if ($tmpdob) {
 214     put_hcfa(20, 53, 2, substr($tmpdob,4,2));
 215     put_hcfa(20, 56, 2, substr($tmpdob,6,2));
 216     put_hcfa(20, 59, 4, substr($tmpdob,0,4));
 217   }
 218   if ($tmpsex) {
 219     put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 220   }
 221
 222   // Box 9b. Other Insured's Birth Date and Sex
 223   if ($new_medicare_logic) {
 224     // TBD: Medigap stuff?
 225   }
 226   else {
 227     if ($claim->payerCount() > 1) {
 228       $tmp = $claim->insuredDOB(1);
 229       put_hcfa(22, 2, 2, substr($tmp,4,2));
 230       put_hcfa(22, 5, 2, substr($tmp,6,2));
 231       put_hcfa(22, 8, 4, substr($tmp,0,4));
 232       put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 233     }
 234   }
 235
 236   // Box 10b. Auto Accident
 237   put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 238   if ($claim->isRelatedAuto())
 239     put_hcfa(22, 45, 2, $claim->autoAccidentState());
 240
 241   // Box 11b. Insured's Employer/School Name
 242   if ($new_medicare_logic) {
 243     $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 244   }
 245   else {
 246     $tmp = $claim->groupName();
 247   }
 248   put_hcfa(22, 50, 30, $tmp);
 249
 250   // Box 9c. Other Insured's Employer/School Name
 251   if ($new_medicare_logic) {
 252     // TBD: Medigap stuff?
 253   }
 254   else {
 255     if ($claim->payerCount() > 1) {
 256       put_hcfa(24, 1, 28, $claim->groupName(1));
 257     }
 258   }
 259
 260   // Box 10c. Other Accident
 261   put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 262
 263   // Box 11c. Insurance Plan Name or Program Name
 264   if ($new_medicare_logic) {
 265     $tmp = '';
 266     if ($claim->payerSequence() != 'P') {
 267       $tmp = $claim->planName(1);
 268       if (!$tmp) $tmp = $claim->payerName(1);
 269     }
 270   }
 271   else {
 272     $tmp = $claim->planName();
 273   }
 274   put_hcfa(24, 50, 30, $tmp);
 275
 276   // Box 9d. Other Insurance Plan Name or Program Name
 277   if ($new_medicare_logic) {
 278     // TBD: Medigap stuff?
 279   }
 280   else {
 281     if ($claim->payerCount() > 1) {
 282       put_hcfa(26, 1, 28, $claim->planName(1));
 283     }
 284   }
 285
 286   // Box 11d. Is There Another Health Benefit Plan
 287   if (!$new_medicare_logic) {
 288     put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 289   }
 290
 291   // Box 12. Patient's or Authorized Person's Signature
 292   put_hcfa(29, 7, 17, 'Signature on File');
 293   // Note: Date does not apply unless the person physically signs the form.
 294
 295   // Box 13. Insured's or Authorized Person's Signature
 296   put_hcfa(29, 55, 17, 'Signature on File');
 297
 298   // Box 14. Date of Current Illness/Injury/Pregnancy
 299   $tmp = $claim->onsetDate();
 300   put_hcfa(32, 2, 2, substr($tmp,4,2));
 301   put_hcfa(32, 5, 2, substr($tmp,6,2));
 302   put_hcfa(32, 8, 4, substr($tmp,0,4));
 303
 304   // Box 15. First Date of Same or Similar Illness, if applicable
 305   $tmp = $claim->dateInitialTreatment();
 306   put_hcfa(32,36, 2, substr($tmp,4,2));
 307   put_hcfa(32,39, 2, substr($tmp,6,2));
 308   put_hcfa(32,42, 4, substr($tmp,0,4));
 309
 310   // Box 16. Dates Patient Unable to Work in Current Occupation
 311   if ($claim->isUnableToWork()) {
 312     $tmp = $claim->offWorkFrom();
 313     put_hcfa(32, 54, 2, substr($tmp,4,2));
 314     put_hcfa(32, 57, 2, substr($tmp,6,2));
 315     put_hcfa(32, 60, 4, substr($tmp,0,4));
 316     $tmp = $claim->offWorkTo();
 317     put_hcfa(32, 68, 2, substr($tmp,4,2));
 318     put_hcfa(32, 71, 2, substr($tmp,6,2));
 319     put_hcfa(32, 74, 4, substr($tmp,0,4));
 320   }
 321
 322   // Referring provider stuff.  Reports are that for primary care doctors,
 323   // Medicare forbids an entry here and other payers require one.
 324   // There is still confusion over this.
 325   //
 326   if ($claim->referrerLastName() &&
 327     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB'))
 328   {
 329     // Box 17a. Referring Provider Alternate Identifier
 330     if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 331       put_hcfa(33, 30,  2, '1G');
 332       put_hcfa(33, 33, 15, $claim->referrerUPIN());
 333     }
 334
 335     // Box 17. Name of Referring Provider or Other Source
 336     $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 337     if ($claim->referrerMiddleName())
 338       $tmp .= ', ' . substr($claim->referrerMiddleName(),0,1);
 339     put_hcfa(34, 1, 25, $tmp);
 340
 341     // Box 17b. Referring Provider NPI
 342     if ($claim->referrerNPI()) {
 343       put_hcfa(34, 33, 15, $claim->referrerNPI());
 344     }
 345   }
 346
 347   // Box 18. Hospitalization Dates Related to Current Services
 348   if ($claim->isHospitalized()) {
 349     $tmp = $claim->hospitalizedFrom();
 350     put_hcfa(34, 54, 2, substr($tmp,4,2));
 351     put_hcfa(34, 57, 2, substr($tmp,6,2));
 352     put_hcfa(34, 60, 4, substr($tmp,0,4));
 353     $tmp = $claim->hospitalizedTo();
 354     put_hcfa(34, 68, 2, substr($tmp,4,2));
 355     put_hcfa(34, 71, 2, substr($tmp,6,2));
 356     put_hcfa(34, 74, 4, substr($tmp,0,4));
 357   }
 358
 359   // Box 19. Reserved for Local Use
 360   put_hcfa(36, 1, 48, $claim->additionalNotes());
 361
 362   // Box 20. Outside Lab
 363   put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 364   if ($claim->isOutsideLab()) {
 365     // Note here that put_hcfa strips the decimal point, as required.
 366     // We right-justify this amount (ending in col. 69).
 367     put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 368   }
 369
 370   // Box 21. Diagnoses
 371   $tmp = $claim->diagArray();
 372   $diags = array();
 373   foreach ($tmp as $diag) $diags[] = $diag;
 374   if (!empty($diags[0])) {
 375     put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 376     put_hcfa(38, 7, 2, substr($diags[0], 3));
 377   }
 378   if (!empty($diags[2])) {
 379     put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 380     put_hcfa(38, 34, 2, substr($diags[2], 3));
 381   }
 382
 383   // Box 22. Medicaid Resubmission Code and Original Ref. No.
 384   put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 385   put_hcfa(38, 62, 10, $claim->medicaidOriginalReference());
 386
 387   // Box 21 continued. Diagnoses
 388   if (!empty($diags[1])) {
 389     put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 390     put_hcfa(40, 7, 2, substr($diags[1], 3));
 391   }
 392   if (!empty($diags[3])) {
 393     put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 394     put_hcfa(40, 34, 2, substr($diags[3], 3));
 395   }
 396
 397   // Box 23. Prior Authorization Number
 398   put_hcfa(40, 50, 28, $claim->priorAuth());
 399
 400   $proccount = $claim->procCount(); // number of procedures
 401
 402   // Charges, adjustments and payments are accumulated by line item so that
 403   // each page of a multi-page claim will stand alone.  Payments include the
 404   // co-pay for the first page only.
 405   $clm_total_charges = 0;
 406   $clm_amount_adjusted = 0;
 407   $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 408
 409   // Procedure loop starts here.
 410   //
 411   for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 412     $dia = $claim->diagIndexArray($hcfa_proc_index);
 413
 414     if (!$claim->cptCharges($hcfa_proc_index)) {
 415       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 416         "' has no charges!\n";
 417     }
 418
 419     if (empty($dia)) {
 420       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 421         "' is not justified!\n";
 422     }
 423
 424     $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 425
 426     // Compute prior payments and "hard" adjustments.
 427     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 428       if ($claim->payerSequence($ins) > $claim->payerSequence())
 429         continue; // skip future payers
 430       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 431       $clm_amount_paid += $payerpaid[1];
 432       $clm_amount_adjusted += $payerpaid[2];
 433     }
 434
 435     ++$svccount;
 436     $lino = $svccount * 2 + 41;
 437
 438     // Drug Information. Medicaid insurers want this with HCPCS codes.
 439     //
 440     $ndc = $claim->cptNDCID($hcfa_proc_index);
 441     if ($ndc) {
 442       if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 443         $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 444       }
 445       else if(preg_match('/^\d{11}$/', $ndc)){
 446
 447       }
 448       else {
 449         $log .= "*** NDC code '$ndc' has invalid format!\n";
 450       }
 451       put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 452         $claim->cptNDCQuantity($hcfa_proc_index));
 453     }
 454
 455     //Note Codes.
 456     put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 457
 458     // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 459     if ($claim->supervisorNumber()) {
 460       // If there is a supervising provider and that person has a
 461       // payer-specific provider number, then we assume that the SP
 462       // must be identified on the claim and this is how we do it
 463       // (but the NPI of the actual rendering provider appears below).
 464       // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 465       put_hcfa($lino, 65,  2, $claim->supervisorNumberType());
 466       put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 467     }
 468     else if ($claim->providerNumber($hcfa_proc_index)) {
 469       put_hcfa($lino, 65,  2, $claim->providerNumberType($hcfa_proc_index));
 470       put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 471     }
 472
 473     ++$lino;
 474
 475     // 24a. Date of Service
 476     $tmp = $claim->serviceDate();
 477     put_hcfa($lino, 1, 2, substr($tmp,4,2));
 478     put_hcfa($lino, 4, 2, substr($tmp,6,2));
 479     put_hcfa($lino, 7, 2, substr($tmp,2,2));
 480     put_hcfa($lino,10, 2, substr($tmp,4,2));
 481     put_hcfa($lino,13, 2, substr($tmp,6,2));
 482     put_hcfa($lino,16, 2, substr($tmp,2,2));
 483
 484     // 24b. Place of Service
 485     put_hcfa($lino, 19, 2, $claim->facilityPOS());
 486
 487     // 24c. EMG
 488     // Not currently supported.
 489
 490     // 24d. Procedures, Services or Supplies
 491     put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 492     // replace colon with space for printing
 493     put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 494
 495     // 24e. Diagnosis Pointer
 496     $tmp = '';
 497     foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) $tmp .= $value;
 498     put_hcfa($lino, 45, 4, $tmp);
 499
 500     // 24f. Charges
 501     put_hcfa($lino, 50, 8, str_replace('.', ' ',
 502       sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
 503
 504     // 24g. Days or Units
 505     put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 506
 507     // 24h. EPSDT Family Plan
 508     // Not currently supported.
 509
 510     // 24j. Rendering Provider NPI
 511     put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 512   }
 513
 514   // 25. Federal Tax ID Number
 515   // FrreB hard coded EIN. Changed it to included SSN as well.
 516   put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 517   if($claim->federalIdType()=='SY'){
 518   put_hcfa(56, 16, 1, 'X'); // The SSN checkbox
 519   }
 520   else{
 521   put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 522   }
 523
 524   // 26. Patient's Account No.
 525   // Instructions say hyphens are not allowed, but freeb used them.
 526   put_hcfa(56, 23, 15, "$pid-$encounter");
 527
 528   // 27. Accept Assignment
 529   put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 530
 531   // 28. Total Charge
 532   put_hcfa(56, 52, 8, str_replace('.',' ',sprintf('%8.2f',$clm_total_charges)));
 533   if (!$clm_total_charges) {
 534     $log .= "*** This claim has no charges!\n";
 535   }
 536
 537   // 29. Amount Paid
 538   put_hcfa(56, 62, 8, str_replace('.',' ',sprintf('%8.2f',$clm_amount_paid)));
 539
 540   // 30. Balance Due
 541   // For secondary payers this reflects primary "contracted rate" adjustments,
 542   // so in general box 30 will not equal box 28 minus box 29.
 543   put_hcfa(56, 71, 8, str_replace('.',' ',sprintf('%8.2f',
 544     $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
 545
 546   // 33. Billing Provider: Phone Number
 547   $tmp = $claim->billingContactPhone();
 548   put_hcfa(57, 66,  3, substr($tmp,0,3));
 549   put_hcfa(57, 70,  7, substr($tmp,3));
 550
 551   // 32. Service Facility Location Information: Name
 552   put_hcfa(58, 23, 25, $claim->facilityName());
 553
 554   // 33. Billing Provider: Name
 555   put_hcfa(58, 50, 25, $claim->billingFacilityName());
 556
 557   // 32. Service Facility Location Information: Street
 558   put_hcfa(59, 23, 25, $claim->facilityStreet());
 559
 560   // 33. Billing Provider: Name
 561   put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 562
 563   // 31. Signature of Physician or Supplier
 564   // FreeB printed the rendering provider's name and the current date here,
 565   // but according to my instructions it must be a real signature and date,
 566   // or else "Signature on File" or "SOF".
 567   put_hcfa(60, 1, 20, 'Signature on File');
 568   //
 569   // $tmp = $claim->providerFirstName();
 570   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 571   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 572
 573   // 32. Service Facility Location Information: City State Zip
 574   $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 575   put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 576     $claim->facilityZip());
 577
 578   // 33. Billing Provider: City State Zip
 579   $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 580   put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 581     $claim->billingFacilityZip());
 582
 583   // 32a. Service Facility NPI
 584   put_hcfa(61, 24, 10, $claim->facilityNPI());
 585
 586   // 32b. Service Facility Other ID
 587   // Note that Medicare does NOT want this any more.
 588   if ($claim->providerGroupNumber()) {
 589     put_hcfa(61, 36,  2, $claim->providerNumberType());
 590     put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 591   }
 592
 593   // 33a. Billing Facility NPI
 594   put_hcfa(61, 51, 10, $claim->billingFacilityNPI());
 595
 596   // 33b. Billing Facility Other ID
 597   // Note that Medicare does NOT want this any more.
 598   if ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 599     put_hcfa(61, 63,  2, $claim->providerNumberType());
 600     put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 601   }
 602
 603   // Put an extra line here for compatibility with old hcfa text generated form
 604     put_hcfa(62, 1, 1, ' ');
 605
 606   return;
 607 }
 608 ?>