library/gen_hcfa_1500.inc.php

   1 <?php
   2 /*
   3  * This program creates the HCFA 1500 claim form.
   4  *
   5  * @package OpenEMR
   6  * @author Rod Roark <rod@sunsetsystems.com>
   7  * @author Stephen Waite <stephen.waite@cmsvt.com>
   8  * @copyright Copyright (c) 2011 Rod Roark <rod@sunsetsystems.com>
   9  * @copyright Copyright (C) 2017 Stephen Waite <stephen.waite@cmsvt.com>
  10  * @link http://www.open-emr.org
  11  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once("gen_hcfa_1500_02_12.inc.php");
  15 require_once(dirname(__FILE__) . "/invoice_summary.inc.php");
  16
  17 use OpenEMR\Billing\Claim;
  18
  19 $hcfa_curr_line = 1;
  20 $hcfa_curr_col = 1;
  21 $hcfa_data = '';
  22 $hcfa_proc_index = 0;
  23
  24
  25 /**
  26  * take the data element and place it at the correct coordinates on the page
  27  *
  28  * @global int $hcfa_curr_line
  29  * @global type $hcfa_curr_col
  30  * @global type $hcfa_data
  31  * @param type $line
  32  * @param type $col
  33  * @param type $maxlen
  34  * @param type $data
  35  * @param type $strip   regular expression for what to strip from the data. period and has are the defaults
  36  *                      02/12 version needs to include periods in the diagnoses hence the need to override
  37  */
  38 function put_hcfa($line, $col, $maxlen, $data, $strip = '/[.#]/')
  39 {
  40     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  41     if ($line < $hcfa_curr_line) {
  42         die("Data item at ($line, $col) precedes current line.");
  43     }
  44
  45     while ($hcfa_curr_line < $line) {
  46         $hcfa_data .= "\n";
  47         ++$hcfa_curr_line;
  48         $hcfa_curr_col = 1;
  49     }
  50
  51     if ($col < $hcfa_curr_col) {
  52         die("Data item at ($line, $col) precedes current column.");
  53     }
  54
  55     while ($hcfa_curr_col < $col) {
  56         $hcfa_data .= " ";
  57         ++$hcfa_curr_col;
  58     }
  59
  60     $data = preg_replace($strip, '', strtoupper($data));
  61     $len = min(strlen($data), $maxlen);
  62     $hcfa_data .= substr($data, 0, $len);
  63     $hcfa_curr_col += $len;
  64 }
  65
  66 function gen_hcfa_1500($pid, $encounter, &$log)
  67 {
  68     global $hcfa_data, $hcfa_proc_index;
  69
  70     $hcfa_data = '';
  71     $hcfa_proc_index = 0;
  72
  73     $today = time();
  74     $claim = new Claim($pid, $encounter);
  75
  76     $log .= "Generating HCFA claim $pid-$encounter for " .
  77     $claim->patientFirstName()  . ' ' .
  78     $claim->patientMiddleName() . ' ' .
  79     $claim->patientLastName()   . ' on ' .
  80     date('Y-m-d H:i', $today) . ".\n";
  81
  82     while ($hcfa_proc_index < $claim->procCount()) {
  83         if ($hcfa_proc_index) {
  84             $hcfa_data .= "\014"; // append form feed for new page
  85         }
  86
  87         gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  88     }
  89
  90     $log .= "\n";
  91     return $hcfa_data;
  92 }
  93
  94 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim)
  95 {
  96     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  97
  98     $hcfa_curr_line = 1;
  99     $hcfa_curr_col = 1;
 100
 101   // According to:
 102   // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
 103   // Medicare interprets sections 9 and 11 of the claim form in its own
 104   // special way.  This flag tells us to do that.  However I'm not 100%
 105   // sure that it applies nationwide, and if you find that it is not right
 106   // for you then set it to false.  -- Rod 2009-03-26
 107     $new_medicare_logic = $claim->claimType() == 'MB';
 108
 109   // Payer name, attn, street.
 110     put_hcfa(2, 41, 31, $claim->payerName());
 111     put_hcfa(3, 41, 31, $claim->payerAttn());
 112     put_hcfa(4, 41, 31, $claim->payerStreet());
 113
 114   // Payer city, state, zip.
 115     $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
 116     put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
 117
 118   // Box 1. Insurance Type
 119   // claimTypeRaw() gets the integer value from insurance_companies.ins_type_code.
 120   // Previous version of this code called claimType() which maps ins_type_code to
 121   // a 2-character code and that was not specific enough.
 122     $ct = $claim->claimTypeRaw();
 123     $tmpcol = 45;                    // Other
 124     if ($ct == 2) {
 125         $tmpcol =  1; // Medicare
 126     } else if ($ct == 3) {
 127         $tmpcol =  8; // Medicaid
 128     } else if ($ct == 5) {
 129         $tmpcol = 15; // TriCare (formerly CHAMPUS)
 130     } else if ($ct == 4) {
 131         $tmpcol = 24; // Champus VA
 132     } else if ($ct == 6) {
 133         $tmpcol = 31; // Group Health Plan (only BCBS?)
 134     } else if ($ct == 7) {
 135         $tmpcol = 39; // FECA
 136     }
 137
 138     put_hcfa(8, $tmpcol, 1, 'X');
 139
 140   // Box 1a. Insured's ID Number
 141     put_hcfa(8, 50, 17, $claim->policyNumber());
 142
 143   // Box 2. Patient's Name
 144     $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 145     if ($claim->patientMiddleName()) {
 146         $tmp .= ', ' . substr($claim->patientMiddleName(), 0, 1);
 147     }
 148
 149     put_hcfa(10, 1, 28, $tmp);
 150
 151   // Box 3. Patient's Birth Date and Sex
 152     $tmp = $claim->patientDOB();
 153     put_hcfa(10, 31, 2, substr($tmp, 4, 2));
 154     put_hcfa(10, 34, 2, substr($tmp, 6, 2));
 155     put_hcfa(10, 37, 4, substr($tmp, 0, 4));
 156     put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 157
 158   // Box 4. Insured's Name
 159     $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 160     if ($claim->insuredMiddleName()) {
 161         $tmp .= ', ' . substr($claim->insuredMiddleName(), 0, 1);
 162     }
 163
 164     put_hcfa(10, 50, 28, $tmp);
 165
 166   // Box 5. Patient's Address
 167     put_hcfa(12, 1, 28, $claim->patientStreet());
 168
 169   // Box 6. Patient Relationship to Insured
 170     $tmp = $claim->insuredRelationship();
 171     $tmpcol = 47;                         // Other
 172     if ($tmp === '18') {
 173         $tmpcol = 33; // self
 174     } else if ($tmp === '01') {
 175         $tmpcol = 38; // spouse
 176     } else if ($tmp === '19') {
 177         $tmpcol = 42; // child
 178     }
 179
 180     put_hcfa(12, $tmpcol, 1, 'X');
 181
 182   // Box 7. Insured's Address
 183     put_hcfa(12, 50, 28, $claim->insuredStreet());
 184
 185   // Box 5 continued. Patient's City and State
 186     put_hcfa(14, 1, 20, $claim->patientCity());
 187     put_hcfa(14, 26, 2, $claim->patientState());
 188
 189   // Box 8. Patient (Marital) Status
 190     if (!hcfa_1500_version_02_12()) {  // Box 8 Reserved for NUCC Use in 02/12
 191         $tmp = $claim->patientStatus();
 192         $tmpcol = 47;                        // Other
 193         if ($tmp === 'S') {
 194             $tmpcol = 35; // Single
 195         } else if ($tmp === 'M') {
 196             $tmpcol = 41; // Married
 197         }
 198
 199         put_hcfa(14, $tmpcol, 1, 'X');
 200     }
 201
 202   // Box 7 continued. Insured's City and State
 203     put_hcfa(14, 50, 20, $claim->insuredCity());
 204     put_hcfa(14, 74, 2, $claim->insuredState());
 205
 206   // Box 5 continued. Patient's Zip Code and Telephone
 207     put_hcfa(16, 1, 10, $claim->patientZip());
 208     $tmp = $claim->patientPhone();
 209     put_hcfa(16, 15, 3, substr($tmp, 0, 3));
 210     put_hcfa(16, 19, 7, substr($tmp, 3));
 211
 212   // Box 8 continued. Patient (Employment) Status
 213     if (!hcfa_1500_version_02_12()) {  // Box 8 Reserved for NUCC Use in 02/12
 214         $tmp = $claim->patientOccupation();
 215         if ($tmp === 'STUDENT') {
 216             put_hcfa(16, 41, 1, 'X');
 217         } else if ($tmp === 'PT STUDENT') {
 218             put_hcfa(16, 47, 1, 'X');
 219         } else if ($tmp !== 'UNEMPLOYED') {
 220             put_hcfa(16, 35, 1, 'X');
 221         }
 222     }
 223
 224   // Box 7 continued. Insured's Zip Code and Telephone
 225     put_hcfa(16, 50, 10, $claim->insuredZip());
 226     $tmp = $claim->insuredPhone();
 227     put_hcfa(16, 65, 3, substr($tmp, 0, 3));
 228     put_hcfa(16, 69, 7, substr($tmp, 3));
 229
 230   // Box 9. Other Insured's Name
 231     if ($new_medicare_logic) {
 232         // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 233     } else {
 234         if ($claim->payerCount() > 1) {
 235             $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 236             if ($claim->insuredMiddleName(1)) {
 237                 $tmp .= ', ' . substr($claim->insuredMiddleName(1), 0, 1);
 238             }
 239
 240             put_hcfa(18, 1, 28, $tmp);
 241         }
 242     }
 243
 244   // Box 11. Insured's Group Number
 245     if ($new_medicare_logic) {
 246         // If this is Medicare secondary then we need the primary's policy number
 247         // here, otherwise the word "NONE".
 248         $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 249     } else {
 250         $tmp = $claim->groupNumber();
 251     }
 252
 253     put_hcfa(18, 50, 30, $tmp);
 254
 255   // Box 9a. Other Insured's Policy or Group Number
 256     if ($new_medicare_logic) {
 257         // TBD: Medigap stuff?
 258     } else {
 259         if ($claim->payerCount() > 1) {
 260             put_hcfa(20, 1, 28, $claim->policyNumber(1));
 261         }
 262     }
 263
 264   // Box 10a. Employment Related
 265     put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 266
 267   // Box 11a. Insured's Birth Date and Sex
 268     if ($new_medicare_logic) {
 269         $tmpdob = $tmpsex = '';
 270         if ($claim->payerSequence() != 'P') {
 271             $tmpdob = $claim->insuredDOB(1);
 272             $tmpsex = $claim->insuredSex(1);
 273         }
 274     } else {
 275         $tmpdob = $claim->insuredDOB();
 276         $tmpsex = $claim->insuredSex();
 277     }
 278
 279     if ($tmpdob) {
 280         put_hcfa(20, 53, 2, substr($tmpdob, 4, 2));
 281         put_hcfa(20, 56, 2, substr($tmpdob, 6, 2));
 282         put_hcfa(20, 59, 4, substr($tmpdob, 0, 4));
 283     }
 284
 285     if ($tmpsex) {
 286         put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 287     }
 288
 289   // Box 9b. Other Insured's Birth Date and Sex
 290     if (!hcfa_1500_version_02_12()) {  // Box 9b Reserved for NUCC Use in 02/12
 291         if ($new_medicare_logic) {
 292             // TBD: Medigap stuff?
 293         } else {
 294             if ($claim->payerCount() > 1) {
 295                 $tmp = $claim->insuredDOB(1);
 296                 put_hcfa(22, 2, 2, substr($tmp, 4, 2));
 297                 put_hcfa(22, 5, 2, substr($tmp, 6, 2));
 298                 put_hcfa(22, 8, 4, substr($tmp, 0, 4));
 299                 put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 300             }
 301         }
 302     }
 303
 304   // Box 10b. Auto Accident
 305     put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 306     if ($claim->isRelatedAuto()) {
 307         put_hcfa(22, 45, 2, $claim->autoAccidentState());
 308     }
 309
 310   // Box 11b. Insured's Employer/School Name
 311     if ($new_medicare_logic) {
 312         $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 313     } else {
 314         $tmp = $claim->groupName();
 315     }
 316
 317     put_hcfa(22, 50, 30, $tmp);
 318
 319   // Box 9c. Other Insured's Employer/School Name
 320     if (!hcfa_1500_version_02_12()) {  // Box 9c Reserved for NUCC Use in 02/12
 321         if ($new_medicare_logic) {
 322             // TBD: Medigap stuff?
 323         } else {
 324             if ($claim->payerCount() > 1) {
 325                 put_hcfa(24, 1, 28, $claim->groupName(1));
 326             }
 327         }
 328     }
 329
 330   // Box 10c. Other Accident
 331     put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 332
 333   // Box 11c. Insurance Plan Name or Program Name
 334     if ($new_medicare_logic) {
 335         $tmp = '';
 336         if ($claim->payerSequence() != 'P') {
 337             $tmp = $claim->planName(1);
 338             if (!$tmp) {
 339                 $tmp = $claim->payerName(1);
 340             }
 341         }
 342     } else {
 343         $tmp = $claim->planName();
 344     }
 345
 346     put_hcfa(24, 50, 30, $tmp);
 347
 348   // Box 9d. Other Insurance Plan Name or Program Name
 349     if ($new_medicare_logic) {
 350         // TBD: Medigap stuff?
 351     } else {
 352         if ($claim->payerCount() > 1) {
 353             put_hcfa(26, 1, 28, $claim->planName(1));
 354         }
 355     }
 356
 357   // Box 10d. Claim Codes  medicaid_referral_code
 358
 359     if ($claim->epsdtFlag()) {
 360         put_hcfa(26, 34, 2, $claim->medicaidReferralCode());
 361     }
 362
 363   // Box 11d. Is There Another Health Benefit Plan
 364
 365     if (!$new_medicare_logic) {
 366         put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 367     }
 368
 369   // Box 12. Patient's or Authorized Person's Signature
 370     put_hcfa(29, 7, 17, 'Signature on File');
 371   // Note: Date does not apply unless the person physically signs the form.
 372
 373   // Box 13. Insured's or Authorized Person's Signature
 374     put_hcfa(29, 55, 17, 'Signature on File');
 375
 376   // Box 14. Date of Current Illness/Injury/Pregnancy
 377     $tmp = $claim->miscOnsetDate();
 378     put_hcfa(32, 2, 2, substr($tmp, 4, 2));
 379     put_hcfa(32, 5, 2, substr($tmp, 6, 2));
 380     put_hcfa(32, 8, 4, substr($tmp, 0, 4));
 381
 382     if (hcfa_1500_version_02_12() && !empty($tmp)) {
 383         // Only include the Box 14 qualifier if using version 02/12 and there is a Box 14 date.
 384         put_hcfa(32, 16, 3, $claim->box14Qualifier());
 385     }
 386
 387   // Box 15. First Date of Same or Similar Illness, if applicable
 388     $tmp = $claim->dateInitialTreatment();
 389     if (hcfa_1500_version_02_12() && !empty($tmp)) {
 390         // Only include the Box 15 qualifier if using version 02/12 and there is a Box 15 date.
 391         put_hcfa(32, 31, 3, $claim->box15Qualifier());
 392     }
 393
 394     put_hcfa(32, 37, 2, substr($tmp, 4, 2));
 395     put_hcfa(32, 40, 2, substr($tmp, 6, 2));
 396     put_hcfa(32, 43, 4, substr($tmp, 0, 4));
 397
 398   // Box 16. Dates Patient Unable to Work in Current Occupation
 399     if ($claim->isUnableToWork()) {
 400         $tmp = $claim->offWorkFrom();
 401         put_hcfa(32, 54, 2, substr($tmp, 4, 2));
 402         put_hcfa(32, 57, 2, substr($tmp, 6, 2));
 403         put_hcfa(32, 60, 4, substr($tmp, 0, 4));
 404         $tmp = $claim->offWorkTo();
 405         put_hcfa(32, 68, 2, substr($tmp, 4, 2));
 406         put_hcfa(32, 71, 2, substr($tmp, 6, 2));
 407         put_hcfa(32, 74, 4, substr($tmp, 0, 4));
 408     }
 409
 410   // Referring provider stuff.  Reports are that for primary care doctors,
 411   // Medicare forbids an entry here and other payers require one.
 412   // There is still confusion over this.
 413   //
 414     if ($claim->referrerLastName() || $claim->billingProviderLastName() &&
 415     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB')) {
 416         // Box 17a. Referring Provider Alternate Identifier
 417         // Commented this out because UPINs are obsolete, leaving the code as an
 418         // example in case some other identifier needs to be supported.
 419         /*****************************************************************
 420       if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 421         put_hcfa(33, 30,  2, '1G');
 422         put_hcfa(33, 33, 15, $claim->referrerUPIN());
 423       }
 424         *****************************************************************/
 425         if ($claim->claimType() == 'MC') {
 426             put_hcfa(33, 30, 2, 'ZZ');
 427             put_hcfa(33, 33, 14, $claim->referrerTaxonomy());
 428         }
 429
 430         // Box 17. Name of Referring Provider or Other Source leave it like it is just check if there is info in misc_billing the use it provider_qualifier_code
 431         # Changed to look first at the misc hcfa billing form to complete this box if nothing on misc hcfa form use referrer
 432         if (strlen($claim->billingProviderLastName()) !=0) {
 433             $tmp2 = $claim->billingProviderLastName() . ', ' . $claim->billingProviderFirstName();
 434             if ($claim->billingProviderMiddleName()) {
 435                 $tmp2 .= ', ' . substr($claim->billingProviderMiddleName(), 0, 1);
 436             }
 437
 438             put_hcfa(34, 1, 3, $claim->billing_options['provider_qualifier_code']);
 439             put_hcfa(34, 4, 25, $tmp2);
 440             if ($claim->billingProviderNPI()) {
 441                 put_hcfa(34, 33, 15, $claim->billingProviderNPI());
 442             }
 443         } else {
 444             $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 445             if ($claim->referrerMiddleName()) {
 446                 $tmp .= ', ' . substr($claim->referrerMiddleName(), 0, 1);
 447             }
 448
 449             put_hcfa(34, 1, 3, 'DN');
 450             put_hcfa(34, 4, 25, $tmp);
 451             if ($claim->referrerNPI()) {
 452                 put_hcfa(34, 33, 15, $claim->referrerNPI());
 453             }
 454         }
 455     }
 456
 457   // Box 18. Hospitalization Dates Related to Current Services
 458     if ($claim->isHospitalized()) {
 459         $tmp = $claim->hospitalizedFrom();
 460         put_hcfa(34, 54, 2, substr($tmp, 4, 2));
 461         put_hcfa(34, 57, 2, substr($tmp, 6, 2));
 462         put_hcfa(34, 60, 4, substr($tmp, 0, 4));
 463         $tmp = $claim->hospitalizedTo();
 464         put_hcfa(34, 68, 2, substr($tmp, 4, 2));
 465         put_hcfa(34, 71, 2, substr($tmp, 6, 2));
 466         put_hcfa(34, 74, 4, substr($tmp, 0, 4));
 467     }
 468
 469   // Box 19. Reserved for Local Use
 470     put_hcfa(36, 1, 48, $claim->additionalNotes());
 471
 472   // Box 20. Outside Lab
 473     put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 474     if ($claim->isOutsideLab()) {
 475         // Note here that put_hcfa strips the decimal point, as required.
 476         // We right-justify this amount (ending in col. 69).
 477         put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 478     }
 479
 480     if (hcfa_1500_version_02_12()) {
 481         process_diagnoses_02_12($claim, $log);
 482     } else {
 483         // Box 21. Diagnoses
 484         $tmp = $claim->diagArray();
 485         $diags = array();
 486         foreach ($tmp as $diag) {
 487             $diags[] = $diag;
 488         }
 489
 490         if (!empty($diags[0])) {
 491             put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 492             put_hcfa(38, 7, 2, substr($diags[0], 3));
 493         }
 494
 495         if (!empty($diags[2])) {
 496             put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 497             put_hcfa(38, 34, 2, substr($diags[2], 3));
 498         }
 499
 500         // Box 22. Medicaid Resubmission Code and Original Ref. No.
 501         put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 502         put_hcfa(38, 62, 15, $claim->medicaidOriginalReference());
 503
 504         // Box 21 continued. Diagnoses
 505         if (!empty($diags[1])) {
 506             put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 507             put_hcfa(40, 7, 2, substr($diags[1], 3));
 508         }
 509
 510         if (!empty($diags[3])) {
 511             put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 512             put_hcfa(40, 34, 2, substr($diags[3], 3));
 513         }
 514
 515         // Box 23. Prior Authorization Number
 516         put_hcfa(40, 50, 28, $claim->priorAuth());
 517     }
 518
 519     $proccount = $claim->procCount(); // number of procedures
 520
 521   // Charges, adjustments and payments are accumulated by line item so that
 522   // each page of a multi-page claim will stand alone.  Payments include the
 523   // co-pay for the first page only.
 524     $clm_total_charges = 0;
 525     $clm_amount_adjusted = 0;
 526     $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 527
 528   // Procedure loop starts here.
 529   //
 530     for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 531         $dia = $claim->diagIndexArray($hcfa_proc_index);
 532
 533         if (!$claim->cptCharges($hcfa_proc_index)) {
 534             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 535             "' has no charges!\n";
 536         }
 537
 538         if (empty($dia)) {
 539             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 540             "' is not justified!\n";
 541         }
 542
 543         $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 544
 545         // Compute prior payments and "hard" adjustments.
 546         for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 547             if ($claim->payerSequence($ins) > $claim->payerSequence()) {
 548                 continue; // skip future payers
 549             }
 550
 551             $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 552             $clm_amount_paid += $payerpaid[1];
 553             $clm_amount_adjusted += $payerpaid[2];
 554         }
 555
 556         ++$svccount;
 557         $lino = $svccount * 2 + 41;
 558
 559         // Drug Information. Medicaid insurers want this with HCPCS codes.
 560         //
 561         $ndc = $claim->cptNDCID($hcfa_proc_index);
 562         if ($ndc) {
 563             if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 564                 $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 565             } else if (preg_match('/^\d{11}$/', $ndc)) {
 566             } else {
 567                 $log .= "*** NDC code '$ndc' has invalid format!\n";
 568             }
 569
 570             put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 571             $claim->cptNDCQuantity($hcfa_proc_index));
 572         }
 573
 574         //Note Codes.
 575         put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 576
 577         // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 578         if ($claim->supervisorNumber()) {
 579             // If there is a supervising provider and that person has a
 580             // payer-specific provider number, then we assume that the SP
 581             // must be identified on the claim and this is how we do it
 582             // (but the NPI of the actual rendering provider appears below).
 583             // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 584             put_hcfa($lino, 65, 2, $claim->supervisorNumberType());
 585             put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 586         } else if ($claim->providerNumber($hcfa_proc_index)) {
 587             put_hcfa($lino, 65, 2, $claim->providerNumberType($hcfa_proc_index));
 588             put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 589         } else if ($claim->claimType() == 'MC') {
 590             put_hcfa($lino, 65, 2, 'ZZ');
 591             put_hcfa($lino, 68, 14, $claim->providerTaxonomy());
 592         }
 593
 594         ++$lino;
 595
 596         // 24a. Date of Service
 597         $tmp = $claim->serviceDate();
 598         put_hcfa($lino, 1, 2, substr($tmp, 4, 2));
 599         put_hcfa($lino, 4, 2, substr($tmp, 6, 2));
 600         put_hcfa($lino, 7, 2, substr($tmp, 2, 2));
 601         put_hcfa($lino, 10, 2, substr($tmp, 4, 2));
 602         put_hcfa($lino, 13, 2, substr($tmp, 6, 2));
 603         put_hcfa($lino, 16, 2, substr($tmp, 2, 2));
 604
 605         // 24b. Place of Service
 606         put_hcfa($lino, 19, 2, $claim->facilityPOS());
 607
 608         // 24c. EMG
 609         // Not currently supported.
 610
 611         // 24d. Procedures, Services or Supplies
 612         put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 613         // replace colon with space for printing
 614         put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 615
 616         // 24e. Diagnosis Pointer
 617         $tmp = '';
 618         foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) {
 619             if (hcfa_1500_version_02_12()) {// For 02/12 Version convert number to letter.
 620             // ASCII A is 65, since diagIndexArray is ones based, this will make 1->A, 2->B...
 621                 $value=chr($value+64);
 622             }
 623
 624             $tmp .= $value;
 625         }
 626
 627         put_hcfa($lino, 45, 4, $tmp);
 628
 629         // 24f. Charges
 630         put_hcfa($lino, 50, 8, str_replace(
 631             '.',
 632             ' ',
 633             sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))
 634         ));
 635
 636         // 24g. Days or Units
 637         put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 638
 639         // 24h. EPSDT Family Plan
 640         //
 641         if ($claim->epsdtFlag()) {
 642               put_hcfa($lino, 63, 2, '03');
 643         }
 644
 645         // 24j. Rendering Provider NPI
 646         put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 647     }
 648
 649   // 25. Federal Tax ID Number
 650   // FrreB hard coded EIN. Changed it to included SSN as well.
 651     put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 652     if ($claim->federalIdType()=='SY') {
 653         put_hcfa(56, 17, 1, 'X'); // The SSN checkbox
 654     } else {
 655         put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 656     }
 657
 658   // 26. Patient's Account No.
 659   // Instructions say hyphens are not allowed.
 660     put_hcfa(56, 23, 15, "$pid-$encounter");
 661
 662   // 27. Accept Assignment
 663     put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 664
 665   // 28. Total Charge
 666     put_hcfa(56, 52, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_total_charges)));
 667     if (!$clm_total_charges) {
 668         $log .= "*** This claim has no charges!\n";
 669     }
 670
 671   // 29. Amount Paid
 672     put_hcfa(56, 62, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_amount_paid)));
 673
 674   // 30. Balance Due
 675   // For secondary payers this reflects primary "contracted rate" adjustments,
 676   // so in general box 30 will not equal box 28 minus box 29.
 677     if (!hcfa_1500_version_02_12()) {  // Box 30 Reserved for NUCC Use in 02/12
 678         put_hcfa(56, 71, 8, str_replace('.', ' ', sprintf(
 679             '%8.2f',
 680             $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted
 681         )));
 682     }
 683
 684   // 33. Billing Provider: Phone Number
 685     $tmp = $claim->billingContactPhone();
 686     put_hcfa(57, 66, 3, substr($tmp, 0, 3));
 687     put_hcfa(57, 70, 3, substr($tmp, 3)); // slight adjustment for better look smw 030315
 688     put_hcfa(57, 73, 1, '-');
 689     put_hcfa(57, 74, 4, substr($tmp, 6));
 690
 691   // 32. Service Facility Location Information: Name
 692     put_hcfa(58, 23, 25, $claim->facilityName());
 693
 694   // 33. Billing Provider: Name
 695     if ($claim->federalIdType() == "SY") { // check entity type for NM*102 1 == person, 2 == non-person entity
 696         $firstName = $claim->providerFirstName();
 697         $lastName = $claim->providerLastName();
 698         $middleName = $claim->providerMiddleName();
 699         $suffixName = $claim->providerSuffixName();
 700         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 701         put_hcfa(58, 50, 25, $billingProviderName);
 702     } else {
 703         put_hcfa(58, 50, 25, $claim->billingFacilityName());
 704     }
 705
 706   // 32. Service Facility Location Information: Street
 707     put_hcfa(59, 23, 25, $claim->facilityStreet());
 708
 709   // 33. Billing Provider: Name
 710     put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 711
 712   // 31. Signature of Physician or Supplier
 713
 714     if ($GLOBALS['cms_1500_box_31_format']==0) {
 715         put_hcfa(60, 1, 20, 'Signature on File');
 716     } else if ($GLOBALS['cms_1500_box_31_format']==1) {
 717         put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 718     }
 719
 720   //
 721   // $tmp = $claim->providerFirstName();
 722   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 723   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 724
 725   // 32. Service Facility Location Information: City State Zip
 726     $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 727     put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 728     $claim->facilityZip());
 729
 730   // 33. Billing Provider: City State Zip
 731     $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 732     put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 733     $claim->billingFacilityZip());
 734
 735   // 31. Signature of Physician or Supplier: Date
 736     if ($GLOBALS['cms_1500_box_31_date']>0) {
 737         if ($GLOBALS['cms_1500_box_31_date']==1) {
 738             $date_of_service= $claim->serviceDate();
 739             $MDY=substr($date_of_service, 4, 2)." ".substr($date_of_service, 6, 2)." ".substr($date_of_service, 2, 2);
 740         } else if ($GLOBALS['cms_1500_box_31_date']==2) {
 741             $MDY=date("m/d/y");
 742         }
 743
 744         put_hcfa(61, 6, 10, $MDY);
 745     }
 746
 747   // 32a. Service Facility NPI
 748     put_hcfa(61, 23, 10, $claim->facilityNPI());
 749
 750   // 32b. Service Facility Other ID
 751   // Note that Medicare does NOT want this any more.
 752     if ($claim->providerGroupNumber()) {
 753         put_hcfa(61, 36, 2, $claim->providerNumberType());
 754         put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 755     }
 756
 757   // 33a. Billing Facility NPI
 758     put_hcfa(61, 50, 10, $claim->billingFacilityNPI());
 759
 760   // 33b. Billing Facility Other ID
 761   // Note that Medicare does NOT want this any more.
 762     if ($claim->claimType() == 'MC') {
 763         put_hcfa(61, 63, 2, 'ZZ');
 764         put_hcfa(61, 65, 14, $claim->providerTaxonomy());
 765     } elseif ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 766         put_hcfa(61, 63, 2, $claim->providerNumberType());
 767         put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 768     }
 769
 770   // Put an extra line here for compatibility with old hcfa text generated form
 771     put_hcfa(62, 1, 1, ' ');
 772   // put a couple more in so that multiple claims correctly print through the text file download
 773     put_hcfa(63, 1, 1, ' ');
 774     put_hcfa(64, 1, 1, ' ');
 775     return;
 776 }