various corrections and improvements to remit processing

[openemr.git] / interface / billing / sl_eob_process.php

<?php
        // Copyright (C) 2006 Rod Roark <rod@sunsetsystems.com>
        //
        // This program is free software; you can redistribute it and/or
        // modify it under the terms of the GNU General Public License
        // as published by the Free Software Foundation; either version 2
        // of the License, or (at your option) any later version.

        // This processes X12 835 remittances and produces a report.

        // Caveats:
        // Currently we assume that all 835's come from primary insurance, and
        // that secondary claims always go out on paper.  This should be made
        // more general at some point.  So far we have only tested with a
        // family practice clinic using Zirmed.

        // Buffer all output so we can archive it to a file.
        ob_start();

        include_once("../globals.php");
        include_once("../../library/invoice_summary.inc.php");
        include_once("../../library/sl_eob.inc.php");
        include_once("../../library/parse_era.inc.php");
        include_once("claim_status_codes.php");
        include_once("adjustment_reason_codes.php");
        include_once("remark_codes.php");

        $debug = $_GET['debug'] ? 1 : 0; // set to 1 for debugging mode
        $encount = 0;

        $last_ptname = '';
        $last_invnumber = '';
        $last_code = '';
        $invoice_total = 0.00;

///////////////////////// Assorted Functions /////////////////////////

        function parse_date($date) {
                $date = substr(trim($date), 0, 10);
                if (preg_match('/^(\d\d\d\d)(\d\d)(\d\d)$/', $date, $matches)) {
                        return $matches[1] . '-' . $matches[2] . '-' . $matches[3];
                }
                return '';
        }

        function writeMessageLine($bgcolor, $class, $description) {
                $dline =
                        " <tr bgcolor='$bgcolor'>\n" .
                        "  <td class='$class' colspan='4'>&nbsp;</td>\n" .
                        "  <td class='$class'>$description</td>\n" .
                        "  <td class='$class' colspan='2'>&nbsp;</td>\n" .
                        " </tr>\n";
                echo $dline;
        }

        function writeDetailLine($bgcolor, $class, $ptname, $invnumber,
                $code, $date, $description, $amount, $balance)
        {
                global $last_ptname, $last_invnumber, $last_code;
                if ($ptname == $last_ptname) $ptname = '&nbsp;';
                        else $last_ptname = $ptname;
                if ($invnumber == $last_invnumber) $invnumber = '&nbsp;';
                        else $last_invnumber = $invnumber;
                if ($code == $last_code) $code = '&nbsp;';
                        else $last_code = $code;
                if ($amount ) $amount  = sprintf("%.2f", $amount );
                if ($balance) $balance = sprintf("%.2f", $balance);
                $dline =
                        " <tr bgcolor='$bgcolor'>\n" .
                        "  <td class='$class'>$ptname</td>\n" .
                        "  <td class='$class'>$invnumber</td>\n" .
                        "  <td class='$class'>$code</td>\n" .
                        "  <td class='$class'>$date</td>\n" .
                        "  <td class='$class'>$description</td>\n" .
                        "  <td class='$class' align='right'>$amount</td>\n" .
                        "  <td class='$class' align='right'>$balance</td>\n" .
                        " </tr>\n";
                echo $dline;
        }

        // This writes detail lines that were already in SQL-Ledger for a given
        // charge item.
        //
        function writeOldDetail(&$prev, $ptname, $invnumber, $dos, $code, $bgcolor) {
                global $invoice_total;
                // $prev['total'] = 0.00; // to accumulate total charges
                ksort($prev['dtl']);
                foreach ($prev['dtl'] as $dkey => $ddata) {
                        $ddate = substr($dkey, 0, 10);
                        $description = $ddata['src'] . $ddata['rsn'];
                        if ($ddate == '          ') { // this is the service item
                                $ddate = $dos;
                                $description = 'Service Item';
                        }
                        $amount = sprintf("%.2f", $ddata['chg'] - $ddata['pmt']);
                        $invoice_total = sprintf("%.2f", $invoice_total + $amount);
                        writeDetailLine($bgcolor, 'olddetail', $ptname, $invnumber,
                                $code, $ddate, $description, $amount, $invoice_total);
                }
        }

        // This is called back by parse_era() once per claim.
        //
        function era_callback(&$out) {
                global $encount, $debug, $claim_status_codes, $adjustment_reasons, $remark_codes;
                global $invoice_total, $last_code;

                // Some heading information.
                if ($encount == 0) {
                        writeMessageLine('#ffffff', 'infdetail',
                                "Payer: " . htmlentities($out['payer_name']));
                        if ($debug) {
                                writeMessageLine('#ffffff', 'infdetail',
                                        "WITHOUT UPDATE is selected; no changes will be applied.");
                        }
                }

                $last_code = '';
                $invoice_total = 0.00;
                $bgcolor = (++$encount & 1) ? "#ddddff" : "#ffdddd";
                list($pid, $encounter, $invnumber) = slInvoiceNumber($out);

                // Get details, if we have them, for the invoice.
                $inverror = true;
                $codes = array();
                if ($pid && $encounter) {
                        // Get invoice data into $arrow.
                        $arres = SLQuery("SELECT ar.id, ar.notes, ar.shipvia, customer.name " .
                                "FROM ar, customer WHERE ar.invnumber = '$invnumber' AND " .
                                "customer.id = ar.customer_id");
                        if ($sl_err) die($sl_err);
                        $arrow = SLGetRow($arres, 0);
                        if ($arrow) {
                                $inverror = false;
                                $codes = get_invoice_summary($arrow['id'], true);
                        } else { // oops, no such invoice
                                $pid = $encounter = 0;
                                $invnumber = $out['our_claim_id'];
                        }
                }

                $insurance_id = 0;
                foreach ($codes as $cdata) {
                        if ($cdata['ins']) {
                                $insurance_id = $cdata['ins'];
                                break;
                        }
                }

                // Show the claim status.
                $csc = $out['claim_status_code'];
                $inslabel = 'Ins1';
                if ($csc == '1' || $csc == '19') $inslabel = 'Ins1';
                if ($csc == '2' || $csc == '20') $inslabel = 'Ins2';
                if ($csc == '3' || $csc == '21') $inslabel = 'Ins3';
                writeMessageLine($bgcolor, 'infdetail',
                        "Claim status $csc: " . $claim_status_codes[$csc]);

                // Show an error message if the claim is missing or already posted.
                if ($inverror) {
                        writeMessageLine($bgcolor, 'errdetail',
                                "The following claim is not in our database");
                }
                else {
                        // Skip this test. Claims can get multiple CLPs from the same payer!
                        //
                        // $insdone = strtolower($arrow['shipvia']);
                        // if (strpos($insdone, 'ins1') !== false) {
                        //  $inverror = true;
                        //  writeMessageLine($bgcolor, 'errdetail',
                        //   "Primary insurance EOB was already posted for the following claim");
                        // }
                }

                if ($out['warnings']) {
                        writeMessageLine($bgcolor, 'infdetail', nl2br(rtrim($out['warnings'])));
                }

                // Simplify some claim attributes for cleaner code.
                $service_date = parse_date($out['dos']);
                $check_date = parse_date($out['check_date']);
                $production_date = parse_date($out['production_date']);
                $patient_name = $arrow['name'] ? $arrow['name'] :
                        ($out['patient_fname'] . ' ' . $out['patient_lname']);

                $error = $inverror;

                // This loops once for each service item in this claim.
                foreach ($out['svc'] as $svc) {
                        $prev = $codes[$svc['code']];

                        // This reports detail lines already on file for this service item.
                        if ($prev) {
                                writeOldDetail($prev, $patient_name, $invnumber, $service_date, $svc['code'], $bgcolor);
                                // Check for sanity in amount charged.
                                $prevchg = sprintf("%.2f", $prev['chg'] + $prev['adj']);
                                if ($prevchg != $svc['chg']) {
                                        writeMessageLine($bgcolor, 'errdetail',
                                                "EOB charge amount " . $svc['chg'] . " for this code does not match our invoice");
                                        $error = true;
                                }

                                // Check for duplicate payment.  Should not happen.
                                //
                                // This is not right.  What we want to do is check if we have
                                // any payments or adjustments from this payer for this service item,
                                // and produce an error if so.  The point is that a duplicated claim
                                // submission may not give the same results as the original.
                                /****
                                foreach ($prev['dtl'] as $dkey => $ddata) {
                                        if (! $ddata['pmt']) continue;
                                        $ddate = parse_date($dkey);
                                        if ($ddate == $check_date && $ddata['pmt'] == $svc['paid']) {
                                                writeMessageLine($bgcolor, 'errdetail',
                                                        "This payment dated $check_date seems to be already posted!");
                                                $error = true;
                                        }
                                }
                                ****/
                                // The following replaces the above.
                                if ((sprintf("%.2f",$prev['chg']) != sprintf("%.2f",$prev['bal']) ||
                                    $prev['adj'] != 0) && $inslabel == 'Ins1')
                                {
                                        writeMessageLine($bgcolor, 'errdetail',
                                                "This service item already has payments and/or adjustments!");
                                        $error = true;
                                }

                                unset($codes[$svc['code']]);
                        }

                        // If the service item is not in our database...
                        else {

                                /****
                                writeDetailLine($bgcolor, 'errdetail', $patient_name, $invnumber,
                                        $svc['code'], $service_date, '*** UNMATCHED SERVICE ITEM ***',
                                        $svc['chg'], '');
                                $error = true;
                                ****/

                                // No, this is not an error. Instead, if we are not in error mode
                                // insert the service item into SL.  Then display it (in green if it
                                // was inserted, or in red if we are in error mode).
                                $description = 'CPT4:' . $svc['code'] . " Added by $inslabel $production_date";
                                if (!$error && !$debug) {
                                        slPostCharge($arrow['id'], $svc['chg'], $service_date, $svc['code'],
                                                $insurance_id, $description, $debug);
                                        $invoice_total += $svc['chg'];
                                }
                                $class = $error ? 'errdetail' : 'newdetail';
                                writeDetailLine($bgcolor, $class, $patient_name, $invnumber,
                                        $svc['code'], $production_date, $description,
                                        $svc['chg'], ($error ? '' : $invoice_total));

                        }

                        $class = $error ? 'errdetail' : 'newdetail';

                        // Report Allowed Amount.
                        if ($svc['allowed']) {
                                // A problem here is that some payers will include an adjustment
                                // reflecting the allowed amount, others not.  So here we need to
                                // check if the adjustment exists, and if not then create it.  We
                                // assume that any nonzero CO (Contractual Obligation) adjustment
                                // is good enough.
                                $contract_adj = sprintf("%.2f", $svc['chg'] - $svc['allowed']);
                                foreach ($svc['adj'] as $adj) {
                                        if ($adj['group_code'] == 'CO' && $adj['amount'] != 0)
                                                $contract_adj = 0;
                                }
                                if ($contract_adj > 0) {
                                        $svc['adj'][] = array('group_code' => 'CO', 'reason_code' => 'A2',
                                                'amount' => $contract_adj);
                                }
                                writeMessageLine($bgcolor, 'infdetail',
                                        'Allowed amount is ' . sprintf("%.2f", $svc['allowed']));
                        }

                        // Report miscellaneous remarks.
                        if ($svc['remark']) {
                                $rmk = $svc['remark'];
                                writeMessageLine($bgcolor, 'infdetail', "$rmk: " . $remark_codes[$rmk]);
                        }

                        // Post and report the payment for this service item from the ERA.
                        if ($svc['paid']) {
                                if (!$error && !$debug) {
                                        slPostPayment($arrow['id'], $svc['paid'], $check_date,
                                                "$inslabel/" . $out['check_number'], $svc['code'], $insurance_id, $debug);
                                        $invoice_total -= $svc['paid'];
                                }
                                writeDetailLine($bgcolor, $class, $patient_name, $invnumber,
                                        $svc['code'], $check_date, "$inslabel/" . $out['check_number'] . ' payment',
                                        0 - $svc['paid'], ($error ? '' : $invoice_total));
                        }

                        // Post and report adjustments from this ERA.  Posted adjustment reasons
                        // must be 25 characters or less in order to fit on patient statements.
                        foreach ($svc['adj'] as $adj) {
                                $description = $adj['reason_code'] . ': ' . $adjustment_reasons[$adj['reason_code']];
                                // Group code PR is Patient Responsibility.  Enter these as zero
                                // adjustments to retain the note without crediting the claim.
                                if ($adj['group_code'] == 'PR') {
                                        $reason = 'Pt resp: '; // Reasons should be 25 chars or less.
                                        if ($adj['reason_code'] == '1') $reason = 'To deductible: ';
                                        else if ($adj['reason_code'] == '2') $reason = 'Coinsurance: ';
                                        else if ($adj['reason_code'] == '3') $reason = 'Co-pay: ';
                                        $reason .= sprintf("%.2f", $adj['amount']);
                                        if (!$error && !$debug) {
                                                slPostAdjustment($arrow['id'], 0, $production_date,
                                                        $out['check_number'], $svc['code'], $insurance_id,
                                                        $reason, $debug);
                                        }
                                        writeMessageLine($bgcolor, $class, $description . ' ' .
                                                sprintf("%.2f", $adj['amount']));
                                }
                                // Other group codes are real adjustments.
                                else {
                                        if (!$error && !$debug) {
                                                slPostAdjustment($arrow['id'], $adj['amount'], $production_date,
                                                        $out['check_number'], $svc['code'], $insurance_id,
                                                        "$inslabel adjust code " . $adj['reason_code'], $debug);
                                                $invoice_total -= $adj['amount'];
                                        }
                                        writeDetailLine($bgcolor, $class, $patient_name, $invnumber,
                                                $svc['code'], $production_date, $description,
                                                0 - $adj['amount'], ($error ? '' : $invoice_total));
                                }
                        }

                } // End of service item

                // Report any existing service items not mentioned in the ERA.
                foreach ($codes as $code => $prev) {
                        writeOldDetail($prev, $arrow['name'], $invnumber, $service_date, $code, $bgcolor);
                }

                // Cleanup: If all is well, mark Ins1 done and check for secondary billing.
                if (!$error && !$debug) {
                        $shipvia = 'Done: Ins1';
                        if ($inslabel != 'Ins1') $shipvia .= ',Ins2';
                        if ($inslabel == 'Ins3') $shipvia .= ',Ins3';
                        $query = "UPDATE ar SET shipvia = '$shipvia' WHERE id = " . $arrow['id'];
                        SLQuery($query);
                        if ($sl_err) die($sl_err);
                        // Check for secondary insurance.
                        $insgot = strtolower($arrow['notes']);
                        if ($inslabel == 'Ins1' && strpos($insgot, 'ins2') !== false) {
                                slSetupSecondary($arrow['id'], $debug);
                                writeMessageLine($bgcolor, 'infdetail',
                                        'This claim is now re-queued for secondary paper billing');
                        }
                }

        }

/////////////////////////// End Functions ////////////////////////////

        $info_msg = "";

        $eraname = $_GET['eraname'];
        if (! $eraname) die(xl("You cannot access this page directly."));

        // Open the output file early so that in case it fails, we do not post a
        // bunch of stuff without saving the report.  Also be sure to retain any old
        // report files.  Do not save the report if this is a no-update situation.
        //
        if (!$debug) {
                $nameprefix = "$webserver_root/era/$eraname";
                $namesuffix = '';
                for ($i = 1; is_file("$nameprefix$namesuffix.html"); ++$i) {
                        $namesuffix = "_$i";
                }
                $fnreport = "$nameprefix$namesuffix.html";
                $fhreport = fopen($fnreport, 'w');
                if (!$fhreport) die(xl("Cannot create") . " '$fnreport'");
        }

        slInitialize();
?>
<html>
<head>
<link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
<style type="text/css">
 body       { font-family:sans-serif; font-size:8pt; font-weight:normal }
 .dehead    { color:#000000; font-family:sans-serif; font-size:9pt; font-weight:bold }
 .olddetail { color:#000000; font-family:sans-serif; font-size:9pt; font-weight:normal }
 .newdetail { color:#00dd00; font-family:sans-serif; font-size:9pt; font-weight:normal }
 .errdetail { color:#dd0000; font-family:sans-serif; font-size:9pt; font-weight:normal }
 .infdetail { color:#0000ff; font-family:sans-serif; font-size:9pt; font-weight:normal }
</style>
<title><?xl('EOB Posting - Electronic Remittances','e')?></title>
<script language="JavaScript">
</script>
</head>
<body leftmargin='0' topmargin='0' marginwidth='0' marginheight='0'>
<center>

<table border='0' cellpadding='2' cellspacing='0' width='100%'>

 <tr bgcolor="#cccccc">
  <td class="dehead">
   <?php xl('Patient','e') ?>
  </td>
  <td class="dehead">
   <?php xl('Invoice','e') ?>
  </td>
  <td class="dehead">
   <?php xl('Code','e') ?>
  </td>
  <td class="dehead">
   <?php xl('Date','e') ?>
  </td>
  <td class="dehead">
   <?php xl('Description','e') ?>
  </td>
  <td class="dehead" align="right">
   <?php xl('Amount','e') ?>&nbsp;
  </td>
  <td class="dehead" align="right">
   <?php xl('Balance','e') ?>&nbsp;
  </td>
 </tr>

<?php
  $alertmsg = parse_era("$webserver_root/era/$eraname.edi", 'era_callback');
  slTerminate();
?>
</table>
</center>
<script language="JavaScript">
<?php
        if ($alertmsg) echo " alert('" . htmlentities($alertmsg) . "');\n";
?>
</script>
</body>
</html>
<?php
        // Save all of this script's output to a report file.
        if (!$debug) {
                fwrite($fhreport, ob_get_contents());
                fclose($fhreport);
        }
        ob_end_flush();
?>