library/parse_era.inc.php

   1 <?php
   2   // Copyright (C) 2006 Rod Roark <rod@sunsetsystems.com>
   3   //
   4   // This program is free software; you can redistribute it and/or
   5   // modify it under the terms of the GNU General Public License
   6   // as published by the Free Software Foundation; either version 2
   7   // of the License, or (at your option) any later version.
   8
   9 function parse_era_2100(&$out, $cb) {
  10         if ($out['loopid'] == '2110' || $out['loopid'] == '2100') {
  11
  12                 // Production date is posted with adjustments, so make sure it exists.
  13                 if (!$out['production_date']) $out['production_date'] = $out['check_date'];
  14
  15                 // Force the sum of service payments to equal the claim payment
  16                 // amount, and the sum of service adjustments to equal the CLP's
  17                 // (charged amount - paid amount - patient responsibility amount).
  18                 // This may result from claim-level adjustments, and in this case the
  19                 // first SVC item that we stored was a 'Claim' type.  It also may result
  20                 // from poorly reported payment reversals, in which case we may need to
  21                 // create the 'Claim' service type here.
  22                 //
  23                 $paytotal = $out['amount_approved'];
  24                 $adjtotal = $out['amount_charged'] - $out['amount_approved'] - $out['amount_patient'];
  25                 foreach ($out['svc'] as $svc) {
  26                         $paytotal -= $svc['paid'];
  27                         foreach ($svc['adj'] as $adj) {
  28                                 if ($adj['group_code'] != 'PR') $adjtotal -= $adj['amount'];
  29                         }
  30                 }
  31                 $paytotal = round($paytotal, 2);
  32                 $adjtotal = round($adjtotal, 2);
  33                 if ($paytotal != 0 || $adjtotal != 0) {
  34                         if ($out['svc'][0]['code'] != 'Claim') {
  35                                 array_unshift($out['svc'], array());
  36                                 $out['svc'][0]['code'] = 'Claim';
  37                                 $out['svc'][0]['mod']  = '';
  38                                 $out['svc'][0]['chg']  = '0';
  39                                 $out['svc'][0]['paid'] = '0';
  40                                 $out['svc'][0]['adj']  = array();
  41                                 $out['warnings'] .= "Procedure 'Claim' is inserted artificially to " .
  42                                         "force claim balancing.\n";
  43                         }
  44                         $out['svc'][0]['paid'] += $paytotal;
  45                         if ($adjtotal) {
  46                                 $j = count($out['svc'][0]['adj']);
  47                                 $out['svc'][0]['adj'][$j] = array();
  48                                 $out['svc'][0]['adj'][$j]['group_code']  = 'CR'; // presuming a correction or reversal
  49                                 $out['svc'][0]['adj'][$j]['reason_code'] = 'Balancing';
  50                                 $out['svc'][0]['adj'][$j]['amount'] = $adjtotal;
  51                         }
  52                         // if ($out['svc'][0]['code'] != 'Claim') {
  53                         //   $out['warnings'] .= "First service item payment amount " .
  54                         //   "adjusted by $paytotal due to payment imbalance. " .
  55                         //   "This should not happen!\n";
  56                         // }
  57                 }
  58
  59                 $cb($out);
  60         }
  61 }
  62
  63 function parse_era($filename, $cb) {
  64         $infh = fopen($filename, 'r');
  65         if (! $infh) return "ERA input file open failed";
  66
  67         $out = array();
  68         $out['loopid'] = '';
  69         $out['st_segment_count'] = 0;
  70         $buffer = '';
  71         $segid = '';
  72
  73         while (true) {
  74                 if (strlen($buffer) < 2048 && ! feof($infh))
  75                         $buffer .= fread($infh, 2048);
  76                 $tpos = strpos($buffer, '~');
  77                 if ($tpos === false) break;
  78                 $inline = substr($buffer, 0, $tpos);
  79                 $buffer = substr($buffer, $tpos + 1);
  80
  81                 $seg = explode('|', $inline);
  82                 $segid = $seg[0];
  83
  84                 if ($segid == 'ISA') {
  85                         if ($out['loopid']) return 'Unexpected ISA segment';
  86                         $out['isa_sender_id']      = trim($seg[6]);
  87                         $out['isa_receiver_id']    = trim($seg[8]);
  88                         $out['isa_control_number'] = trim($seg[13]);
  89                         // TBD: clear some stuff if we allow multiple transmission files.
  90                 }
  91                 else if ($segid == 'GS') {
  92                         if ($out['loopid']) return 'Unexpected GS segment';
  93                         $out['gs_date'] = trim($seg[4]);
  94                         $out['gs_time'] = trim($seg[5]);
  95                         $out['gs_control_number'] = trim($seg[6]);
  96                 }
  97                 else if ($segid == 'ST') {
  98                         parse_era_2100($out, $cb);
  99                         $out['loopid'] = '';
 100                         $out['st_control_number'] = trim($seg[2]);
 101                         $out['st_segment_count'] = 0;
 102                 }
 103                 else if ($segid == 'BPR') {
 104                         if ($out['loopid']) return 'Unexpected BPR segment';
 105                         $out['check_amount'] = trim($seg[2]);
 106                         $out['check_date'] = trim($seg[16]); // yyyymmdd
 107                         // TBD: BPR04 is a payment method code.
 108                 }
 109                 else if ($segid == 'TRN') {
 110                         if ($out['loopid']) return 'Unexpected TRN segment';
 111                         $out['check_number'] = trim($seg[2]);
 112                         $out['payer_tax_id'] = substr($seg[3], 1); // 9 digits
 113                         $out['payer_id'] = trim($seg[4]);
 114                         // Note: TRN04 further qualifies the paying entity within the
 115                         // organization identified by TRN03.
 116                 }
 117                 else if ($segid == 'REF' && $seg[1] == 'EV') {
 118                         if ($out['loopid']) return 'Unexpected REF|EV segment';
 119                 }
 120                 else if ($segid == 'CUR' && ! $out['loopid']) {
 121                         if ($seg[3] && $seg[3] != 1.0) {
 122                                 return("We cannot handle foreign currencies!");
 123                         }
 124                 }
 125                 else if ($segid == 'REF' && ! $out['loopid']) {
 126                         // ignore
 127                 }
 128                 else if ($segid == 'DTM' && $seg[1] == '405') {
 129                         if ($out['loopid']) return 'Unexpected DTM|405 segment';
 130                         $out['production_date'] = trim($seg[2]); // yyyymmdd
 131                 }
 132                 //
 133                 // Loop 1000A is Payer Information.
 134                 //
 135                 else if ($segid == 'N1' && $seg[1] == 'PR') {
 136                         if ($out['loopid']) return 'Unexpected N1|PR segment';
 137                         $out['loopid'] = '1000A';
 138                         $out['payer_name'] = trim($seg[2]);
 139                 }
 140                 else if ($segid == 'N3' && $out['loopid'] == '1000A') {
 141                         $out['payer_street'] = trim($seg[1]);
 142                         // TBD: N302 may exist as an additional address line.
 143                 }
 144                 else if ($segid == 'N4' && $out['loopid'] == '1000A') {
 145                         $out['payer_city']  = trim($seg[1]);
 146                         $out['payer_state'] = trim($seg[2]);
 147                         $out['payer_zip']   = trim($seg[3]);
 148                 }
 149                 else if ($segid == 'REF' && $out['loopid'] == '1000A') {
 150                         // Other types of REFs may be given to identify the payer, but we
 151                         // ignore them.
 152                 }
 153                 else if ($segid == 'PER' && $out['loopid'] == '1000A') {
 154                         // TBD: Report payer contact information as a note.
 155                 }
 156                 //
 157                 // Loop 1000B is Payee Identification.
 158                 //
 159                 else if ($segid == 'N1' && $seg[1] == 'PE') {
 160                         if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 161                         $out['loopid'] = '1000B';
 162                         $out['payee_name']   = trim($seg[2]);
 163                         $out['payee_tax_id'] = trim($seg[4]);
 164                 }
 165                 else if ($segid == 'N3' && $out['loopid'] == '1000B') {
 166                         $out['payee_street'] = trim($seg[1]);
 167                 }
 168                 else if ($segid == 'N4' && $out['loopid'] == '1000B') {
 169                         $out['payee_city']  = trim($seg[1]);
 170                         $out['payee_state'] = trim($seg[2]);
 171                         $out['payee_zip']   = trim($seg[3]);
 172                 }
 173                 else if ($segid == 'REF' && $out['loopid'] == '1000B') {
 174                         // Used to report additional ID numbers.  Ignored.
 175                 }
 176                 //
 177                 // Loop 2000 provides for logical grouping of claim payment information.
 178                 // LX is required if any CLPs are present, but so far we do not care
 179                 // about loop 2000 content.
 180                 //
 181                 else if ($segid == 'LX') {
 182                         if (! $out['loopid']) return 'Unexpected LX segment';
 183                         parse_era_2100($out, $cb);
 184                         $out['loopid'] = '2000';
 185                 }
 186                 else if ($segid == 'TS2' && $out['loopid'] == '2000') {
 187                         // ignore
 188                 }
 189                 else if ($segid == 'TS3' && $out['loopid'] == '2000') {
 190                         // ignore
 191                 }
 192                 //
 193                 // Loop 2100 is Claim Payment Information. The good stuff begins here.
 194                 //
 195                 else if ($segid == 'CLP') {
 196                         if (! $out['loopid']) return 'Unexpected CLP segment';
 197                         parse_era_2100($out, $cb);
 198                         $out['loopid'] = '2100';
 199                         $out['warnings'] = '';
 200                         // Clear some stuff to start the new claim:
 201                         $out['subscriber_lname']     = '';
 202                         $out['subscriber_fname']     = '';
 203                         $out['subscriber_mname']     = '';
 204                         $out['subscriber_member_id'] = '';
 205                         $out['svc'] = array();
 206                         //
 207                         // This is the poorly-named "Patient Account Number".  For 837p
 208                         // it comes from CLM01 which we populated as pid-diagid-procid,
 209                         // where diagid and procid are id values from the billing table.
 210                         // For HCFA 1500 claims it comes from field 26 which we
 211                         // populated with our familiar pid-encounter billing key.
 212                         //
 213                         // The 835 spec calls this the "provider-assigned claim control
 214                         // number" and notes that it is specifically intended for
 215                         // identifying the claim in the provider's database.
 216                         $out['our_claim_id']      = trim($seg[1]);
 217                         //
 218                         $out['claim_status_code'] = trim($seg[2]);
 219                         $out['amount_charged']    = trim($seg[3]);
 220                         $out['amount_approved']   = trim($seg[4]);
 221                         $out['amount_patient']    = trim($seg[5]); // pt responsibility, copay + deductible
 222                         $out['payer_claim_id']    = trim($seg[7]); // payer's claim number
 223                 }
 224                 else if ($segid == 'CAS' && $out['loopid'] == '2100') {
 225                         // This is a claim-level adjustment and should be unusual.
 226                         // Handle it by creating a dummy zero-charge service item and
 227                         // then populating the adjustments into it.  See also code in
 228                         // parse_era_2100() which will later plug in a payment reversal
 229                         // amount that offsets these adjustments.
 230                         $i = 0; // if present, the dummy service item will be first.
 231                         if (!$out['svc'][$i]) {
 232                                 $out['svc'][$i] = array();
 233                                 $out['svc'][$i]['code'] = 'Claim';
 234                                 $out['svc'][$i]['mod']  = '';
 235                                 $out['svc'][$i]['chg']  = '0';
 236                                 $out['svc'][$i]['paid'] = '0';
 237                                 $out['svc'][$i]['adj']  = array();
 238                         }
 239                         for ($k = 2; $k < 20; $k += 3) {
 240                                 if (!$seg[$k]) break;
 241                                 $j = count($out['svc'][$i]['adj']);
 242                                 $out['svc'][$i]['adj'][$j] = array();
 243                                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 244                                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 245                                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 246                         }
 247                 }
 248                 // QC = Patient
 249                 else if ($segid == 'NM1' && $seg[1] == 'QC' && $out['loopid'] == '2100') {
 250                         $out['patient_lname']     = trim($seg[3]);
 251                         $out['patient_fname']     = trim($seg[4]);
 252                         $out['patient_mname']     = trim($seg[5]);
 253                         $out['patient_member_id'] = trim($seg[9]);
 254                 }
 255                 // IL = Insured or Subscriber
 256                 else if ($segid == 'NM1' && $seg[1] == 'IL' && $out['loopid'] == '2100') {
 257                         $out['subscriber_lname']     = trim($seg[3]);
 258                         $out['subscriber_fname']     = trim($seg[4]);
 259                         $out['subscriber_mname']     = trim($seg[5]);
 260                         $out['subscriber_member_id'] = trim($seg[9]);
 261                 }
 262                 // 82 = Rendering Provider
 263                 else if ($segid == 'NM1' && $seg[1] == '82' && $out['loopid'] == '2100') {
 264                         $out['provider_lname']     = trim($seg[3]);
 265                         $out['provider_fname']     = trim($seg[4]);
 266                         $out['provider_mname']     = trim($seg[5]);
 267                         $out['provider_member_id'] = trim($seg[9]);
 268                 }
 269                 // 74 = Corrected Insured
 270                 // TT = Crossover Carrier (Transfer To another payer)
 271                 // PR = Corrected Payer
 272                 else if ($segid == 'NM1' && $out['loopid'] == '2100') {
 273                         // $out['warnings'] .= "NM1 segment at claim level ignored.\n";
 274                 }
 275                 else if ($segid == 'MOA' && $out['loopid'] == '2100') {
 276                         $out['warnings'] .= "MOA segment at claim level ignored.\n";
 277                 }
 278                 // REF segments may provide various identifying numbers, where REF02
 279                 // indicates the type of number.
 280                 else if ($segid == 'REF' && $seg[1] == '1W' && $out['loopid'] == '2100') {
 281                         $out['claim_comment'] = trim($seg[2]);
 282                 }
 283                 else if ($segid == 'REF' && $out['loopid'] == '2100') {
 284                         // ignore
 285                 }
 286                 else if ($segid == 'DTM' && $seg[1] == '050' && $out['loopid'] == '2100') {
 287                         $out['claim_date'] = trim($seg[2]); // yyyymmdd
 288                 }
 289                 // 036 = expiration date of coverage
 290                 // 050 = date claim received by payer
 291                 // 232 = claim statement period start
 292                 // 233 = claim statement period end
 293                 else if ($segid == 'DTM' && $out['loopid'] == '2100') {
 294                         // ignore?
 295                 }
 296                 else if ($segid == 'PER' && $out['loopid'] == '2100') {
 297                         $out['warnings'] .= 'Claim contact information: ' .
 298                                 $seg[4] . "\n";
 299                 }
 300                 // For AMT01 see the Amount Qualifier Codes on pages 135-135 of the
 301                 // Implementation Guide.  AMT is only good for comments and is not
 302                 // part of claim balancing.
 303                 else if ($segid == 'AMT' && $out['loopid'] == '2100') {
 304                         $out['warnings'] .= "AMT segment at claim level ignored.\n";
 305                 }
 306                 // For QTY01 see the Quantity Qualifier Codes on pages 137-138 of the
 307                 // Implementation Guide.  QTY is only good for comments and is not
 308                 // part of claim balancing.
 309                 else if ($segid == 'QTY' && $out['loopid'] == '2100') {
 310                         $out['warnings'] .= "QTY segment at claim level ignored.\n";
 311                 }
 312                 //
 313                 // Loop 2110 is Service Payment Information.
 314                 //
 315                 else if ($segid == 'SVC') {
 316                         if (! $out['loopid']) return 'Unexpected SVC segment';
 317                         $out['loopid'] = '2110';
 318                         if ($seg[6]) {
 319                                 // SVC06 if present is our original procedure code that they are changing.
 320                                 // We will not put their crap in our invoice, but rather log a note and
 321                                 // treat it as adjustments to our originally submitted coding.
 322                                 $svc = explode('^', $seg[6]);
 323                                 $tmp = explode('^', $seg[1]);
 324                                 $out['warnings'] .= "Payer is restating our procedure " . $svc[1] .
 325                                         " as " . $tmp[1] . ".\n";
 326                         } else {
 327                                 $svc = explode('^', $seg[1]);
 328                         }
 329                         if ($svc[0] != 'HC') return 'SVC segment has unexpected qualifier';
 330                         // TBD: Other qualifiers are possible; see IG pages 140-141.
 331                         $i = count($out['svc']);
 332                         $out['svc'][$i] = array();
 333                         $out['svc'][$i]['code'] = $svc[1];
 334                         $out['svc'][$i]['mod']  = $svc[2] ? $svc[2] : '';
 335                         // TBD: There may be up to 4 procedure modifiers in $svc[2] thru [5].
 336                         $out['svc'][$i]['chg']  = $seg[2];
 337                         $out['svc'][$i]['paid'] = $seg[3];
 338                         $out['svc'][$i]['adj']  = array();
 339                         // Note: SVC05, if present, indicates the paid units of service.
 340                         // It defaults to 1.
 341                 }
 342                 // DTM01 identifies the type of service date:
 343                 // 472 = a single date of service
 344                 // 150 = service period start
 345                 // 151 = service period end
 346                 else if ($segid == 'DTM' && $out['loopid'] == '2110') {
 347                         $out['dos'] = trim($seg[2]); // yyyymmdd
 348                 }
 349                 else if ($segid == 'CAS' && $out['loopid'] == '2110') {
 350                         $i = count($out['svc']) - 1;
 351                         for ($k = 2; $k < 20; $k += 3) {
 352                                 if (!$seg[$k]) break;
 353                                 $j = count($out['svc'][$i]['adj']);
 354                                 $out['svc'][$i]['adj'][$j] = array();
 355                                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 356                                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 357                                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 358                                 // Note: $seg[$k+2] is "quantity".  A value here indicates a change to
 359                                 // the number of units of service.  We're ignoring that for now.
 360                         }
 361                 }
 362                 else if ($segid == 'REF' && $out['loopid'] == '2110') {
 363                         // ignore
 364                 }
 365                 else if ($segid == 'AMT' && $seg[1] == 'B6' && $out['loopid'] == '2110') {
 366                         $i = count($out['svc']) - 1;
 367                         $out['svc'][$i]['allowed'] = $seg[2]; // report this amount as a note
 368                 }
 369                 else if ($segid == 'LQ' && $seg[1] == 'HE' && $out['loopid'] == '2110') {
 370                         $i = count($out['svc']) - 1;
 371                         $out['svc'][$i]['remark'] = $seg[2];
 372                 }
 373                 else if ($segid == 'QTY' && $out['loopid'] == '2110') {
 374                         $out['warnings'] .= "QTY segment at service level ignored.\n";
 375                 }
 376                 else if ($segid == 'PLB') {
 377                         // Provider-level adjustments are a General Ledger thing and should not
 378                         // alter the A/R for the claim, so we just report them as notes.
 379                         for ($k = 3; $k < 15; $k += 2) {
 380                                 if (!$seg[$k]) break;
 381                                 $out['warnings'] .= 'PROVIDER LEVEL ADJUSTMENT (not claim-specific): $' .
 382                                         sprintf('%.2f', $seg[$k+1]) . " with reason code " . $seg[$k] . "\n";
 383                                 // Note: For PLB adjustment reason codes see IG pages 165-170.
 384                         }
 385                 }
 386                 else if ($segid == 'SE') {
 387                         parse_era_2100($out, $cb);
 388                         $out['loopid'] = '';
 389                         if ($out['st_control_number'] != trim($seg[2])) {
 390                                 return 'Ending transaction set control number mismatch';
 391                         }
 392                         if (($out['st_segment_count'] + 1) != trim($seg[1])) {
 393                                 return 'Ending transaction set segment count mismatch';
 394                         }
 395                 }
 396                 else if ($segid == 'GE') {
 397                         if ($out['loopid']) return 'Unexpected GE segment';
 398                         if ($out['gs_control_number'] != trim($seg[2])) {
 399                                 return 'Ending functional group control number mismatch';
 400                         }
 401                 }
 402                 else if ($segid == 'IEA') {
 403                         if ($out['loopid']) return 'Unexpected IEA segment';
 404                         if ($out['isa_control_number'] != trim($seg[2])) {
 405                                 return 'Ending interchange control number mismatch';
 406                         }
 407                 }
 408                 else {
 409                         return "Unknown or unexpected segment ID $segid";
 410                 }
 411
 412                 ++$out['st_segment_count'];
 413         }
 414
 415         if ($segid != 'IEA') return 'Premature end of ERA file';
 416         return '';
 417 }
 418 ?>