library/gen_hcfa_1500.inc.php

   1 <?php
   2 // Copyright (C) 2008 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
  11 $hcfa_curr_line = 1;
  12 $hcfa_curr_col = 1;
  13 $hcfa_data = '';
  14 $hcfa_proc_index = 0;
  15
  16 function put_hcfa($line, $col, $maxlen, $data) {
  17   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  18   if ($line < $hcfa_curr_line)
  19     die("Data item at ($line, $col) precedes current line.");
  20   while ($hcfa_curr_line < $line) {
  21     $hcfa_data .= "\n";
  22     ++$hcfa_curr_line;
  23     $hcfa_curr_col = 1;
  24   }
  25   if ($col < $hcfa_curr_col)
  26     die("Data item at ($line, $col) precedes current column.");
  27   while ($hcfa_curr_col < $col) {
  28     $hcfa_data .= " ";
  29     ++$hcfa_curr_col;
  30   }
  31   $data = preg_replace('/[.#]/', '', strtoupper($data));
  32   $len = min(strlen($data), $maxlen);
  33   $hcfa_data .= substr($data, 0, $len);
  34   $hcfa_curr_col += $len;
  35 }
  36
  37 function gen_hcfa_1500($pid, $encounter, &$log) {
  38   global $hcfa_data, $hcfa_proc_index;
  39
  40   $hcfa_data = '';
  41   $hcfa_proc_index = 0;
  42
  43   $today = time();
  44   $claim = new Claim($pid, $encounter);
  45
  46   $log .= "Generating HCFA claim $pid-$encounter for " .
  47     $claim->patientFirstName()  . ' ' .
  48     $claim->patientMiddleName() . ' ' .
  49     $claim->patientLastName()   . ' on ' .
  50     date('Y-m-d H:i', $today) . ".\n";
  51
  52   while ($hcfa_proc_index < $claim->procCount()) {
  53     if ($hcfa_proc_index) $hcfa_data .= "\014"; // append form feed for new page
  54     gen_hcfa_1500_page($pid, $encounter, &$log, &$claim);
  55   }
  56
  57   $log .= "\n";
  58   return $hcfa_data;
  59 }
  60
  61 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim) {
  62   global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  63
  64   $hcfa_curr_line = 1;
  65   $hcfa_curr_col = 1;
  66
  67   // Payer name, attn, street.
  68   put_hcfa(2, 41, 31, $claim->payerName());
  69   put_hcfa(3, 41, 31, $claim->payerAttn());
  70   put_hcfa(4, 41, 31, $claim->payerStreet());
  71
  72   // Payer city, state, zip.
  73   $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
  74   put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
  75
  76   // Box 1. Insurance Type
  77   $ct = $claim->claimType();
  78   $tmpcol = 45;                        // Other
  79   if      ($ct === 'MB') $tmpcol =  1; // Medicare
  80   else if ($ct === 'MC') $tmpcol =  8; // Medicaid
  81   else if ($ct === 'CH') $tmpcol = 15; // Champus
  82   else if ($ct === 'CH') $tmpcol = 24; // Champus VA (why same code?)
  83   else if ($ct === 'BL') $tmpcol = 31; // Group Health Plan (only BCBS?)
  84   else if ($ct === '16') $tmpcol = 39; // FECA
  85   put_hcfa(8, $tmpcol, 1, 'X');
  86
  87   // Box 1a. Insured's ID Number
  88   put_hcfa(8, 50, 17, $claim->policyNumber());
  89
  90   // Box 2. Patient's Name
  91   $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
  92   if ($claim->patientMiddleName())
  93     $tmp .= ', ' . substr($claim->patientMiddleName(),0,1);
  94   put_hcfa(10, 1, 28, $tmp);
  95
  96   // Box 3. Patient's Birth Date and Sex
  97   $tmp = $claim->patientDOB();
  98   put_hcfa(10, 31, 2, substr($tmp,4,2));
  99   put_hcfa(10, 34, 2, substr($tmp,6,2));
 100   put_hcfa(10, 37, 4, substr($tmp,0,4));
 101   put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 102
 103   // Box 4. Insured's Name
 104   $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 105   if ($claim->insuredMiddleName())
 106     $tmp .= ', ' . substr($claim->insuredMiddleName(),0,1);
 107   put_hcfa(10, 50, 28, $tmp);
 108
 109   // Box 5. Patient's Address
 110   put_hcfa(12, 1, 28, $claim->patientStreet());
 111
 112   // Box 6. Patient Relationship to Insured
 113   $tmp = $claim->insuredRelationship();
 114   $tmpcol = 47;                         // Other
 115   if      ($tmp === '18') $tmpcol = 33; // self
 116   else if ($tmp === '01') $tmpcol = 38; // spouse
 117   else if ($tmp === '19') $tmpcol = 42; // child
 118   put_hcfa(12, $tmpcol, 1, 'X');
 119
 120   // Box 7. Insured's Address
 121   put_hcfa(12, 50, 28, $claim->insuredStreet());
 122
 123   // Box 5 continued. Patient's City and State
 124   put_hcfa(14,  1, 20, $claim->patientCity());
 125   put_hcfa(14, 26,  2, $claim->patientState());
 126
 127   // Box 8. Patient (Marital) Status
 128   $tmp = $claim->patientStatus();
 129   $tmpcol = 47;                        // Other
 130   if      ($tmp === 'S') $tmpcol = 35; // Single
 131   else if ($tmp === 'M') $tmpcol = 41; // Married
 132   put_hcfa(14, $tmpcol, 1, 'X');
 133
 134   // Box 7 continued. Insured's City and State
 135   put_hcfa(14, 50, 20, $claim->insuredCity());
 136   put_hcfa(14, 74,  2, $claim->insuredState());
 137
 138   // Box 5 continued. Patient's Zip Code and Telephone
 139   put_hcfa(16,  1, 10, $claim->patientZip());
 140   $tmp = $claim->patientPhone();
 141   put_hcfa(16, 15,  3, substr($tmp,0,3));
 142   put_hcfa(16, 19,  7, substr($tmp,3));
 143
 144   // Box 8 continued. Patient (Employment) Status
 145   $tmp = $claim->patientOccupation();
 146   if      ($tmp === 'STUDENT'   ) put_hcfa(16, 41, 1, 'X');
 147   else if ($tmp === 'PT STUDENT') put_hcfa(16, 47, 1, 'X');
 148   else if ($tmp !== 'UNEMPLOYED') put_hcfa(16, 35, 1, 'X');
 149
 150   // Box 7 continued. Insured's Zip Code and Telephone
 151   put_hcfa(16, 50, 10, $claim->insuredZip());
 152   $tmp = $claim->insuredPhone();
 153   put_hcfa(16, 65,  3, substr($tmp,0,3));
 154   put_hcfa(16, 69,  7, substr($tmp,3));
 155
 156   // Box 9. Other Insured's Name
 157   if ($claim->payerCount() > 1) {
 158     $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 159     if ($claim->insuredMiddleName(1))
 160       $tmp .= ', ' . substr($claim->insuredMiddleName(1),0,1);
 161     put_hcfa(18, 1, 28, $tmp);
 162   }
 163
 164   // Box 11. Insured's Group Number
 165   put_hcfa(18, 50, 30, $claim->groupNumber());
 166
 167   // Box 9a. Other Insured's Policy or Group Number
 168   if ($claim->payerCount() > 1) {
 169     put_hcfa(20, 1, 28, $claim->policyNumber(1));
 170   }
 171
 172   // Box 10a. Employment Related
 173   put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 174
 175   // Box 11a. Insured's Birth Date and Sex
 176   $tmp = $claim->insuredDOB();
 177   put_hcfa(20, 53, 2, substr($tmp,4,2));
 178   put_hcfa(20, 56, 2, substr($tmp,6,2));
 179   put_hcfa(20, 59, 4, substr($tmp,0,4));
 180   put_hcfa(20, $claim->insuredSex() == 'M' ? 68 : 75, 1, 'X');
 181
 182   // Box 9b. Other Insured's Birth Date and Sex
 183   if ($claim->payerCount() > 1) {
 184     $tmp = $claim->insuredDOB(1);
 185     put_hcfa(22, 2, 2, substr($tmp,4,2));
 186     put_hcfa(22, 5, 2, substr($tmp,6,2));
 187     put_hcfa(22, 8, 4, substr($tmp,0,4));
 188     put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
 189   }
 190
 191   // Box 10b. Auto Accident
 192   put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 193   if ($claim->isRelatedAuto())
 194     put_hcfa(22, 45, 2, $claim->autoAccidentState());
 195
 196   // Box 11b. Insured's Employer/School Name
 197   put_hcfa(22, 50, 30, $claim->groupName());
 198
 199   // Box 9c. Other Insured's Employer/School Name
 200   if ($claim->payerCount() > 1) {
 201     put_hcfa(24, 1, 28, $claim->groupName(1));
 202   }
 203
 204   // Box 10c. Other Accident
 205   put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 206
 207   // Box 11c. Insurance Plan Name or Program Name
 208   put_hcfa(24, 50, 30, $claim->planName());
 209
 210   // Box 9d. Other Insurance Plan Name or Program Name
 211   if ($claim->payerCount() > 1) {
 212     put_hcfa(26, 1, 28, $claim->planName(1));
 213   }
 214
 215   // Box 11d. Is There Another Health Benefit Plan
 216   put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 217
 218   // Box 12. Patient's or Authorized Person's Signature
 219   put_hcfa(29, 7, 17, 'Signature on File');
 220   // Note: Date does not apply unless the person physically signs the form.
 221
 222   // Box 13. Insured's or Authorized Person's Signature
 223   put_hcfa(29, 55, 17, 'Signature on File');
 224
 225   // Box 14. Date of Current Illness/Injury/Pregnancy
 226   $tmp = $claim->onsetDate();
 227   put_hcfa(32, 2, 2, substr($tmp,4,2));
 228   put_hcfa(32, 5, 2, substr($tmp,6,2));
 229   put_hcfa(32, 8, 4, substr($tmp,0,4));
 230
 231   // Box 15. Date of First Occurrence
 232   // Not currently supported.
 233
 234   // Box 16. Dates Patient Unable to Work in Current Occupation
 235   if ($claim->isUnableToWork()) {
 236     $tmp = $claim->offWorkFrom();
 237     put_hcfa(32, 54, 2, substr($tmp,4,2));
 238     put_hcfa(32, 57, 2, substr($tmp,6,2));
 239     put_hcfa(32, 60, 4, substr($tmp,0,4));
 240     $tmp = $claim->offWorkTo();
 241     put_hcfa(32, 68, 2, substr($tmp,4,2));
 242     put_hcfa(32, 71, 2, substr($tmp,6,2));
 243     put_hcfa(32, 74, 4, substr($tmp,0,4));
 244   }
 245
 246   // Referring provider stuff.  Reports are that for primary care doctors,
 247   // Medicare forbids an entry here and other payers require one.
 248   // There is still confusion over this.
 249   //
 250   if ($claim->referrerLastName() &&
 251     (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB'))
 252   {
 253     // Box 17a. Referring Provider Alternate Identifier
 254     if ($claim->referrerUPIN()) {
 255       put_hcfa(33, 30,  2, '1G');
 256       put_hcfa(33, 33, 15, $claim->referrerUPIN());
 257     }
 258
 259     // Box 17. Name of Referring Provider or Other Source
 260     $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 261     if ($claim->referrerMiddleName())
 262       $tmp .= ', ' . substr($claim->referrerMiddleName(),0,1);
 263     put_hcfa(34, 1, 25, $tmp);
 264
 265     // Box 17b. Referring Provider NPI
 266     if ($claim->referrerNPI()) {
 267       put_hcfa(34, 33, 15, $claim->referrerNPI());
 268     }
 269   }
 270
 271   // Box 18. Hospitalization Dates Related to Current Services
 272   if ($claim->isHospitalized()) {
 273     $tmp = $claim->hospitalizedFrom();
 274     put_hcfa(34, 54, 2, substr($tmp,4,2));
 275     put_hcfa(34, 57, 2, substr($tmp,6,2));
 276     put_hcfa(34, 60, 4, substr($tmp,0,4));
 277     $tmp = $claim->hospitalizedTo();
 278     put_hcfa(34, 68, 2, substr($tmp,4,2));
 279     put_hcfa(34, 71, 2, substr($tmp,6,2));
 280     put_hcfa(34, 74, 4, substr($tmp,0,4));
 281   }
 282
 283   // Box 19. Reserved for Local Use
 284   put_hcfa(36, 1, 48, $claim->additionalNotes());
 285
 286   // Box 20. Outside Lab
 287   put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 288   if ($claim->isOutsideLab()) {
 289     // Note here that put_hcfa strips the decimal point, as required.
 290     // We right-justify this amount (ending in col. 69).
 291     put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 292   }
 293
 294   // Box 21. Diagnoses
 295   $tmp = $claim->diagArray();
 296   $diags = array();
 297   foreach ($tmp as $diag) $diags[] = $diag;
 298   if (!empty($diags[0])) {
 299     put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
 300     put_hcfa(38, 7, 2, substr($diags[0], 3));
 301   }
 302   if (!empty($diags[2])) {
 303     put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
 304     put_hcfa(38, 34, 2, substr($diags[2], 3));
 305   }
 306
 307   // Box 22. Medicaid Resubmission Code and Original Ref. No.
 308   put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
 309   put_hcfa(38, 62, 10, $claim->medicaidOriginalReference());
 310
 311   // Box 21 continued. Diagnoses
 312   if (!empty($diags[1])) {
 313     put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
 314     put_hcfa(40, 7, 2, substr($diags[1], 3));
 315   }
 316   if (!empty($diags[3])) {
 317     put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
 318     put_hcfa(40, 34, 2, substr($diags[3], 3));
 319   }
 320
 321   // Box 23. Prior Authorization Number
 322   put_hcfa(40, 50, 28, $claim->priorAuth());
 323
 324   $proccount = $claim->procCount(); // number of procedures
 325
 326   // Charges, adjustments and payments are accumulated by line item so that
 327   // each page of a multi-page claim will stand alone.  Payments include the
 328   // co-pay for the first page only.
 329   $clm_total_charges = 0;
 330   $clm_amount_adjusted = 0;
 331   $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 332
 333   // Procedure loop starts here.
 334   //
 335   for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 336     $dia = $claim->diagIndexArray($hcfa_proc_index);
 337
 338     if (!$claim->cptCharges($hcfa_proc_index)) {
 339       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 340         "' has no charges!\n";
 341     }
 342
 343     if (empty($dia)) {
 344       $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 345         "' is not justified!\n";
 346     }
 347
 348     $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 349
 350     // Compute prior payments and "hard" adjustments.
 351     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 352       if ($claim->payerSequence($ins) > $claim->payerSequence())
 353         continue; // skip future payers
 354       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 355       $clm_amount_paid += $payerpaid[1];
 356       $clm_amount_adjusted += $payerpaid[2];
 357     }
 358
 359     ++$svccount;
 360     $lino = $svccount * 2 + 41;
 361
 362     // Drug Information. Medicaid insurers want this with HCPCS codes.
 363     //
 364     $ndc = $claim->cptNDCID($hcfa_proc_index);
 365     if ($ndc) {
 366       if (preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 367         $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 368       } else {
 369         $log .= "*** NDC code '$ndc' has invalid format!\n";
 370       }
 371       put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 372         $claim->cptNDCQuantity($hcfa_proc_index));
 373     }
 374
 375     // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 376     if ($claim->providerNumber()) {
 377       put_hcfa($lino, 65,  2, $claim->providerNumberType());
 378       put_hcfa($lino, 68, 10, $claim->providerNumber());
 379     }
 380
 381     ++$lino;
 382
 383     // 24a. Date of Service
 384     $tmp = $claim->serviceDate();
 385     put_hcfa($lino, 1, 2, substr($tmp,4,2));
 386     put_hcfa($lino, 4, 2, substr($tmp,6,2));
 387     put_hcfa($lino, 7, 2, substr($tmp,2,2));
 388     put_hcfa($lino,10, 2, substr($tmp,4,2));
 389     put_hcfa($lino,13, 2, substr($tmp,6,2));
 390     put_hcfa($lino,16, 2, substr($tmp,2,2));
 391
 392     // 24b. Place of Service
 393     put_hcfa($lino, 19, 2, $claim->facilityPOS());
 394
 395     // 24c. EMG
 396     // Not currently supported.
 397
 398     // 24d. Procedures, Services or Supplies
 399     put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 400     put_hcfa($lino, 33, 6, $claim->cptModifier($hcfa_proc_index));
 401
 402     // 24e. Diagnosis Pointer
 403     $tmp = '';
 404     foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) $tmp .= $value;
 405     put_hcfa($lino, 45, 4, $tmp);
 406
 407     // 24f. Charges
 408     put_hcfa($lino, 50, 8, str_replace('.', ' ',
 409       sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
 410
 411     // 24g. Days or Units
 412     put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 413
 414     // 24h. EPSDT Family Plan
 415     // Not currently supported.
 416
 417     // 24j. Rendering Provider NPI
 418     put_hcfa($lino, 68, 10, $claim->providerNPI());
 419   }
 420
 421   // 25. Federal Tax ID Number
 422   // Using the Billing Facility EIN because that's what FreeB did.
 423   put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 424   put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 425
 426   // 26. Patient's Account No.
 427   // Instructions say hyphens are not allowed, but freeb used them.
 428   put_hcfa(56, 23, 15, "$pid-$encounter");
 429
 430   // 27. Accept Assignment
 431   put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 432
 433   // 28. Total Charge
 434   put_hcfa(56, 52, 8, str_replace('.',' ',sprintf('%8.2f',$clm_total_charges)));
 435   if (!$clm_total_charges) {
 436     $log .= "*** This claim has no charges!\n";
 437   }
 438
 439   // 29. Amount Paid
 440   put_hcfa(56, 62, 8, str_replace('.',' ',sprintf('%8.2f',$clm_amount_paid)));
 441
 442   // 30. Balance Due
 443   // For secondary payers this reflects primary "contracted rate" adjustments,
 444   // so in general box 30 will not equal box 28 minus box 29.
 445   put_hcfa(56, 71, 8, str_replace('.',' ',sprintf('%8.2f',
 446     $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
 447
 448   // 33. Billing Provider: Phone Number
 449   $tmp = $claim->billingContactPhone();
 450   put_hcfa(57, 66,  3, substr($tmp,0,3));
 451   put_hcfa(57, 70,  7, substr($tmp,3));
 452
 453   // 32. Service Facility Location Information: Name
 454   put_hcfa(58, 23, 25, $claim->facilityName());
 455
 456   // 33. Billing Provider: Name
 457   put_hcfa(58, 50, 25, $claim->billingFacilityName());
 458
 459   // 32. Service Facility Location Information: Street
 460   put_hcfa(59, 23, 25, $claim->facilityStreet());
 461
 462   // 33. Billing Provider: Name
 463   put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 464
 465   // 31. Signature of Physician or Supplier
 466   // FreeB printed the rendering provider's name and the current date here,
 467   // but according to my instructions it must be a real signature and date,
 468   // or else "Signature on File" or "SOF".
 469   put_hcfa(60, 1, 20, 'Signature on File');
 470   //
 471   // $tmp = $claim->providerFirstName();
 472   // if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
 473   // put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
 474
 475   // 32. Service Facility Location Information: City State Zip
 476   $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 477   put_hcfa(60, 23, 25, $tmp . $claim->facilityState() . ' ' .
 478     $claim->facilityZip());
 479
 480   // 32. Billing Provider: City State Zip
 481   $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 482   put_hcfa(60, 50, 25, $tmp . $claim->billingFacilityState() . ' ' .
 483     $claim->billingFacilityZip());
 484
 485   // 32a. Service Facility NPI
 486   put_hcfa(61, 24, 10, $claim->facilityNPI());
 487
 488   // 32b. Service Facility Other ID
 489   // Note that Medicare does NOT want this any more.
 490   if ($claim->providerGroupNumber()) {
 491     put_hcfa(61, 36,  2, $claim->providerNumberType());
 492     put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 493   }
 494
 495   // 33a. Billing Facility NPI
 496   put_hcfa(61, 51, 10, $claim->billingFacilityNPI());
 497
 498   // 33b. Billing Facility Other ID
 499   // Note that Medicare does NOT want this any more.
 500   if ($claim->providerGroupNumber()) {
 501     put_hcfa(61, 63,  2, $claim->providerNumberType());
 502     put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 503   }
 504
 505   return;
 506 }
 507 ?>