library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007-2011 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 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   if ($claim->dateInitialTreatment()) {
 388     ++$edicount;
 389     $out .= "DTP" .       // Date of Initial Treatment
 390       "*454" .
 391       "*D8" .
 392       "*" . $claim->dateInitialTreatment() .
 393       "~\n";
 394   }
 395
 396   ++$edicount;
 397   $out .= "DTP" .       // Date of Onset
 398     "*431" .
 399     "*D8" .
 400     "*" . $claim->onsetDate() .
 401     "~\n";
 402
 403   if (strcmp($claim->facilityPOS(),'21') == 0) {
 404     ++$edicount;
 405     $out .= "DTP" .     // Date of Hospitalization
 406       "*435" .
 407       "*D8" .
 408       "*" . $claim->onsetDate() .
 409       "~\n";
 410   }
 411
 412   $patientpaid = $claim->patientPaidAmount();
 413   if ($patientpaid != 0) {
 414     ++$edicount;
 415     $out .= "AMT" .     // Patient paid amount. Page 220.
 416       "*F5" .
 417       "*" . $patientpaid .
 418       "~\n";
 419   }
 420
 421   if ($claim->priorAuth()) {
 422     ++$edicount;
 423     $out .= "REF" .     // Prior Authorization Number
 424       "*G1" .
 425       "*" . $claim->priorAuth() .
 426       "~\n";
 427   }
 428
 429   if ($claim->cliaCode() and $claim->claimType() === 'MB') {
 430     // Required by Medicare when in-house labs are done.
 431     ++$edicount;
 432     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 433       "*X4" .
 434       "*" . $claim->cliaCode() .
 435       "~\n";
 436   }
 437
 438   // Note: This would be the place to implement the NTE segment for loop 2300.
 439   if ($claim->additionalNotes()) {
 440     // Claim note.
 441     ++$edicount;
 442     $out .= "NTE" .     // comments box 19
 443       "*" .
 444       "*" . $claim->additionalNotes() .
 445       "~\n";
 446   }
 447
 448   // Diagnoses, up to 8 per HI segment.
 449   $da = $claim->diagArray();
 450   $diag_type_code = 'BK';
 451   $tmp = 0;
 452   foreach ($da as $diag) {
 453     if ($tmp % 8 == 0) {
 454       if ($tmp) $out .= "~\n";
 455       ++$edicount;
 456       $out .= "HI";         // Health Diagnosis Codes
 457     }
 458     $out .= "*$diag_type_code:" . $diag;
 459     $diag_type_code = 'BF';
 460     ++$tmp;
 461   }
 462   if ($tmp) $out .= "~\n";
 463
 464   if ($claim->referrerLastName()) {
 465     // Medicare requires referring provider's name and UPIN.
 466     ++$edicount;
 467     $out .= "NM1" .     // Loop 2310A Referring Provider
 468       "*DN" .
 469       "*1" .
 470       "*" . $claim->referrerLastName() .
 471       "*" . $claim->referrerFirstName() .
 472       "*" . $claim->referrerMiddleName() .
 473       "*" .
 474       "*";
 475     if ($claim->referrerNPI()) { $out .=
 476       "*XX" .
 477       "*" . $claim->referrerNPI();
 478     } else { $out .=
 479       "*34" .
 480       "*" . $claim->referrerSSN();
 481     }
 482     $out .= "~\n";
 483
 484     if ($claim->referrerTaxonomy()) {
 485       ++$edicount;
 486       $out .= "PRV" .
 487         "*RF" . // ReFerring provider
 488         "*ZZ" .
 489         "*" . $claim->referrerTaxonomy() .
 490         "~\n";
 491     }
 492
 493     if ($claim->referrerUPIN()) {
 494       ++$edicount;
 495       $out .= "REF" .   // Referring Provider Secondary Identification
 496         "*1G" .
 497         "*" . $claim->referrerUPIN() .
 498         "~\n";
 499     }
 500   }
 501
 502   ++$edicount;
 503   $out .= "NM1" .       // Loop 2310B Rendering Provider
 504     "*82" .
 505     "*1" .
 506     "*" . $claim->providerLastName() .
 507     "*" . $claim->providerFirstName() .
 508     "*" . $claim->providerMiddleName() .
 509     "*" .
 510     "*";
 511   if ($claim->providerNPI()) { $out .=
 512     "*XX" .
 513     "*" . $claim->providerNPI();
 514   } else { $out .=
 515     "*34" .
 516     "*" . $claim->providerSSN();
 517     $log .= "*** Rendering provider has no NPI.\n";
 518   }
 519   $out .= "~\n";
 520
 521   if ($claim->providerTaxonomy()) {
 522     ++$edicount;
 523     $out .= "PRV" .
 524       "*PE" . // PErforming provider
 525       "*ZZ" .
 526       "*" . $claim->providerTaxonomy() .
 527       "~\n";
 528   }
 529
 530   // REF*1C is required here for the Medicare provider number if NPI was
 531   // specified in NM109.  Not sure if other payers require anything here.
 532   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 533
 534    if (trim($claim->x12gsreceiverid()) != '470819582') { // if NOT ECLAIMS EDI
 535       if ($claim->providerNumber()) {
 536         ++$edicount;
 537         $out .= "REF" .
 538           "*" . $claim->providerNumberType() .
 539           "*" . $claim->providerNumber() .
 540           "~\n";
 541       }
 542    }
 543
 544   // Loop 2310D is omitted in the case of home visits (POS=12).
 545   if ($claim->facilityPOS() != 12) {
 546     ++$edicount;
 547     $out .= "NM1" .       // Loop 2310D Service Location
 548       "*77" .
 549       "*2";
 550    //Field length is limited to 35. See nucc dataset page 77 www.nucc.org
 551         $facilityName=substr($claim->facilityName(),0,35);
 552     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 553       "*" . $facilityName;
 554     }
 555     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 556       "*" .
 557       "*" .
 558       "*" .
 559       "*";
 560       if ($claim->facilityNPI()) { $out .=
 561         "*XX*" . $claim->facilityNPI();
 562       } else { $out .=
 563         "*24*" . $claim->facilityETIN();
 564         $log .= "*** Service location has no NPI.\n";
 565       }
 566     }
 567     $out .= "~\n";
 568     if ($claim->facilityStreet()) {
 569       ++$edicount;
 570       $out .= "N3" .
 571         "*" . $claim->facilityStreet() .
 572         "~\n";
 573     }
 574     if ($claim->facilityState()) {
 575       ++$edicount;
 576       $out .= "N4" .
 577         "*" . $claim->facilityCity() .
 578         "*" . $claim->facilityState() .
 579         "*" . $claim->facilityZip() .
 580         "~\n";
 581     }
 582   }
 583
 584   // Loop 2310E, Supervising Provider
 585   //
 586   if ($claim->supervisorLastName()) {
 587     ++$edicount;
 588     $out .= "NM1" .
 589       "*DQ" . // Supervising Physician
 590       "*1" .  // Person
 591       "*" . $claim->supervisorLastName() .
 592       "*" . $claim->supervisorFirstName() .
 593       "*" . $claim->supervisorMiddleName() .
 594       "*" .   // NM106 not used
 595       "*";    // Name Suffix
 596     if ($claim->supervisorNPI()) { $out .=
 597       "*XX" .
 598       "*" . $claim->supervisorNPI();
 599     } else { $out .=
 600       "*34" .
 601       "*" . $claim->supervisorSSN();
 602     }
 603     $out .= "~\n";
 604
 605     if ($claim->supervisorNumber()) {
 606       ++$edicount;
 607       $out .= "REF" .
 608         "*" . $claim->supervisorNumberType() .
 609         "*" . $claim->supervisorNumber() .
 610         "~\n";
 611     }
 612   }
 613
 614   $prev_pt_resp = $clm_total_charges; // for computation below
 615
 616   // Loops 2320 and 2330*, other subscriber/payer information.
 617   //
 618   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 619
 620     $tmp1 = $claim->claimType($ins);
 621     $tmp2 = 'C1'; // Here a kludge. See page 321.
 622     if ($tmp1 === 'CI') $tmp2 = 'C1';
 623     if ($tmp1 === 'AM') $tmp2 = 'AP';
 624     if ($tmp1 === 'HM') $tmp2 = 'HM';
 625     if ($tmp1 === 'MB') $tmp2 = 'MB';
 626     if ($tmp1 === 'MC') $tmp2 = 'MC';
 627     if ($tmp1 === '09') $tmp2 = 'PP';
 628     ++$edicount;
 629     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 630       "*" . $claim->payerSequence($ins) .
 631       "*" . $claim->insuredRelationship($ins) .
 632       "*" . $claim->groupNumber($ins) .
 633       "*" . $claim->groupName($ins) .
 634       "*" . $tmp2 .
 635       "*" .
 636       "*" .
 637       "*" .
 638       "*" . $claim->claimType($ins) .
 639       "~\n";
 640
 641     // Things that apply only to previous payers, not future payers.
 642     //
 643     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 644
 645       // Generate claim-level adjustments.
 646       $aarr = $claim->payerAdjustments($ins);
 647       foreach ($aarr as $a) {
 648         ++$edicount;
 649         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 650           "*" . $a[1] .
 651           "*" . $a[2] .
 652           "*" . $a[3] .
 653           "~\n";
 654       }
 655
 656       $payerpaid = $claim->payerTotals($ins);
 657       ++$edicount;
 658       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 659         "*D" .
 660         "*" . $payerpaid[1] .
 661         "~\n";
 662
 663       // Patient responsibility amount as of this previous payer.
 664       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 665       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 666
 667       ++$edicount;
 668       $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 669         "*B6" .
 670         "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 671         "~\n";
 672
 673       ++$edicount;
 674       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 675         "*F2" .
 676         "*" . sprintf('%.2f', $prev_pt_resp) .
 677         "~\n";
 678
 679     } // End of things that apply only to previous payers.
 680
 681     ++$edicount;
 682     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 683       "*D8" .
 684       "*" . $claim->insuredDOB($ins) .
 685       "*" . $claim->insuredSex($ins) .
 686       "~\n";
 687
 688     ++$edicount;
 689     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 690       "*" .
 691       "*" .
 692       "*Y" .
 693       "*B" .
 694       "*" .
 695       "*Y" .
 696       "~\n";
 697
 698     ++$edicount;
 699     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 700       "*IL" .
 701       "*1" .
 702       "*" . $claim->insuredLastName($ins) .
 703       "*" . $claim->insuredFirstName($ins) .
 704       "*" . $claim->insuredMiddleName($ins) .
 705       "*" .
 706       "*" .
 707       "*MI" .
 708       "*" . $claim->policyNumber($ins) .
 709       "~\n";
 710
 711     ++$edicount;
 712     $out .= "N3" .
 713       "*" . $claim->insuredStreet($ins) .
 714       "~\n";
 715
 716     ++$edicount;
 717     $out .= "N4" .
 718       "*" . $claim->insuredCity($ins) .
 719       "*" . $claim->insuredState($ins) .
 720       "*" . $claim->insuredZip($ins) .
 721       "~\n";
 722
 723     ++$edicount;
 724     //Field length is limited to 35. See nucc dataset page 81 www.nucc.org
 725     $payerName=substr($claim->payerName($ins),0,35);
 726     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 727       "*PR" .
 728       "*2" .
 729       "*" . $payerName .
 730       "*" .
 731       "*" .
 732       "*" .
 733       "*" .
 734       "*PI" .
 735       "*" . $claim->payerID($ins) .
 736       "~\n";
 737
 738     // if (!$claim->payerID($ins)) {
 739     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 740     // }
 741
 742     // Payer address (N3 and N4) are added below so that Gateway EDI can
 743     // auto-generate secondary claims.  These do NOT appear in my copy of
 744     // the spec!  -- Rod 2008-06-12
 745
 746     if (trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 747       ++$edicount;
 748       $out .= "N3" .
 749         "*" . $claim->payerStreet($ins) .
 750         "~\n";
 751       //
 752       ++$edicount;
 753       $out .= "N4" .
 754         "*" . $claim->payerCity($ins) .
 755         "*" . $claim->payerState($ins) .
 756         "*" . $claim->payerZip($ins) .
 757         "~\n";
 758     } // end Gateway EDI
 759
 760   } // End loops 2320/2330*.
 761
 762   $loopcount = 0;
 763
 764   // Procedure loop starts here.
 765   //
 766   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 767     ++$loopcount;
 768
 769     ++$edicount;
 770     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 771       "*$loopcount" .
 772       "~\n";
 773
 774     ++$edicount;
 775     $out .= "SV1" .     // Professional Service. Page 400.
 776       "*HC:" . $claim->cptKey($prockey) .
 777       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 778       "*UN" .
 779       "*" . $claim->cptUnits($prockey) .
 780       "*" .
 781       "*" .
 782       "*";
 783     $dia = $claim->diagIndexArray($prockey);
 784     $i = 0;
 785     foreach ($dia as $dindex) {
 786       if ($i) $out .= ':';
 787       $out .= $dindex;
 788       if (++$i >= 4) break;
 789     }
 790     $out .= "~\n";
 791
 792     if (!$claim->cptCharges($prockey)) {
 793       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 794     }
 795
 796     if (empty($dia)) {
 797       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 798     }
 799
 800     ++$edicount;
 801     $out .= "DTP" .     // Date of Service. Page 435.
 802       "*472" .
 803       "*D8" .
 804       "*" . $claim->serviceDate() .
 805       "~\n";
 806
 807     // AMT*AAE segment for Approved Amount from previous payer.
 808     // Medicare secondaries seem to require this.
 809     //
 810     for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
 811       if ($claim->payerSequence($ins) > $claim->payerSequence())
 812         continue; // payer is future, not previous
 813       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 814       ++$edicount;
 815       $out .= "AMT" . // Approved amount per previous payer. Page 485.
 816         "*AAE" .
 817         "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
 818         "~\n";
 819       break;
 820     }
 821
 822     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 823     // with HCPCS codes.
 824     //
 825     $ndc = $claim->cptNDCID($prockey);
 826     if ($ndc) {
 827       ++$edicount;
 828       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 829         "*" .         // Per addendum, LIN01 is not used.
 830         "*N4" .
 831         "*" . $ndc .
 832         "~\n";
 833
 834       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 835         $log .= "*** NDC code '$ndc' has invalid format!\n";
 836       }
 837
 838       ++$edicount;
 839       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 840       if (!$tmpunits) $tmpunits = 1;
 841       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 842         "*" .
 843         "*" .
 844         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 845         "*" . $claim->cptNDCQuantity($prockey) .
 846         "*" . $claim->cptNDCUOM($prockey) .
 847         "~\n";
 848     }
 849
 850     // Loop 2420A, Rendering Provider (service-specific).
 851     // Used if the rendering provider for this service line is different
 852     // from that in loop 2310B.
 853     //
 854     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
 855       ++$edicount;
 856       $out .= "NM1" .       // Loop 2310B Rendering Provider
 857         "*82" .
 858         "*1" .
 859         "*" . $claim->providerLastName($prockey) .
 860         "*" . $claim->providerFirstName($prockey) .
 861         "*" . $claim->providerMiddleName($prockey) .
 862         "*" .
 863         "*";
 864       if ($claim->providerNPI($prockey)) { $out .=
 865         "*XX" .
 866         "*" . $claim->providerNPI($prockey);
 867       } else { $out .=
 868         "*34" .
 869         "*" . $claim->providerSSN($prockey);
 870         $log .= "*** Rendering provider has no NPI.\n";
 871       }
 872       $out .= "~\n";
 873
 874       if ($claim->providerTaxonomy($prockey)) {
 875         ++$edicount;
 876         $out .= "PRV" .
 877           "*PE" . // PErforming provider
 878           "*ZZ" .
 879           "*" . $claim->providerTaxonomy($prockey) .
 880           "~\n";
 881       }
 882
 883       // REF*1C is required here for the Medicare provider number if NPI was
 884       // specified in NM109.  Not sure if other payers require anything here.
 885       if ($claim->providerNumber($prockey)) {
 886         ++$edicount;
 887         $out .= "REF" .
 888           "*" . $claim->providerNumberType($prockey) .
 889           "*" . $claim->providerNumber($prockey) .
 890           "~\n";
 891       }
 892     }
 893
 894     // Loop 2430, adjudication by previous payers.
 895     //
 896     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 897       if ($claim->payerSequence($ins) > $claim->payerSequence())
 898         continue; // payer is future, not previous
 899
 900       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 901       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 902
 903       if ($payerpaid[1] == 0 && !count($aarr)) {
 904         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 905           "' has no payments or adjustments from previous payer!\n";
 906         continue;
 907       }
 908
 909       ++$edicount;
 910       $out .= "SVD" . // Service line adjudication. Page 554.
 911         "*" . $claim->payerID($ins) .
 912         "*" . $payerpaid[1] .
 913         "*HC:" . $claim->cptKey($prockey) .
 914         "*" .
 915         "*" . $claim->cptUnits($prockey) .
 916         "~\n";
 917
 918       $tmpdate = $payerpaid[0];
 919       foreach ($aarr as $a) {
 920         ++$edicount;
 921         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 922           "*" . $a[1] .
 923           "*" . $a[2] .
 924           "*" . $a[3] .
 925           "~\n";
 926         if (!$tmpdate) $tmpdate = $a[0];
 927         if ( isset($a[4]) &&
 928                 $a[4] != null ) {
 929                 $out .= "CAS02" . // Previous payer's adjustment reason
 930                   "*" . $a[4] .
 931                   "~\n";
 932         }
 933       }
 934
 935       if ($tmpdate) {
 936         ++$edicount;
 937         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 938           "*573" .
 939           "*D8" .
 940           "*$tmpdate" .
 941           "~\n";
 942       }
 943     } // end loop 2430
 944   } // end this procedure
 945
 946   ++$edicount;
 947   $out .= "SE" .        // SE Trailer
 948     "*$edicount" .
 949     "*0021" .
 950     "~\n";
 951
 952   $out .= "GE" .        // GE Trailer
 953     "*1" .
 954     "*1" .
 955     "~\n";
 956
 957   $out .= "IEA" .       // IEA Trailer
 958     "*1" .
 959     "*000000001" .
 960     "~\n";
 961
 962   $log .= "\n";
 963   return $out;
 964 }
 965 ?>