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.ins_type_code.
 101   // Previous version of this code called claimType() which maps ins_type_code 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, $claim->planName(1));
 313     }
 314   }
 315
 316   # Box 10d. Claim Codes  medicaid_referral_code
 317
 318   if($claim->epsdtFlag()) {
 319       put_hcfa(26, 34, 2, $claim->medicaidReferralCode());
 320     }
 321
 322   # Box 10d. Claim Codes  medicaid_referral_code
 323
 324   if($claim->epsdtFlag()) {
 325       put_hcfa(26, 34, 2, $claim->medicaidReferralCode());
 326     }
 327
 328   // Box 11d. Is There Another Health Benefit Plan
 329   if (!$new_medicare_logic) {
 330     put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 331   }
 332
 333   // Box 12. Patient's or Authorized Person's Signature
 334   put_hcfa(29, 7, 17, 'Signature on File');
 335   // Note: Date does not apply unless the person physically signs the form.
 336
 337   // Box 13. Insured's or Authorized Person's Signature
 338   put_hcfa(29, 55, 17, 'Signature on File');
 339
 340   // Box 14. Date of Current Illness/Injury/Pregnancy
 341   $tmp = $claim->onsetDate();
 342   put_hcfa(32, 2, 2, substr($tmp,4,2));
 343   put_hcfa(32, 5, 2, substr($tmp,6,2));
 344   put_hcfa(32, 8, 4, substr($tmp,0,4));
 345
 346   if(hcfa_1500_version_02_12() && !empty($tmp))
 347   {
 348     // Only include the Box 14 qualifier if there we are using version 02/12 and there is a Box 14 date.
 349     put_hcfa(32, 16, 3, $claim->box14qualifier());
 350
 351   }
 352   // Box 15. First Date of Same or Similar Illness, if applicable
 353   $tmp = $claim->dateInitialTreatment();
 354   if(hcfa_1500_version_02_12() && !empty($tmp))
 355   {
 356     // Only include the Box 15 qualifier if there we are using version 02/12 and there is a Box 15 date.
 357     put_hcfa(32, 31, 3, $claim->box15qualifier());
 358   }
 359
 360
 361   put_hcfa(32,37, 2, substr($tmp,4,2));
 362   put_hcfa(32,40, 2, substr($tmp,6,2));
 363   put_hcfa(32,43, 4, substr($tmp,0,4));
 364
 365
 366   // Box 16. Dates Patient Unable to Work in Current Occupation
 367   if ($claim->isUnableToWork()) {
 368     $tmp = $claim->offWorkFrom();
 369     put_hcfa(32, 54, 2, substr($tmp,4,2));
 370     put_hcfa(32, 57, 2, substr($tmp,6,2));
 371     put_hcfa(32, 60, 4, substr($tmp,0,4));
 372     $tmp = $claim->offWorkTo();
 373     put_hcfa(32, 68, 2, substr($tmp,4,2));
 374     put_hcfa(32, 71, 2, substr($tmp,6,2));
 375     put_hcfa(32, 74, 4, substr($tmp,0,4));
 376   }
 377
 378   // Referring provider stuff.  Reports are that for primary care doctors,
 379   // Medicare forbids an entry here and other payers require one.
 380   // There is still confusion over this.
 381   //
 382   if ($claim->referrerLastName() || $claim->billingProviderLastName() &&
 383     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB'))
 384   {
 385     // Box 17a. Referring Provider Alternate Identifier
 386     // Commented this out because UPINs are obsolete, leaving the code as an
 387     // example in case some other identifier needs to be supported.
 388     /*****************************************************************
 389     if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 390       put_hcfa(33, 30,  2, '1G');
 391       put_hcfa(33, 33, 15, $claim->referrerUPIN());
 392     }
 393     *****************************************************************/
 394   if ($claim->claimType() == 'MC') {
 395     put_hcfa(33, 30,  2, 'ZZ');
 396     put_hcfa(33, 33, 14, $claim->referrerTaxonomy());
 397   }
 398
 399
 400
 401     // Box 17. Name of Referring Provider or Other Source leave it like it is just check if there is info in misc_billing the use it provider_qualifier_code
 402     # Changed to look first at the misc hcfa billing form to complete this box if nothing on misc hcfa form use referrer
 403     if (strlen($claim->billingProviderLastName()) !=0) {
 404       $tmp2 = $claim->billingProviderLastName() . ', ' . $claim->billingProviderFirstName();
 405       if ($claim->billingProviderMiddleName())
 406         $tmp2 .= ', ' . substr($claim->billingProviderMiddleName(),0,1);
 407       put_hcfa(34, 1, 3, $claim->billing_options['provider_qualifier_code']);
 408       put_hcfa(34, 4, 25, $tmp2);
 409       if ($claim->billingProviderNPI()) {
 410         put_hcfa(34, 33, 15, $claim->billingProviderNPI());
 411       }
 412     }
 413     else
 414     {
 415     $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 416     if ($claim->referrerMiddleName())
 417       $tmp .= ', ' . substr($claim->referrerMiddleName(),0,1);
 418     put_hcfa(34, 1, 3, 'DN');
 419     put_hcfa(34, 4, 25, $tmp);
 420     if ($claim->referrerNPI()) {
 421       put_hcfa(34, 33, 15, $claim->referrerNPI());
 422     }
 423   }
 424   }
 425
 426   // Box 18. Hospitalization Dates Related to Current Services
 427   if ($claim->isHospitalized()) {
 428     $tmp = $claim->hospitalizedFrom();
 429     put_hcfa(34, 54, 2, substr($tmp,4,2));
 430     put_hcfa(34, 57, 2, substr($tmp,6,2));
 431     put_hcfa(34, 60, 4, substr($tmp,0,4));
 432     $tmp = $claim->hospitalizedTo();
 433     put_hcfa(34, 68, 2, substr($tmp,4,2));
 434     put_hcfa(34, 71, 2, substr($tmp,6,2));
 435     put_hcfa(34, 74, 4, substr($tmp,0,4));
 436   }
 437
 438   // Box 19. Reserved for Local Use
 439   put_hcfa(36, 1, 48, $claim->additionalNotes());
 440
 441   // Box 20. Outside Lab
 442   put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 443   if ($claim->isOutsideLab()) {
 444     // Note here that put_hcfa strips the decimal point, as required.
 445     // We right-justify this amount (ending in col. 69).
 446     put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 447   }
 448
 449   if(hcfa_1500_version_02_12())
 450   {
 451       process_diagnoses_02_12($claim,$log);
 452   }
 453   else
 454   {
 455         // Box 21. Diagnoses
 456         $tmp = $claim->diagArray();
 457         $diags = array();
 458         foreach ($tmp as $diag) $diags[] = $diag;
 459         if (!empty($diags[0])) {
 460           put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 461           put_hcfa(38, 7, 2, substr($diags[0], 3));
 462         }
 463         if (!empty($diags[2])) {
 464           put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 465           put_hcfa(38, 34, 2, substr($diags[2], 3));
 466         }
 467
 468         // Box 22. Medicaid Resubmission Code and Original Ref. No.
 469         put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 470         put_hcfa(38, 62, 15, $claim->medicaidOriginalReference());
 471
 472         // Box 21 continued. Diagnoses
 473         if (!empty($diags[1])) {
 474           put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 475           put_hcfa(40, 7, 2, substr($diags[1], 3));
 476         }
 477         if (!empty($diags[3])) {
 478           put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 479           put_hcfa(40, 34, 2, substr($diags[3], 3));
 480         }
 481
 482         // Box 23. Prior Authorization Number
 483         put_hcfa(40, 50, 28, $claim->priorAuth());
 484   }
 485   $proccount = $claim->procCount(); // number of procedures
 486
 487   // Charges, adjustments and payments are accumulated by line item so that
 488   // each page of a multi-page claim will stand alone.  Payments include the
 489   // co-pay for the first page only.
 490   $clm_total_charges = 0;
 491   $clm_amount_adjusted = 0;
 492   $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 493
 494   // Procedure loop starts here.
 495   //
 496   for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 497     $dia = $claim->diagIndexArray($hcfa_proc_index);
 498
 499     if (!$claim->cptCharges($hcfa_proc_index)) {
 500       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 501         "' has no charges!\n";
 502     }
 503
 504     if (empty($dia)) {
 505       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 506         "' is not justified!\n";
 507     }
 508
 509     $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 510
 511     // Compute prior payments and "hard" adjustments.
 512     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 513       if ($claim->payerSequence($ins) > $claim->payerSequence())
 514         continue; // skip future payers
 515       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 516       $clm_amount_paid += $payerpaid[1];
 517       $clm_amount_adjusted += $payerpaid[2];
 518     }
 519
 520     ++$svccount;
 521     $lino = $svccount * 2 + 41;
 522
 523     // Drug Information. Medicaid insurers want this with HCPCS codes.
 524     //
 525     $ndc = $claim->cptNDCID($hcfa_proc_index);
 526     if ($ndc) {
 527       if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 528         $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 529       }
 530       else if(preg_match('/^\d{11}$/', $ndc)){
 531
 532       }
 533       else {
 534         $log .= "*** NDC code '$ndc' has invalid format!\n";
 535       }
 536       put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 537         $claim->cptNDCQuantity($hcfa_proc_index));
 538     }
 539
 540     //Note Codes.
 541     put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 542
 543     // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 544     if ($claim->supervisorNumber()) {
 545       // If there is a supervising provider and that person has a
 546       // payer-specific provider number, then we assume that the SP
 547       // must be identified on the claim and this is how we do it
 548       // (but the NPI of the actual rendering provider appears below).
 549       // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 550       put_hcfa($lino, 65,  2, $claim->supervisorNumberType());
 551       put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 552     }
 553     else if ($claim->providerNumber($hcfa_proc_index)) {
 554       put_hcfa($lino, 65,  2, $claim->providerNumberType($hcfa_proc_index));
 555       put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 556     }
 557     else if ($claim->claimType() == 'MC') {
 558      put_hcfa($lino, 65,  2, 'ZZ');
 559      put_hcfa($lino, 68, 14, $claim->providerTaxonomy());
 560     }
 561
 562     ++$lino;
 563
 564     // 24a. Date of Service
 565     $tmp = $claim->serviceDate();
 566     put_hcfa($lino, 1, 2, substr($tmp,4,2));
 567     put_hcfa($lino, 4, 2, substr($tmp,6,2));
 568     put_hcfa($lino, 7, 2, substr($tmp,2,2));
 569     put_hcfa($lino,10, 2, substr($tmp,4,2));
 570     put_hcfa($lino,13, 2, substr($tmp,6,2));
 571     put_hcfa($lino,16, 2, substr($tmp,2,2));
 572
 573     // 24b. Place of Service
 574     put_hcfa($lino, 19, 2, $claim->facilityPOS());
 575
 576     // 24c. EMG
 577     // Not currently supported.
 578
 579     // 24d. Procedures, Services or Supplies
 580     put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 581     // replace colon with space for printing
 582     put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 583
 584     // 24e. Diagnosis Pointer
 585     $tmp = '';
 586     foreach ($claim->diagIndexArray($hcfa_proc_index) as $value)
 587     {
 588         if(hcfa_1500_version_02_12())// For 02/12 Version convert number to letter.
 589         {
 590             // ASCII A is 65, since diagIndexArray is ones based, this will make 1->A, 2->B...
 591             $value=chr($value+64);
 592         }
 593         $tmp .= $value;
 594     }
 595     put_hcfa($lino, 45, 4, $tmp);
 596
 597     // 24f. Charges
 598     put_hcfa($lino, 50, 8, str_replace('.', ' ',
 599       sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
 600
 601     // 24g. Days or Units
 602     put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 603
 604     // 24h. EPSDT Family Plan
 605     //
 606     if($claim->epsdtFlag()) {
 607       put_hcfa($lino, 63, 2, '03');
 608     }
 609
 610     // 24j. Rendering Provider NPI
 611     put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 612   }
 613
 614   // 25. Federal Tax ID Number
 615   // FrreB hard coded EIN. Changed it to included SSN as well.
 616   put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 617   if($claim->federalIdType()=='SY'){
 618   put_hcfa(56, 17, 1, 'X'); // The SSN checkbox
 619   }
 620   else{
 621   put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 622   }
 623
 624   // 26. Patient's Account No.
 625   // Instructions say hyphens are not allowed.
 626   put_hcfa(56, 23, 15, "$pid-$encounter");
 627
 628   // 27. Accept Assignment
 629   put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 630
 631   // 28. Total Charge
 632   put_hcfa(56, 52, 8, str_replace('.',' ',sprintf('%8.2f',$clm_total_charges)));
 633   if (!$clm_total_charges) {
 634     $log .= "*** This claim has no charges!\n";
 635   }
 636
 637   // 29. Amount Paid
 638   put_hcfa(56, 62, 8, str_replace('.',' ',sprintf('%8.2f',$clm_amount_paid)));
 639
 640   // 30. Balance Due
 641   // For secondary payers this reflects primary "contracted rate" adjustments,
 642   // so in general box 30 will not equal box 28 minus box 29.
 643   if(!hcfa_1500_version_02_12())  // Box 30 Reserved for NUCC Use in 02/12
 644   {
 645       put_hcfa(56, 71, 8, str_replace('.',' ',sprintf('%8.2f',
 646         $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
 647   }
 648
 649   // 33. Billing Provider: Phone Number
 650   $tmp = $claim->billingContactPhone();
 651   put_hcfa(57, 66,  3, substr($tmp,0,3));
 652   put_hcfa(57, 70, 3, substr($tmp,3)); // slight adjustment for better look smw 030315
 653   put_hcfa(57, 73, 1, '-');
 654   put_hcfa(57, 74, 4, substr($tmp,6));
 655
 656   // 32. Service Facility Location Information: Name
 657   put_hcfa(58, 23, 25, $claim->facilityName());
 658
 659   // 33. Billing Provider: Name
 660   if($claim->federalIdType()=='SY'){
 661     $tempName = $claim->billingFacilityName();
 662     $partsName = explode(' ', $tempName);// entity == person
 663     $num_parts = count($partsName);
 664     switch ($num_parts) {
 665       case "2":
 666         $firstName = $partsName[0];
 667         $lastName = $partsName[1];
 668         $billingProviderName = $lastName . ", " . $firstName;
 669         break;
 670       case "3":
 671         $firstName = $partsName[0];
 672         $middleName = $partsName[1];
 673         $lastName = $partsName[2];
 674         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName;
 675         break;
 676       case "4":
 677         $firstName = $partsName[0];
 678         $middleName = $partsName[1];
 679         $lastName = $partsName[2];
 680         $suffixName = $partsName[3];
 681         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 682         break;
 683       default:
 684         $log .= "*** individual name has more than 4 parts and may not be desirable on the claim form\n";
 685         $firstName = $partsName[0];
 686         $middleName = $partsName[1];
 687         $lastName = $partsName[2];
 688         $suffixName = $partsName[3];
 689         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 690     }
 691     put_hcfa(58, 50, 25, $billingProviderName);
 692   }
 693   else {
 694   put_hcfa(58, 50, 25, $claim->billingFacilityName());
 695   }
 696   // 32. Service Facility Location Information: Street
 697   put_hcfa(59, 23, 25, $claim->facilityStreet());
 698
 699   // 33. Billing Provider: Name
 700   put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 701
 702   // 31. Signature of Physician or Supplier
 703
 704    if($GLOBALS['cms_1500_box_31_format']==0)
 705    {
 706       put_hcfa(60, 1, 20, 'Signature on File');
 707    }
 708    else if($GLOBALS['cms_1500_box_31_format']==1)
 709    {
 710       put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 711    }
 712   //
 713   // $tmp = $claim->providerFirstName();
 714   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 715   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 716
 717   // 32. Service Facility Location Information: City State Zip
 718   $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 719   put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 720     $claim->facilityZip());
 721
 722   // 33. Billing Provider: City State Zip
 723   $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 724   put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 725     $claim->billingFacilityZip());
 726
 727   // 31. Signature of Physician or Supplier: Date
 728    if($GLOBALS['cms_1500_box_31_date']>0)
 729    {
 730        if($GLOBALS['cms_1500_box_31_date']==1)
 731        {
 732             $date_of_service= $claim->serviceDate();
 733             $MDY=substr($date_of_service,4,2)." ".substr($date_of_service,6,2)." ".substr($date_of_service,2,2);
 734        }
 735        else if($GLOBALS['cms_1500_box_31_date']==2)
 736        {
 737            $MDY=date("m/d/y");
 738        }
 739        put_hcfa(61,6,10,$MDY);
 740    }
 741
 742   // 32a. Service Facility NPI
 743   put_hcfa(61, 23, 10, $claim->facilityNPI());
 744
 745   // 32b. Service Facility Other ID
 746   // Note that Medicare does NOT want this any more.
 747   if ($claim->providerGroupNumber()) {
 748     put_hcfa(61, 36,  2, $claim->providerNumberType());
 749     put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 750   }
 751
 752   // 33a. Billing Facility NPI
 753   put_hcfa(61, 50, 10, $claim->billingFacilityNPI());
 754
 755   // 33b. Billing Facility Other ID
 756   // Note that Medicare does NOT want this any more.
 757   if ($claim->claimType() == 'MC') {
 758     put_hcfa(61, 63,  2, 'ZZ');
 759     put_hcfa(61, 65, 14, $claim->providerTaxonomy());
 760   }
 761   if ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 762     put_hcfa(61, 63,  2, $claim->providerNumberType());
 763     put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 764   }
 765
 766   // Put an extra line here for compatibility with old hcfa text generated form
 767     put_hcfa(62, 1, 1, ' ');
 768   // put a couple more in so that multiple claims correctly print through the text file download
 769     put_hcfa(63, 1, 1, ' ');
 770     put_hcfa(64, 1, 1, ' ');
 771   return;
 772 }
 773 ?>