library/gen_hcfa_1500.inc.php

   1 <?php
   2 // Copyright (C) 2008-2011 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("Claim.class.php");
  10 require_once("gen_hcfa_1500_02_12.inc.php");
  11
  12 $hcfa_curr_line = 1;
  13 $hcfa_curr_col = 1;
  14 $hcfa_data = '';
  15 $hcfa_proc_index = 0;
  16
  17
  18 /**
  19  * take the data element and place it at the correct coordinates on the page
  20  *
  21  * @global int $hcfa_curr_line
  22  * @global type $hcfa_curr_col
  23  * @global type $hcfa_data
  24  * @param type $line
  25  * @param type $col
  26  * @param type $maxlen
  27  * @param type $data
  28  * @param type $strip   regular expression for what to strip from the data. period and has are the defaults
  29  *                      02/12 version needs to include periods in the diagnoses hence the need to override
  30  */
  31 function put_hcfa($line, $col, $maxlen, $data,$strip='/[.#]/') {
  32   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  33   if ($line < $hcfa_curr_line)
  34     die("Data item at ($line, $col) precedes current line.");
  35   while ($hcfa_curr_line < $line) {
  36     $hcfa_data .= "\n";
  37     ++$hcfa_curr_line;
  38     $hcfa_curr_col = 1;
  39   }
  40   if ($col < $hcfa_curr_col)
  41     die("Data item at ($line, $col) precedes current column.");
  42   while ($hcfa_curr_col < $col) {
  43     $hcfa_data .= " ";
  44     ++$hcfa_curr_col;
  45   }
  46   $data = preg_replace($strip, '', strtoupper($data));
  47   $len = min(strlen($data), $maxlen);
  48   $hcfa_data .= substr($data, 0, $len);
  49   $hcfa_curr_col += $len;
  50 }
  51
  52 function gen_hcfa_1500($pid, $encounter, &$log) {
  53   global $hcfa_data, $hcfa_proc_index;
  54
  55   $hcfa_data = '';
  56   $hcfa_proc_index = 0;
  57
  58   $today = time();
  59   $claim = new Claim($pid, $encounter);
  60
  61   $log .= "Generating HCFA claim $pid-$encounter for " .
  62     $claim->patientFirstName()  . ' ' .
  63     $claim->patientMiddleName() . ' ' .
  64     $claim->patientLastName()   . ' on ' .
  65     date('Y-m-d H:i', $today) . ".\n";
  66
  67   while ($hcfa_proc_index < $claim->procCount()) {
  68     if ($hcfa_proc_index) $hcfa_data .= "\014"; // append form feed for new page
  69     gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  70   }
  71
  72   $log .= "\n";
  73   return $hcfa_data;
  74 }
  75
  76 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim) {
  77   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  78
  79   $hcfa_curr_line = 1;
  80   $hcfa_curr_col = 1;
  81
  82   // According to:
  83   // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
  84   // Medicare interprets sections 9 and 11 of the claim form in its own
  85   // special way.  This flag tells us to do that.  However I'm not 100%
  86   // sure that it applies nationwide, and if you find that it is not right
  87   // for you then set it to false.  -- Rod 2009-03-26
  88   $new_medicare_logic = $claim->claimType() == 'MB';
  89
  90   // Payer name, attn, street.
  91   put_hcfa(2, 41, 31, $claim->payerName());
  92   put_hcfa(3, 41, 31, $claim->payerAttn());
  93   put_hcfa(4, 41, 31, $claim->payerStreet());
  94
  95   // Payer city, state, zip.
  96   $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
  97   put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
  98
  99   // Box 1. Insurance Type
 100   // claimTypeRaw() gets the integer value from insurance_companies.freeb_type.
 101   // Previous version of this code called claimType() which maps freeb_type to
 102   // a 2-character code and that was not specific enough.
 103   $ct = $claim->claimTypeRaw();
 104   $tmpcol = 45;                    // Other
 105   if      ($ct == 2) $tmpcol =  1; // Medicare
 106   else if ($ct == 3) $tmpcol =  8; // Medicaid
 107   else if ($ct == 5) $tmpcol = 15; // TriCare (formerly CHAMPUS)
 108   else if ($ct == 4) $tmpcol = 24; // Champus VA
 109   else if ($ct == 6) $tmpcol = 31; // Group Health Plan (only BCBS?)
 110   else if ($ct == 7) $tmpcol = 39; // FECA
 111   put_hcfa(8, $tmpcol, 1, 'X');
 112
 113   // Box 1a. Insured's ID Number
 114   put_hcfa(8, 50, 17, $claim->policyNumber());
 115
 116   // Box 2. Patient's Name
 117   $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 118   if ($claim->patientMiddleName())
 119     $tmp .= ', ' . substr($claim->patientMiddleName(),0,1);
 120   put_hcfa(10, 1, 28, $tmp);
 121
 122   // Box 3. Patient's Birth Date and Sex
 123   $tmp = $claim->patientDOB();
 124   put_hcfa(10, 31, 2, substr($tmp,4,2));
 125   put_hcfa(10, 34, 2, substr($tmp,6,2));
 126   put_hcfa(10, 37, 4, substr($tmp,0,4));
 127   put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 128
 129   // Box 4. Insured's Name
 130   $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 131   if ($claim->insuredMiddleName())
 132     $tmp .= ', ' . substr($claim->insuredMiddleName(),0,1);
 133   put_hcfa(10, 50, 28, $tmp);
 134
 135   // Box 5. Patient's Address
 136   put_hcfa(12, 1, 28, $claim->patientStreet());
 137
 138   // Box 6. Patient Relationship to Insured
 139   $tmp = $claim->insuredRelationship();
 140   $tmpcol = 47;                         // Other
 141   if      ($tmp === '18') $tmpcol = 33; // self
 142   else if ($tmp === '01') $tmpcol = 38; // spouse
 143   else if ($tmp === '19') $tmpcol = 42; // child
 144   put_hcfa(12, $tmpcol, 1, 'X');
 145
 146   // Box 7. Insured's Address
 147   put_hcfa(12, 50, 28, $claim->insuredStreet());
 148
 149   // Box 5 continued. Patient's City and State
 150   put_hcfa(14,  1, 20, $claim->patientCity());
 151   put_hcfa(14, 26,  2, $claim->patientState());
 152
 153   // Box 8. Patient (Marital) Status
 154   if(!hcfa_1500_version_02_12())  // Box 8 Reserved for NUCC Use in 02/12
 155   {
 156     $tmp = $claim->patientStatus();
 157     $tmpcol = 47;                        // Other
 158     if      ($tmp === 'S') $tmpcol = 35; // Single
 159     else if ($tmp === 'M') $tmpcol = 41; // Married
 160     put_hcfa(14, $tmpcol, 1, 'X');
 161   }
 162
 163   // Box 7 continued. Insured's City and State
 164   put_hcfa(14, 50, 20, $claim->insuredCity());
 165   put_hcfa(14, 74,  2, $claim->insuredState());
 166
 167   // Box 5 continued. Patient's Zip Code and Telephone
 168   put_hcfa(16,  1, 10, $claim->patientZip());
 169   $tmp = $claim->patientPhone();
 170   put_hcfa(16, 15,  3, substr($tmp,0,3));
 171   put_hcfa(16, 19,  7, substr($tmp,3));
 172
 173   // Box 8 continued. Patient (Employment) Status
 174   if(!hcfa_1500_version_02_12())  // Box 8 Reserved for NUCC Use in 02/12
 175   {
 176     $tmp = $claim->patientOccupation();
 177     if      ($tmp === 'STUDENT'   ) put_hcfa(16, 41, 1, 'X');
 178     else if ($tmp === 'PT STUDENT') put_hcfa(16, 47, 1, 'X');
 179     else if ($tmp !== 'UNEMPLOYED') put_hcfa(16, 35, 1, 'X');
 180   }
 181
 182   // Box 7 continued. Insured's Zip Code and Telephone
 183   put_hcfa(16, 50, 10, $claim->insuredZip());
 184   $tmp = $claim->insuredPhone();
 185   put_hcfa(16, 65,  3, substr($tmp,0,3));
 186   put_hcfa(16, 69,  7, substr($tmp,3));
 187
 188   // Box 9. Other Insured's Name
 189   if ($new_medicare_logic) {
 190     // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 191   }
 192   else {
 193     if ($claim->payerCount() > 1) {
 194       $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 195       if ($claim->insuredMiddleName(1))
 196         $tmp .= ', ' . substr($claim->insuredMiddleName(1),0,1);
 197       put_hcfa(18, 1, 28, $tmp);
 198     }
 199   }
 200
 201   // Box 11. Insured's Group Number
 202   if ($new_medicare_logic) {
 203     // If this is Medicare secondary then we need the primary's policy number
 204     // here, otherwise the word "NONE".
 205     $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 206   }
 207   else {
 208     $tmp = $claim->groupNumber();
 209   }
 210   put_hcfa(18, 50, 30, $tmp);
 211
 212   // Box 9a. Other Insured's Policy or Group Number
 213   if ($new_medicare_logic) {
 214     // TBD: Medigap stuff?
 215   }
 216   else {
 217     if ($claim->payerCount() > 1) {
 218       put_hcfa(20, 1, 28, $claim->policyNumber(1));
 219     }
 220   }
 221
 222   // Box 10a. Employment Related
 223   put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 224
 225   // Box 11a. Insured's Birth Date and Sex
 226   if ($new_medicare_logic) {
 227     $tmpdob = $tmpsex = '';
 228     if ($claim->payerSequence() != 'P') {
 229       $tmpdob = $claim->insuredDOB(1);
 230       $tmpsex = $claim->insuredSex(1);
 231     }
 232    }
 233   else {
 234     $tmpdob = $claim->insuredDOB();
 235     $tmpsex = $claim->insuredSex();
 236   }
 237   if ($tmpdob) {
 238     put_hcfa(20, 53, 2, substr($tmpdob,4,2));
 239     put_hcfa(20, 56, 2, substr($tmpdob,6,2));
 240     put_hcfa(20, 59, 4, substr($tmpdob,0,4));
 241   }
 242   if ($tmpsex) {
 243     put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 244   }
 245
 246   // Box 9b. Other Insured's Birth Date and Sex
 247   if(!hcfa_1500_version_02_12())  // Box 9b Reserved for NUCC Use in 02/12
 248   {
 249     if ($new_medicare_logic) {
 250       // TBD: Medigap stuff?
 251     }
 252     else {
 253       if ($claim->payerCount() > 1) {
 254         $tmp = $claim->insuredDOB(1);
 255         put_hcfa(22, 2, 2, substr($tmp,4,2));
 256         put_hcfa(22, 5, 2, substr($tmp,6,2));
 257         put_hcfa(22, 8, 4, substr($tmp,0,4));
 258         put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 259       }
 260     }
 261   }
 262
 263   // Box 10b. Auto Accident
 264   put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 265   if ($claim->isRelatedAuto())
 266     put_hcfa(22, 45, 2, $claim->autoAccidentState());
 267
 268   // Box 11b. Insured's Employer/School Name
 269   if ($new_medicare_logic) {
 270     $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 271   }
 272   else {
 273     $tmp = $claim->groupName();
 274   }
 275   put_hcfa(22, 50, 30, $tmp);
 276
 277   // Box 9c. Other Insured's Employer/School Name
 278   if(!hcfa_1500_version_02_12())  // Box 9c Reserved for NUCC Use in 02/12
 279   {
 280     if ($new_medicare_logic) {
 281       // TBD: Medigap stuff?
 282     }
 283     else {
 284       if ($claim->payerCount() > 1) {
 285         put_hcfa(24, 1, 28, $claim->groupName(1));
 286       }
 287     }
 288   }
 289
 290   // Box 10c. Other Accident
 291   put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 292
 293   // Box 11c. Insurance Plan Name or Program Name
 294   if ($new_medicare_logic) {
 295     $tmp = '';
 296     if ($claim->payerSequence() != 'P') {
 297       $tmp = $claim->planName(1);
 298       if (!$tmp) $tmp = $claim->payerName(1);
 299     }
 300   }
 301   else {
 302     $tmp = $claim->planName();
 303   }
 304   put_hcfa(24, 50, 30, $tmp);
 305
 306   // Box 9d. Other Insurance Plan Name or Program Name
 307   if ($new_medicare_logic) {
 308     // TBD: Medigap stuff?
 309   }
 310   else {
 311     if ($claim->payerCount() > 1) {
 312       put_hcfa(26, 1, 28, $claim->planName(1));
 313     }
 314   }
 315
 316   // Box 11d. Is There Another Health Benefit Plan
 317   if (!$new_medicare_logic) {
 318     put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 319   }
 320
 321   // Box 12. Patient's or Authorized Person's Signature
 322   put_hcfa(29, 7, 17, 'Signature on File');
 323   // Note: Date does not apply unless the person physically signs the form.
 324
 325   // Box 13. Insured's or Authorized Person's Signature
 326   put_hcfa(29, 55, 17, 'Signature on File');
 327
 328   // Box 14. Date of Current Illness/Injury/Pregnancy
 329   $tmp = $claim->onsetDate();
 330   put_hcfa(32, 2, 2, substr($tmp,4,2));
 331   put_hcfa(32, 5, 2, substr($tmp,6,2));
 332   put_hcfa(32, 8, 4, substr($tmp,0,4));
 333
 334   if(hcfa_1500_version_02_12() && !empty($tmp))
 335   {
 336     // Only include the Box 14 qualifier if there we are using version 02/12 and there is a Box 14 date.
 337     put_hcfa(32, 16, 3, $claim->box14qualifier());
 338
 339   }
 340   // Box 15. First Date of Same or Similar Illness, if applicable
 341   $tmp = $claim->dateInitialTreatment();
 342   if(hcfa_1500_version_02_12() && !empty($tmp))
 343   {
 344     // Only include the Box 15 qualifier if there we are using version 02/12 and there is a Box 15 date.
 345     put_hcfa(32, 31, 3, $claim->box15qualifier());
 346   }
 347
 348
 349   put_hcfa(32,37, 2, substr($tmp,4,2));
 350   put_hcfa(32,40, 2, substr($tmp,6,2));
 351   put_hcfa(32,43, 4, substr($tmp,0,4));
 352
 353
 354   // Box 16. Dates Patient Unable to Work in Current Occupation
 355   if ($claim->isUnableToWork()) {
 356     $tmp = $claim->offWorkFrom();
 357     put_hcfa(32, 54, 2, substr($tmp,4,2));
 358     put_hcfa(32, 57, 2, substr($tmp,6,2));
 359     put_hcfa(32, 60, 4, substr($tmp,0,4));
 360     $tmp = $claim->offWorkTo();
 361     put_hcfa(32, 68, 2, substr($tmp,4,2));
 362     put_hcfa(32, 71, 2, substr($tmp,6,2));
 363     put_hcfa(32, 74, 4, substr($tmp,0,4));
 364   }
 365
 366   // Referring provider stuff.  Reports are that for primary care doctors,
 367   // Medicare forbids an entry here and other payers require one.
 368   // There is still confusion over this.
 369   //
 370   if ($claim->referrerLastName() &&
 371     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB'))
 372   {
 373     // Box 17a. Referring Provider Alternate Identifier
 374     // Commented this out because UPINs are obsolete, leaving the code as an
 375     // example in case some other identifier needs to be supported.
 376     /*****************************************************************
 377     if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 378       put_hcfa(33, 30,  2, '1G');
 379       put_hcfa(33, 33, 15, $claim->referrerUPIN());
 380     }
 381     *****************************************************************/
 382
 383     // Box 17. Name of Referring Provider or Other Source
 384     $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 385     if ($claim->referrerMiddleName())
 386       $tmp .= ', ' . substr($claim->referrerMiddleName(),0,1);
 387     put_hcfa(34, 1, 25, $tmp);
 388
 389     // Box 17b. Referring Provider NPI
 390     if ($claim->referrerNPI()) {
 391       put_hcfa(34, 33, 15, $claim->referrerNPI());
 392     }
 393   }
 394
 395   // Box 18. Hospitalization Dates Related to Current Services
 396   if ($claim->isHospitalized()) {
 397     $tmp = $claim->hospitalizedFrom();
 398     put_hcfa(34, 54, 2, substr($tmp,4,2));
 399     put_hcfa(34, 57, 2, substr($tmp,6,2));
 400     put_hcfa(34, 60, 4, substr($tmp,0,4));
 401     $tmp = $claim->hospitalizedTo();
 402     put_hcfa(34, 68, 2, substr($tmp,4,2));
 403     put_hcfa(34, 71, 2, substr($tmp,6,2));
 404     put_hcfa(34, 74, 4, substr($tmp,0,4));
 405   }
 406
 407   // Box 19. Reserved for Local Use
 408   put_hcfa(36, 1, 48, $claim->additionalNotes());
 409
 410   // Box 20. Outside Lab
 411   put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 412   if ($claim->isOutsideLab()) {
 413     // Note here that put_hcfa strips the decimal point, as required.
 414     // We right-justify this amount (ending in col. 69).
 415     put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 416   }
 417
 418   if(hcfa_1500_version_02_12())
 419   {
 420       process_diagnoses_02_12($claim,$log);
 421   }
 422   else
 423   {
 424         // Box 21. Diagnoses
 425         $tmp = $claim->diagArray();
 426         $diags = array();
 427         foreach ($tmp as $diag) $diags[] = $diag;
 428         if (!empty($diags[0])) {
 429           put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 430           put_hcfa(38, 7, 2, substr($diags[0], 3));
 431         }
 432         if (!empty($diags[2])) {
 433           put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 434           put_hcfa(38, 34, 2, substr($diags[2], 3));
 435         }
 436
 437         // Box 22. Medicaid Resubmission Code and Original Ref. No.
 438         put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 439         put_hcfa(38, 62, 10, $claim->medicaidOriginalReference());
 440
 441         // Box 21 continued. Diagnoses
 442         if (!empty($diags[1])) {
 443           put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 444           put_hcfa(40, 7, 2, substr($diags[1], 3));
 445         }
 446         if (!empty($diags[3])) {
 447           put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 448           put_hcfa(40, 34, 2, substr($diags[3], 3));
 449         }
 450
 451         // Box 23. Prior Authorization Number
 452         put_hcfa(40, 50, 28, $claim->priorAuth());
 453   }
 454   $proccount = $claim->procCount(); // number of procedures
 455
 456   // Charges, adjustments and payments are accumulated by line item so that
 457   // each page of a multi-page claim will stand alone.  Payments include the
 458   // co-pay for the first page only.
 459   $clm_total_charges = 0;
 460   $clm_amount_adjusted = 0;
 461   $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 462
 463   // Procedure loop starts here.
 464   //
 465   for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 466     $dia = $claim->diagIndexArray($hcfa_proc_index);
 467
 468     if (!$claim->cptCharges($hcfa_proc_index)) {
 469       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 470         "' has no charges!\n";
 471     }
 472
 473     if (empty($dia)) {
 474       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 475         "' is not justified!\n";
 476     }
 477
 478     $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 479
 480     // Compute prior payments and "hard" adjustments.
 481     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 482       if ($claim->payerSequence($ins) > $claim->payerSequence())
 483         continue; // skip future payers
 484       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 485       $clm_amount_paid += $payerpaid[1];
 486       $clm_amount_adjusted += $payerpaid[2];
 487     }
 488
 489     ++$svccount;
 490     $lino = $svccount * 2 + 41;
 491
 492     // Drug Information. Medicaid insurers want this with HCPCS codes.
 493     //
 494     $ndc = $claim->cptNDCID($hcfa_proc_index);
 495     if ($ndc) {
 496       if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 497         $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 498       }
 499       else if(preg_match('/^\d{11}$/', $ndc)){
 500
 501       }
 502       else {
 503         $log .= "*** NDC code '$ndc' has invalid format!\n";
 504       }
 505       put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 506         $claim->cptNDCQuantity($hcfa_proc_index));
 507     }
 508
 509     //Note Codes.
 510     put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 511
 512     // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 513     if ($claim->supervisorNumber()) {
 514       // If there is a supervising provider and that person has a
 515       // payer-specific provider number, then we assume that the SP
 516       // must be identified on the claim and this is how we do it
 517       // (but the NPI of the actual rendering provider appears below).
 518       // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 519       put_hcfa($lino, 65,  2, $claim->supervisorNumberType());
 520       put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 521     }
 522     else if ($claim->providerNumber($hcfa_proc_index)) {
 523       put_hcfa($lino, 65,  2, $claim->providerNumberType($hcfa_proc_index));
 524       put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 525     }
 526
 527     ++$lino;
 528
 529     // 24a. Date of Service
 530     $tmp = $claim->serviceDate();
 531     put_hcfa($lino, 1, 2, substr($tmp,4,2));
 532     put_hcfa($lino, 4, 2, substr($tmp,6,2));
 533     put_hcfa($lino, 7, 2, substr($tmp,2,2));
 534     put_hcfa($lino,10, 2, substr($tmp,4,2));
 535     put_hcfa($lino,13, 2, substr($tmp,6,2));
 536     put_hcfa($lino,16, 2, substr($tmp,2,2));
 537
 538     // 24b. Place of Service
 539     put_hcfa($lino, 19, 2, $claim->facilityPOS());
 540
 541     // 24c. EMG
 542     // Not currently supported.
 543
 544     // 24d. Procedures, Services or Supplies
 545     put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 546     // replace colon with space for printing
 547     put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 548
 549     // 24e. Diagnosis Pointer
 550     $tmp = '';
 551     foreach ($claim->diagIndexArray($hcfa_proc_index) as $value)
 552     {
 553         if(hcfa_1500_version_02_12())// For 02/12 Version convert number to letter.
 554         {
 555             // ASCII A is 65, since diagIndexArray is ones based, this will make 1->A, 2->B...
 556             $value=chr($value+64);
 557         }
 558         $tmp .= $value;
 559     }
 560     put_hcfa($lino, 45, 4, $tmp);
 561
 562     // 24f. Charges
 563     put_hcfa($lino, 50, 8, str_replace('.', ' ',
 564       sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
 565
 566     // 24g. Days or Units
 567     put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 568
 569     // 24h. EPSDT Family Plan
 570     // Not currently supported.
 571
 572     // 24j. Rendering Provider NPI
 573     put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 574   }
 575
 576   // 25. Federal Tax ID Number
 577   // FrreB hard coded EIN. Changed it to included SSN as well.
 578   put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 579   if($claim->federalIdType()=='SY'){
 580   put_hcfa(56, 17, 1, 'X'); // The SSN checkbox
 581   }
 582   else{
 583   put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 584   }
 585
 586   // 26. Patient's Account No.
 587   // Instructions say hyphens are not allowed, but freeb used them.
 588   put_hcfa(56, 23, 15, "$pid-$encounter");
 589
 590   // 27. Accept Assignment
 591   put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 592
 593   // 28. Total Charge
 594   put_hcfa(56, 52, 8, str_replace('.',' ',sprintf('%8.2f',$clm_total_charges)));
 595   if (!$clm_total_charges) {
 596     $log .= "*** This claim has no charges!\n";
 597   }
 598
 599   // 29. Amount Paid
 600   put_hcfa(56, 62, 8, str_replace('.',' ',sprintf('%8.2f',$clm_amount_paid)));
 601
 602   // 30. Balance Due
 603   // For secondary payers this reflects primary "contracted rate" adjustments,
 604   // so in general box 30 will not equal box 28 minus box 29.
 605   if(!hcfa_1500_version_02_12())  // Box 30 Reserved for NUCC Use in 02/12
 606   {
 607       put_hcfa(56, 71, 8, str_replace('.',' ',sprintf('%8.2f',
 608         $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
 609   }
 610
 611   // 33. Billing Provider: Phone Number
 612   $tmp = $claim->billingContactPhone();
 613   put_hcfa(57, 66,  3, substr($tmp,0,3));
 614   put_hcfa(57, 70, 3, substr($tmp,3)); // slight adjustment for better look smw 030315
 615   put_hcfa(57, 73, 1, '-');
 616   put_hcfa(57, 74, 4, substr($tmp,6));
 617
 618   // 32. Service Facility Location Information: Name
 619   put_hcfa(58, 23, 25, $claim->facilityName());
 620
 621   // 33. Billing Provider: Name
 622   if($claim->federalIdType()=='SY'){
 623     $tempName = $claim->billingFacilityName();
 624     $partsName = explode(' ', $tempName);// entity == person
 625     $num_parts = count($partsName);
 626     switch ($num_parts) {
 627       case "2":
 628         $firstName = $partsName[0];
 629         $lastName = $partsName[1];
 630         $billingProviderName = $lastName . ", " . $firstName;
 631         break;
 632       case "3":
 633         $firstName = $partsName[0];
 634         $middleName = $partsName[1];
 635         $lastName = $partsName[2];
 636         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName;
 637         break;
 638       case "4":
 639         $firstName = $partsName[0];
 640         $middleName = $partsName[1];
 641         $lastName = $partsName[2];
 642         $suffixName = $partsName[3];
 643         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 644         break;
 645       default:
 646         $log .= "*** individual name has more than 4 parts and may not be desirable on the claim form\n";
 647         $firstName = $partsName[0];
 648         $middleName = $partsName[1];
 649         $lastName = $partsName[2];
 650         $suffixName = $partsName[3];
 651         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 652     }
 653     put_hcfa(58, 50, 25, $billingProviderName);
 654   }
 655   else {
 656   put_hcfa(58, 50, 25, $claim->billingFacilityName());
 657   }
 658   // 32. Service Facility Location Information: Street
 659   put_hcfa(59, 23, 25, $claim->facilityStreet());
 660
 661   // 33. Billing Provider: Name
 662   put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 663
 664   // 31. Signature of Physician or Supplier
 665   // FreeB printed the rendering provider's name and the current date here,
 666   // but according to my instructions it must be a real signature and date,
 667   // or else "Signature on File" or "SOF".
 668
 669    if($GLOBALS['cms_1500_box_31_format']==0)
 670    {
 671       put_hcfa(60, 1, 20, 'Signature on File');
 672    }
 673    else if($GLOBALS['cms_1500_box_31_format']==1)
 674    {
 675       put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 676    }
 677   //
 678   // $tmp = $claim->providerFirstName();
 679   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 680   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 681
 682   // 32. Service Facility Location Information: City State Zip
 683   $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 684   put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 685     $claim->facilityZip());
 686
 687   // 33. Billing Provider: City State Zip
 688   $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 689   put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 690     $claim->billingFacilityZip());
 691
 692   // 31. Signature of Physician or Supplier: Date
 693    if($GLOBALS['cms_1500_box_31_date']>0)
 694    {
 695        if($GLOBALS['cms_1500_box_31_date']==1)
 696        {
 697             $date_of_service= $claim->serviceDate();
 698             $MDY=substr($date_of_service,4,2)." ".substr($date_of_service,6,2)." ".substr($date_of_service,2,2);
 699        }
 700        else if($GLOBALS['cms_1500_box_31_date']==2)
 701        {
 702            $MDY=date("m/d/y");
 703        }
 704        put_hcfa(61,6,10,$MDY);
 705    }
 706
 707   // 32a. Service Facility NPI
 708   put_hcfa(61, 23, 10, $claim->facilityNPI());
 709
 710   // 32b. Service Facility Other ID
 711   // Note that Medicare does NOT want this any more.
 712   if ($claim->providerGroupNumber()) {
 713     put_hcfa(61, 36,  2, $claim->providerNumberType());
 714     put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 715   }
 716
 717   // 33a. Billing Facility NPI
 718   put_hcfa(61, 50, 10, $claim->billingFacilityNPI());
 719
 720   // 33b. Billing Facility Other ID
 721   // Note that Medicare does NOT want this any more.
 722   if ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 723     put_hcfa(61, 63,  2, $claim->providerNumberType());
 724     put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 725   }
 726
 727   // Put an extra line here for compatibility with old hcfa text generated form
 728     put_hcfa(62, 1, 1, ' ');
 729   // put a couple more in so that multiple claims correctly print through the text file download
 730     put_hcfa(63, 1, 1, ' ');
 731     put_hcfa(64, 1, 1, ' ');
 732   return;
 733 }
 734 ?>