library/parse_era.inc.php

   1 <?php
   2   // Copyright (C) 2006 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 function parse_era_2100(&$out, $cb) {
  10         if ($out['loopid'] == '2110') {
  11
  12                 // Force the sum of service payments to equal the claim payment
  13                 // amount.  Whenever this is an issue it should result from
  14                 // claim-level adjustments, and in this case the first SVC item
  15                 // that we stored was a 'Claim' type.
  16                 $paytotal = $out['amount_approved'];
  17                 foreach ($out['svc'] as $svc) $paytotal -= $svc['paid'];
  18                 $paytotal = round($paytotal, 2);
  19                 if ($paytotal != 0) {
  20                         $out['svc'][0]['paid'] += $paytotal;
  21                         if ($out['svc'][0]['code'] != 'Claim') {
  22                                 $out['warnings'] .= "First service item payment amount " .
  23                                         "adjusted by $paytotal due to payment imbalance. " .
  24                                         "This should not happen!\n";
  25                         }
  26                 }
  27
  28                 $cb($out);
  29         }
  30 }
  31
  32 function parse_era($filename, $cb) {
  33         $infh = fopen($filename, 'r');
  34         if (! $infh) return "ERA input file open failed";
  35
  36         $out = array();
  37         $out['loopid'] = '';
  38         $out['st_segment_count'] = 0;
  39         $buffer = '';
  40         $segid = '';
  41
  42         while (true) {
  43                 if (strlen($buffer) < 2048 && ! feof($infh))
  44                         $buffer .= fread($infh, 2048);
  45                 $tpos = strpos($buffer, '~');
  46                 if ($tpos === false) break;
  47                 $inline = substr($buffer, 0, $tpos);
  48                 $buffer = substr($buffer, $tpos + 1);
  49
  50                 $seg = explode('|', $inline);
  51                 $segid = $seg[0];
  52
  53                 if ($segid == 'ISA') {
  54                         if ($out['loopid']) return 'Unexpected ISA segment';
  55                         $out['isa_sender_id']      = trim($seg[6]);
  56                         $out['isa_receiver_id']    = trim($seg[8]);
  57                         $out['isa_control_number'] = trim($seg[13]);
  58                         // TBD: clear some stuff if we allow multiple transmission files.
  59                 }
  60                 else if ($segid == 'GS') {
  61                         if ($out['loopid']) return 'Unexpected GS segment';
  62                         $out['gs_date'] = trim($seg[4]);
  63                         $out['gs_time'] = trim($seg[5]);
  64                         $out['gs_control_number'] = trim($seg[6]);
  65                 }
  66                 else if ($segid == 'ST') {
  67                         parse_era_2100($out, $cb);
  68                         $out['loopid'] = '';
  69                         $out['st_control_number'] = trim($seg[2]);
  70                         $out['st_segment_count'] = 0;
  71                 }
  72                 else if ($segid == 'BPR') {
  73                         if ($out['loopid']) return 'Unexpected BPR segment';
  74                         $out['check_amount'] = trim($seg[2]);
  75                         $out['check_date'] = trim($seg[16]); // yyyymmdd
  76                         // TBD: BPR04 is a payment method code.
  77                 }
  78                 else if ($segid == 'TRN') {
  79                         if ($out['loopid']) return 'Unexpected TRN segment';
  80                         $out['check_number'] = trim($seg[2]);
  81                         $out['payer_tax_id'] = substr($seg[3], 1); // 9 digits
  82                         $out['payer_id'] = trim($seg[4]);
  83                         // Note: TRN04 further qualifies the paying entity within the
  84                         // organization identified by TRN03.
  85                 }
  86                 else if ($segid == 'REF' && $seg[1] == 'EV') {
  87                         if ($out['loopid']) return 'Unexpected REF|EV segment';
  88                 }
  89                 else if ($segid == 'CUR' && ! $out['loopid']) {
  90                         if ($seg[3] && $seg[3] != 1.0) {
  91                                 return("We cannot handle foreign currencies!");
  92                         }
  93                 }
  94                 else if ($segid == 'REF' && ! $out['loopid']) {
  95                         // ignore
  96                 }
  97                 else if ($segid == 'DTM' && $seg[1] == '405') {
  98                         if ($out['loopid']) return 'Unexpected DTM|405 segment';
  99                         $out['production_date'] = trim($seg[2]); // yyyymmdd
 100                 }
 101                 //
 102                 // Loop 1000A is Payer Information.
 103                 //
 104                 else if ($segid == 'N1' && $seg[1] == 'PR') {
 105                         if ($out['loopid']) return 'Unexpected N1|PR segment';
 106                         $out['loopid'] = '1000A';
 107                         $out['payer_name'] = trim($seg[2]);
 108                 }
 109                 else if ($segid == 'N3' && $out['loopid'] == '1000A') {
 110                         $out['payer_street'] = trim($seg[1]);
 111                         // TBD: N302 may exist as an additional address line.
 112                 }
 113                 else if ($segid == 'N4' && $out['loopid'] == '1000A') {
 114                         $out['payer_city']  = trim($seg[1]);
 115                         $out['payer_state'] = trim($seg[2]);
 116                         $out['payer_zip']   = trim($seg[3]);
 117                 }
 118                 else if ($segid == 'REF' && $out['loopid'] == '1000A') {
 119                         // Other types of REFs may be given to identify the payer, but we
 120                         // ignore them.
 121                 }
 122                 else if ($segid == 'PER' && $out['loopid'] == '1000A') {
 123                         // TBD: Report payer contact information as a note.
 124                 }
 125                 //
 126                 // Loop 1000B is Payee Identification.
 127                 //
 128                 else if ($segid == 'N1' && $seg[1] == 'PE') {
 129                         if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 130                         $out['loopid'] = '1000B';
 131                         $out['payee_name']   = trim($seg[2]);
 132                         $out['payee_tax_id'] = trim($seg[4]);
 133                 }
 134                 else if ($segid == 'N3' && $out['loopid'] == '1000B') {
 135                         $out['payee_street'] = trim($seg[1]);
 136                 }
 137                 else if ($segid == 'N4' && $out['loopid'] == '1000B') {
 138                         $out['payee_city']  = trim($seg[1]);
 139                         $out['payee_state'] = trim($seg[2]);
 140                         $out['payee_zip']   = trim($seg[3]);
 141                 }
 142                 else if ($segid == 'REF' && $out['loopid'] == '1000B') {
 143                         // Used to report additional ID numbers.  Ignored.
 144                 }
 145                 //
 146                 // Loop 2000 provides for logical grouping of claim payment information.
 147                 // LX is required if any CLPs are present, but so far we do not care
 148                 // about loop 2000 content.
 149                 //
 150                 else if ($segid == 'LX') {
 151                         if (! $out['loopid']) return 'Unexpected LX segment';
 152                         parse_era_2100($out, $cb);
 153                         $out['loopid'] = '2000';
 154                 }
 155                 else if ($segid == 'TS2' && $out['loopid'] == '2000') {
 156                         // ignore
 157                 }
 158                 else if ($segid == 'TS3' && $out['loopid'] == '2000') {
 159                         // ignore
 160                 }
 161                 //
 162                 // Loop 2100 is Claim Payment Information. The good stuff begins here.
 163                 //
 164                 else if ($segid == 'CLP') {
 165                         if (! $out['loopid']) return 'Unexpected CLP segment';
 166                         parse_era_2100($out, $cb);
 167                         $out['loopid'] = '2100';
 168                         $out['warnings'] = '';
 169                         // Clear some stuff to start the new claim:
 170                         $out['subscriber_lname']     = '';
 171                         $out['subscriber_fname']     = '';
 172                         $out['subscriber_mname']     = '';
 173                         $out['subscriber_member_id'] = '';
 174                         $out['svc'] = array();
 175                         //
 176                         // This is the poorly-named "Patient Account Number".  For 837p
 177                         // it comes from CLM01 which we populated as pid-diagid-procid,
 178                         // where diagid and procid are id values from the billing table.
 179                         // For HCFA 1500 claims it comes from field 26 which we
 180                         // populated with our familiar pid-encounter billing key.
 181                         //
 182                         // The 835 spec calls this the "provider-assigned claim control
 183                         // number" and notes that it is specifically intended for
 184                         // identifying the claim in the provider's database.
 185                         $out['our_claim_id']      = trim($seg[1]);
 186                         //
 187                         $out['claim_status_code'] = trim($seg[2]);
 188                         $out['amount_charged']    = trim($seg[3]);
 189                         $out['amount_approved']   = trim($seg[4]);
 190                         $out['amount_patient']    = trim($seg[5]); // pt responsibility, copay + deductible
 191                         $out['payer_claim_id']    = trim($seg[7]); // payer's claim number
 192                 }
 193                 else if ($segid == 'CAS' && $out['loopid'] == '2100') {
 194                         // This is a claim-level adjustment and should be unusual.
 195                         // Handle it by creating a dummy zero-charge service item and
 196                         // then populating the adjustments into it.  See also code in
 197                         // parse_era_2100() which will later plug in a payment reversal
 198                         // amount that offsets these adjustments.
 199                         $i = 0; // if present, the dummy service item will be first.
 200                         if (!$out['svc'][$i]) {
 201                                 $out['svc'][$i] = array();
 202                                 $out['svc'][$i]['code'] = 'Claim';
 203                                 $out['svc'][$i]['mod']  = '';
 204                                 $out['svc'][$i]['chg']  = '0';
 205                                 $out['svc'][$i]['paid'] = '0';
 206                                 $out['svc'][$i]['adj']  = array();
 207                         }
 208                         for ($k = 2; $k < 20; $k += 3) {
 209                                 if (!$seg[$k]) break;
 210                                 $j = count($out['svc'][$i]['adj']);
 211                                 $out['svc'][$i]['adj'][$j] = array();
 212                                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 213                                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 214                                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 215                         }
 216                 }
 217                 // QC = Patient
 218                 else if ($segid == 'NM1' && $seg[1] == 'QC' && $out['loopid'] == '2100') {
 219                         $out['patient_lname']     = trim($seg[3]);
 220                         $out['patient_fname']     = trim($seg[4]);
 221                         $out['patient_mname']     = trim($seg[5]);
 222                         $out['patient_member_id'] = trim($seg[9]);
 223                 }
 224                 // IL = Insured or Subscriber
 225                 else if ($segid == 'NM1' && $seg[1] == 'IL' && $out['loopid'] == '2100') {
 226                         $out['subscriber_lname']     = trim($seg[3]);
 227                         $out['subscriber_fname']     = trim($seg[4]);
 228                         $out['subscriber_mname']     = trim($seg[5]);
 229                         $out['subscriber_member_id'] = trim($seg[9]);
 230                 }
 231                 // 82 = Rendering Provider
 232                 else if ($segid == 'NM1' && $seg[1] == '82' && $out['loopid'] == '2100') {
 233                         $out['provider_lname']     = trim($seg[3]);
 234                         $out['provider_fname']     = trim($seg[4]);
 235                         $out['provider_mname']     = trim($seg[5]);
 236                         $out['provider_member_id'] = trim($seg[9]);
 237                 }
 238                 // 74 = Corrected Insured
 239                 // TT = Crossover Carrier (Transfer To another payer)
 240                 // PR = Corrected Payer
 241                 else if ($segid == 'NM1' && $out['loopid'] == '2100') {
 242                         // $out['warnings'] .= "NM1 segment at claim level ignored.\n";
 243                 }
 244                 else if ($segid == 'MOA' && $out['loopid'] == '2100') {
 245                         $out['warnings'] .= "MOA segment at claim level ignored.\n";
 246                 }
 247                 // REF segments may provide various identifying numbers, where REF02
 248                 // indicates the type of number.
 249                 else if ($segid == 'REF' && $seg[1] == '1W' && $out['loopid'] == '2100') {
 250                         $out['claim_comment'] = trim($seg[2]);
 251                 }
 252                 else if ($segid == 'REF' && $out['loopid'] == '2100') {
 253                         // ignore
 254                 }
 255                 else if ($segid == 'DTM' && $seg[1] == '050' && $out['loopid'] == '2100') {
 256                         $out['claim_date'] = trim($seg[2]); // yyyymmdd
 257                 }
 258                 // 036 = expiration date of coverage
 259                 // 050 = date claim received by payer
 260                 // 232 = claim statement period start
 261                 // 233 = claim statement period end
 262                 else if ($segid == 'DTM' && $out['loopid'] == '2100') {
 263                         // ignore?
 264                 }
 265                 else if ($segid == 'PER' && $out['loopid'] == '2100') {
 266                         $out['warnings'] .= 'Claim contact information: ' .
 267                                 $seg[4] . "\n";
 268                 }
 269                 // For AMT01 see the Amount Qualifier Codes on pages 135-135 of the
 270                 // Implementation Guide.  AMT is only good for comments and is not
 271                 // part of claim balancing.
 272                 else if ($segid == 'AMT' && $out['loopid'] == '2100') {
 273                         $out['warnings'] .= "AMT segment at claim level ignored.\n";
 274                 }
 275                 // For QTY01 see the Quantity Qualifier Codes on pages 137-138 of the
 276                 // Implementation Guide.  QTY is only good for comments and is not
 277                 // part of claim balancing.
 278                 else if ($segid == 'QTY' && $out['loopid'] == '2100') {
 279                         $out['warnings'] .= "QTY segment at claim level ignored.\n";
 280                 }
 281                 //
 282                 // Loop 2110 is Service Payment Information.
 283                 //
 284                 else if ($segid == 'SVC') {
 285                         if (! $out['loopid']) return 'Unexpected SVC segment';
 286                         $out['loopid'] = '2110';
 287                         $svc = explode('^', $seg[1]);
 288                         if ($svc[0] != 'HC') return 'SVC segment has unexpected qualifier';
 289                         // TBD: Other qualifiers are possible; see IG pages 140-141.
 290                         $i = count($out['svc']);
 291                         $out['svc'][$i] = array();
 292                         $out['svc'][$i]['code'] = $svc[1];
 293                         $out['svc'][$i]['mod']  = $svc[2] ? $svc[2] : '';
 294                         // TBD: There may be up to 4 procedure modifiers in $svc[2] thru [5].
 295                         $out['svc'][$i]['chg']  = $seg[2];
 296                         $out['svc'][$i]['paid'] = $seg[3];
 297                         $out['svc'][$i]['adj']  = array();
 298                         // Note: SVC05, if present, indicates the paid units of service.
 299                         // It defaults to 1.
 300                         // Note: In the case of bundling, SVC06 reports the original procedure
 301                         // code, there are adjustments of the old procedure codes that zero out
 302                         // the original charge amounts, a negative adjustment of the new
 303                         // procedure code(s) reflecting the old charges, and other "normal"
 304                         // adjustments to these charges.
 305                 }
 306                 // DTM01 identifies the type of service date:
 307                 // 472 = a single date of service
 308                 // 150 = service period start
 309                 // 151 = service period end
 310                 else if ($segid == 'DTM' && $out['loopid'] == '2110') {
 311                         $out['dos'] = trim($seg[2]); // yyyymmdd
 312                 }
 313                 else if ($segid == 'CAS' && $out['loopid'] == '2110') {
 314                         $i = count($out['svc']) - 1;
 315                         for ($k = 2; $k < 20; $k += 3) {
 316                                 if (!$seg[$k]) break;
 317                                 $j = count($out['svc'][$i]['adj']);
 318                                 $out['svc'][$i]['adj'][$j] = array();
 319                                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 320                                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 321                                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 322                                 // Note: $seg[$k+2] is "quantity".  A value here indicates a change to
 323                                 // the number of units of service.  We're ignoring that for now.
 324                         }
 325                 }
 326                 else if ($segid == 'REF' && $out['loopid'] == '2110') {
 327                         // ignore
 328                 }
 329                 else if ($segid == 'AMT' && $seg[1] == 'B6' && $out['loopid'] == '2110') {
 330                         $i = count($out['svc']) - 1;
 331                         $out['svc'][$i]['allowed'] = $seg[2]; // report this amount as a note
 332                 }
 333                 else if ($segid == 'LQ' && $seg[1] == 'HE' && $out['loopid'] == '2110') {
 334                         $i = count($out['svc']) - 1;
 335                         $out['svc'][$i]['remark'] = $seg[2];
 336                 }
 337                 else if ($segid == 'QTY' && $out['loopid'] == '2110') {
 338                         $out['warnings'] .= "QTY segment at service level ignored.\n";
 339                 }
 340                 else if ($segid == 'PLB') {
 341                         // Provider-level adjustments are a General Ledger thing and should not
 342                         // alter the A/R for the claim, so we just report them as notes.
 343                         for ($k = 3; $k < 15; $k += 2) {
 344                                 if (!$seg[$k]) break;
 345                                 $out['warnings'] .= 'PROVIDER LEVEL ADJUSTMENT (not claim-specific): $' .
 346                                         sprintf('%.2f', $seg[$k+1]) . " with reason code " . $seg[$k] . "\n";
 347                                 // Note: For PLB adjustment reason codes see IG pages 165-170.
 348                         }
 349                 }
 350                 else if ($segid == 'SE') {
 351                         parse_era_2100($out, $cb);
 352                         $out['loopid'] = '';
 353                         if ($out['st_control_number'] != trim($seg[2])) {
 354                                 return 'Ending transaction set control number mismatch';
 355                         }
 356                         if (($out['st_segment_count'] + 1) != trim($seg[1])) {
 357                                 return 'Ending transaction set segment count mismatch';
 358                         }
 359                 }
 360                 else if ($segid == 'GE') {
 361                         if ($out['loopid']) return 'Unexpected GE segment';
 362                         if ($out['gs_control_number'] != trim($seg[2])) {
 363                                 return 'Ending functional group control number mismatch';
 364                         }
 365                 }
 366                 else if ($segid == 'IEA') {
 367                         if ($out['loopid']) return 'Unexpected IEA segment';
 368                         if ($out['isa_control_number'] != trim($seg[2])) {
 369                                 return 'Ending interchange control number mismatch';
 370                         }
 371                 }
 372                 else {
 373                         return "Unknown or unexpected segment ID $segid";
 374                 }
 375
 376                 ++$out['st_segment_count'];
 377         }
 378
 379         if ($segid != 'IEA') return 'Premature end of ERA file';
 380         return '';
 381 }
 382 ?>