library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007 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 function gen_x12_837($pid, $encounter, &$log) {
  12
  13   $today = time();
  14   $out = '';
  15   $claim = new Claim($pid, $encounter);
  16   $edicount = 0;
  17
  18   $log .= "Generating claim $pid-$encounter for " .
  19     $claim->patientFirstName()  . ' ' .
  20     $claim->patientMiddleName() . ' ' .
  21     $claim->patientLastName()   . ' on ' .
  22     date('Y-m-d H:i', $today) . ".\n";
  23
  24   $out .= "ISA" .
  25     "*00" .
  26     "*          " .
  27     "*00" .
  28     "*          " .
  29     "*ZZ" .
  30     "*" . $claim->x12gssenderid() .
  31     "*ZZ" .
  32     "*" . $claim->x12gsreceiverid() .
  33     "*030911" .
  34     "*1630" .
  35     "*U" .
  36     "*00401" .
  37     "*000000001" .
  38     "*0" .
  39     "*P" .
  40     "*:" .
  41     "~\n";
  42
  43   $out .= "GS" .
  44     "*HC" .
  45     "*" . $claim->x12gssenderid() .
  46     "*" . $claim->x12gsreceiverid() .
  47     "*" . date('Ymd', $today) .
  48     "*" . date('Hi', $today) .
  49     "*1" .
  50     "*X" .
  51     "*" . $claim->x12gsversionstring() .
  52     "~\n";
  53
  54   ++$edicount;
  55   $out .= "ST" .
  56     "*837" .
  57     "*0021" .
  58     "~\n";
  59
  60   ++$edicount;
  61   $out .= "BHT" .
  62     "*0019" .
  63     "*00" .
  64     "*0123" .
  65     "*" . date('Ymd', $today) .
  66     "*1023" .
  67     "*CH" .
  68     "~\n";
  69
  70   ++$edicount;
  71   $out .= "REF" .
  72     "*87" .
  73     "*" . $claim->x12gsversionstring() .
  74     "~\n";
  75
  76   ++$edicount;
  77   $out .= "NM1" .       // Loop 1000A Submitter
  78     "*41" .
  79     "*2" .
  80     "*" . $claim->billingFacilityName() .
  81     "*" .
  82     "*" .
  83     "*" .
  84     "*" .
  85     "*46" .
  86     "*" . $claim->billingFacilityETIN() .
  87     "~\n";
  88
  89   ++$edicount;
  90   $out .= "PER" .
  91     "*IC" .
  92     "*" . $claim->billingContactName() .
  93     "*TE" .
  94     "*" . $claim->billingContactPhone() .
  95     "~\n";
  96
  97   ++$edicount;
  98   $out .= "NM1" .       // Loop 1000B Receiver
  99     "*40" .
 100     "*2" .
 101     "*" . $claim->clearingHouseName() .
 102     "*" .
 103     "*" .
 104     "*" .
 105     "*" .
 106     "*46" .
 107     "*" . $claim->clearingHouseETIN() .
 108     "~\n";
 109
 110   $HLcount = 1;
 111
 112   ++$edicount;
 113   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 114     "*$HLcount" .
 115     "*" .
 116     "*20" .
 117     "*1" .
 118     "~\n";
 119
 120   $HLBillingPayToProvider = $HLcount++;
 121
 122   ++$edicount;
 123   $out .= "NM1" .       // Loop 2010AA Billing Provider
 124     "*85" .
 125     "*2" .
 126     "*" . $claim->billingFacilityName() .
 127     "*" .
 128     "*" .
 129     "*" .
 130     "*";
 131   if ($claim->billingFacilityNPI()) {
 132     $out .= "*XX*" . $claim->billingFacilityNPI();
 133   } else {
 134     $log .= "*** Billing facility has no NPI.\n";
 135     $out .= "*24*" . $claim->billingFacilityETIN();
 136   }
 137   $out .= "~\n";
 138
 139   ++$edicount;
 140   $out .= "N3" .
 141     "*" . $claim->billingFacilityStreet() .
 142     "~\n";
 143
 144   ++$edicount;
 145   $out .= "N4" .
 146     "*" . $claim->billingFacilityCity() .
 147     "*" . $claim->billingFacilityState() .
 148     "*" . $claim->billingFacilityZip() .
 149     "~\n";
 150
 151   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 152
 153   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 154     ++$edicount;
 155     $out .= "REF" .
 156       "*EI" .
 157       "*" . $claim->billingFacilityETIN() .
 158       "~\n";
 159   }
 160
 161   ++$edicount;
 162   $out .= "REF" .
 163     "*" . $claim->providerNumberType() .
 164     "*" . $claim->providerNumber() .
 165     "~\n";
 166
 167   ++$edicount;
 168   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 169     "*87" .
 170     "*2" .
 171     "*" . $claim->billingFacilityName() .
 172     "*" .
 173     "*" .
 174     "*" .
 175     "*";
 176   if ($claim->billingFacilityNPI())
 177     $out .= "*XX*" . $claim->billingFacilityNPI();
 178   else
 179     $out .= "*24*" . $claim->billingFacilityETIN();
 180   $out .= "~\n";
 181
 182   ++$edicount;
 183   $out .= "N3" .
 184     "*" . $claim->billingFacilityStreet() .
 185     "~\n";
 186
 187   ++$edicount;
 188   $out .= "N4" .
 189     "*" . $claim->billingFacilityCity() .
 190     "*" . $claim->billingFacilityState() .
 191     "*" . $claim->billingFacilityZip() .
 192     "~\n";
 193
 194   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 195     ++$edicount;
 196     $out .= "REF" .
 197       "*EI" .
 198       "*" . $claim->billingFacilityETIN() .
 199       "~\n";
 200   }
 201
 202   $PatientHL = 0;
 203
 204   ++$edicount;
 205   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 206     "*$HLcount" .
 207     "*$HLBillingPayToProvider" .
 208     "*22" .
 209     "*$PatientHL" .
 210     "~\n";
 211
 212   $HLSubscriber = $HLcount++;
 213
 214   ++$edicount;
 215   $out .= "SBR" .       // Subscriber Information
 216     "*" . $claim->payerSequence() .
 217     "*" . $claim->insuredRelationship() .
 218     "*" . $claim->groupNumber() .
 219     "*" . $claim->groupName() .
 220     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 221     "*" .
 222     "*" .
 223     "*" .
 224     "*" . $claim->claimType() . // Zirmed replaces this
 225     "~\n";
 226
 227   ++$edicount;
 228   $out .= "NM1" .       // Loop 2010BA Subscriber
 229     "*IL" .
 230     "*1" .
 231     "*" . $claim->insuredLastName() .
 232     "*" . $claim->insuredFirstName() .
 233     "*" . $claim->insuredMiddleName() .
 234     "*" .
 235     "*" .
 236     "*MI" .
 237     "*" . $claim->policyNumber() .
 238     "~\n";
 239
 240   ++$edicount;
 241   $out .= "N3" .
 242     "*" . $claim->insuredStreet() .
 243     "~\n";
 244
 245   ++$edicount;
 246   $out .= "N4" .
 247     "*" . $claim->insuredCity() .
 248     "*" . $claim->insuredState() .
 249     "*" . $claim->insuredZip() .
 250     "~\n";
 251
 252   ++$edicount;
 253   $out .= "DMG" .
 254     "*D8" .
 255     "*" . $claim->insuredDOB() .
 256     "*" . $claim->insuredSex() .
 257     "~\n";
 258
 259   ++$edicount;
 260   $out .= "NM1" .       // Loop 2010BB Payer
 261     "*PR" .
 262     "*2" .
 263     "*" . $claim->payerName() .
 264     "*" .
 265     "*" .
 266     "*" .
 267     "*" .
 268     "*PI" .
 269     "*" . $claim->payerID() . // Zirmed ignores this if using Payer Name Matching.
 270     "~\n";
 271
 272   // if (!$claim->payerID()) {
 273   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 274   // }
 275
 276   ++$edicount;
 277   $out .= "N3" .
 278     "*" . $claim->payerStreet() .
 279     "~\n";
 280
 281   ++$edicount;
 282   $out .= "N4" .
 283     "*" . $claim->payerCity() .
 284     "*" . $claim->payerState() .
 285     "*" . $claim->payerZip() .
 286     "~\n";
 287
 288   if (! $claim->isSelfOfInsured()) {
 289     ++$edicount;
 290     $out .= "HL" .        // Loop 2000C Patient Information
 291       "*$HLcount" .
 292       "*$HLSubscriber" .
 293       "*23" .
 294       "*0" .
 295       "~\n";
 296
 297     $HLcount++;
 298
 299     ++$edicount;
 300     $out .= "PAT" .
 301       "*" . $claim->insuredRelationship() .
 302       "~\n";
 303
 304     ++$edicount;
 305     $out .= "NM1" .       // Loop 2010CA Patient
 306       "*QC" .
 307       "*1" .
 308       "*" . $claim->patientLastName() .
 309       "*" . $claim->patientFirstName() .
 310       "*" . $claim->patientMiddleName() .
 311       "~\n";
 312
 313     ++$edicount;
 314     $out .= "N3" .
 315       "*" . $claim->patientStreet() .
 316       "~\n";
 317
 318     ++$edicount;
 319     $out .= "N4" .
 320       "*" . $claim->patientCity() .
 321       "*" . $claim->patientState() .
 322       "*" . $claim->patientZip() .
 323       "~\n";
 324
 325     ++$edicount;
 326     $out .= "DMG" .
 327       "*D8" .
 328       "*" . $claim->patientDOB() .
 329       "*" . $claim->patientSex() .
 330       "~\n";
 331   } // end of patient different from insured
 332
 333   $proccount = $claim->procCount();
 334
 335   $clm_total_charges = 0;
 336   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 337     $clm_total_charges += $claim->cptCharges($prockey);
 338   }
 339
 340   if (!$clm_total_charges) {
 341     $log .= "*** This claim has no charges!\n";
 342   }
 343
 344   ++$edicount;
 345   $out .= "CLM" .       // Loop 2300 Claim
 346     "*$pid-$encounter" .
 347     "*" . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 348     "*" .
 349     "*" .
 350     "*" . $claim->facilityPOS() . "::1" .
 351     "*Y" .
 352     "*A" .
 353     "*Y" .
 354     "*Y" .
 355     "*C" .
 356     "~\n";
 357
 358   ++$edicount;
 359   $out .= "DTP" .       // Date of Onset
 360     "*431" .
 361     "*D8" .
 362     "*" . $claim->onsetDate() .
 363     "~\n";
 364
 365   if (strcmp($claim->facilityPOS(),'21') == 0) {
 366     ++$edicount;
 367     $out .= "DTP" .     // Date of Hospitalization
 368       "*435" .
 369       "*D8" .
 370       "*" . $claim->onsetDate() .
 371       "~\n";
 372   }
 373
 374   $patientpaid = $claim->patientPaidAmount();
 375   if ($patientpaid != 0) {
 376     ++$edicount;
 377     $out .= "AMT" .     // Patient paid amount. Page 220.
 378       "*F5" .
 379       "*" . $patientpaid .
 380       "~\n";
 381   }
 382
 383   if ($claim->priorAuth()) {
 384     ++$edicount;
 385     $out .= "REF" .     // Prior Authorization Number
 386       "*G1" .
 387       "*" . $claim->priorAuth() .
 388       "~\n";
 389   }
 390
 391   if ($claim->cliaCode()) {
 392     // Required by Medicare when in-house labs are done.
 393     ++$edicount;
 394     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 395       "*X4" .
 396       "*" . $claim->cliaCode() .
 397       "~\n";
 398   }
 399
 400   $da = $claim->diagArray();
 401   ++$edicount;
 402   $out .= "HI";         // Health Diagnosis Codes
 403   $diag_type_code = 'BK';
 404   foreach ($da as $diag) {
 405     $out .= "*$diag_type_code:" . $diag;
 406     $diag_type_code = 'BF';
 407   }
 408   $out .= "~\n";
 409
 410   if ($claim->referrerLastName()) {
 411     // Medicare requires referring provider's name and UPIN.
 412     ++$edicount;
 413     $out .= "NM1" .     // Loop 2310A Referring Provider
 414       "*DN" .
 415       "*1" .
 416       "*" . $claim->referrerLastName() .
 417       "*" . $claim->referrerFirstName() .
 418       "*" . $claim->referrerMiddleName() .
 419       "*" .
 420       "*";
 421     if ($claim->referrerNPI()) { $out .=
 422       "*XX" .
 423       "*" . $claim->referrerNPI();
 424     } else { $out .=
 425       "*34" .
 426       "*" . $claim->referrerSSN();
 427     }
 428     $out .= "~\n";
 429
 430     ++$edicount;
 431     $out .= "REF" .     // Referring Provider Secondary Identification
 432       "*1G" .
 433       "*" . $claim->referrerUPIN() .
 434       "~\n";
 435   }
 436
 437   ++$edicount;
 438   $out .= "NM1" .       // Loop 2310B Rendering Provider
 439     "*82" .
 440     "*1" .
 441     "*" . $claim->providerLastName() .
 442     "*" . $claim->providerFirstName() .
 443     "*" . $claim->providerMiddleName() .
 444     "*" .
 445     "*";
 446   if ($claim->providerNPI()) { $out .=
 447     "*XX" .
 448     "*" . $claim->providerNPI();
 449   } else { $out .=
 450     "*34" .
 451     "*" . $claim->providerSSN();
 452     $log .= "*** Rendering provider has no NPI.\n";
 453   }
 454   $out .= "~\n";
 455
 456   ++$edicount;
 457   $out .= "PRV" .       // Rendering Provider Information
 458     "*PE" .
 459     "*ZZ" .
 460     "*207Q00000X" .
 461     "~\n";
 462
 463   ++$edicount;
 464   $out .= "NM1" .       // Loop 2310B Service Location
 465     "*77" .
 466     "*2" .
 467     "*" . $claim->facilityName() .
 468     "*" .
 469     "*" .
 470     "*" .
 471     "*";
 472   if ($claim->facilityNPI()) { $out .=
 473     "*XX*" . $claim->facilityNPI();
 474   } else { $out .=
 475     "*24*" . $claim->facilityETIN();
 476     $log .= "*** Service location has no NPI.\n";
 477   }
 478   $out .= "~\n";
 479
 480   ++$edicount;
 481   $out .= "N3" .
 482     "*" . $claim->facilityStreet() .
 483     "~\n";
 484
 485   ++$edicount;
 486   $out .= "N4" .
 487     "*" . $claim->facilityCity() .
 488     "*" . $claim->facilityState() .
 489     "*" . $claim->facilityZip() .
 490     "~\n";
 491
 492   $prev_pt_resp = $clm_total_charges; // for computation below
 493
 494   // Loops 2320 and 2330*, other subscriber/payer information.
 495   //
 496   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 497
 498     ++$edicount;
 499     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 500       "*" . $claim->payerSequence($ins) .
 501       "*" . $claim->insuredRelationship($ins) .
 502       "*" . $claim->groupNumber($ins) .
 503       "*" . $claim->groupName($ins) .
 504       "*" .
 505       "*" .
 506       "*" .
 507       "*" .
 508       "*" . $claim->claimType($ins) .
 509       "~\n";
 510
 511     // Things that apply only to previous payers, not future payers.
 512     //
 513     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 514
 515       // Generate claim-level adjustments.
 516       $aarr = $claim->payerAdjustments($ins);
 517       foreach ($aarr as $a) {
 518         ++$edicount;
 519         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 520           "*" . $a[1] .
 521           "*" . $a[2] .
 522           "*" . $a[3] .
 523           "~\n";
 524       }
 525
 526       $payerpaid = $claim->payerTotals($ins);
 527       ++$edicount;
 528       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 529         "*D" .
 530         "*" . $payerpaid[1] .
 531         "~\n";
 532
 533       // Patient responsibility amount as of this previous payer.
 534       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 535       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 536
 537       ++$edicount;
 538       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 539         "*F2" .
 540         "*" . sprintf('%.2f', $prev_pt_resp) .
 541         "~\n";
 542
 543     } // End of things that apply only to previous payers.
 544
 545     ++$edicount;
 546     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 547       "*D8" .
 548       "*" . $claim->insuredDOB($ins) .
 549       "*" . $claim->insuredSex($ins) .
 550       "~\n";
 551
 552     ++$edicount;
 553     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 554       "*" .
 555       "*" .
 556       "*Y" .
 557       "*B" .
 558       "*" .
 559       "*Y" .
 560       "~\n";
 561
 562     ++$edicount;
 563     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 564       "*IL" .
 565       "*1" .
 566       "*" . $claim->insuredLastName($ins) .
 567       "*" . $claim->insuredFirstName($ins) .
 568       "*" . $claim->insuredMiddleName($ins) .
 569       "*" .
 570       "*" .
 571       "*MI" .
 572       "*" . $claim->policyNumber($ins) .
 573       "~\n";
 574
 575     ++$edicount;
 576     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 577       "*PR" .
 578       "*2" .
 579       "*" . $claim->payerName($ins) .
 580       "*" .
 581       "*" .
 582       "*" .
 583       "*" .
 584       "*PI" .
 585       "*" . $claim->payerID($ins) .
 586       "~\n";
 587
 588     // if (!$claim->payerID($ins)) {
 589     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 590     // }
 591
 592   } // End loops 2320/2330*.
 593
 594   $loopcount = 0;
 595
 596   // Procedure loop starts here.
 597   //
 598   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 599     ++$loopcount;
 600
 601     ++$edicount;
 602     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 603       "*$loopcount" .
 604       "~\n";
 605
 606     ++$edicount;
 607     $out .= "SV1" .     // Professional Service. Page 400.
 608       "*HC:" . $claim->cptKey($prockey) .
 609       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 610       "*UN" .
 611       "*" . $claim->cptUnits($prockey) .
 612       "*" .
 613       "*" .
 614       "*" . $claim->diagIndex($prockey) .
 615       "~\n";
 616
 617     if (!$claim->cptCharges($prockey)) {
 618       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 619     }
 620
 621     if (!$claim->diagIndex($prockey)) {
 622       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 623     }
 624
 625     ++$edicount;
 626     $out .= "DTP" .     // Date of Service. Page 435.
 627       "*472" .
 628       "*D8" .
 629       "*" . $claim->serviceDate() .
 630       "~\n";
 631
 632     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 633     // with HCPCS codes.
 634     //
 635     $ndc = $claim->cptNDCID($prockey);
 636     if ($ndc) {
 637       ++$edicount;
 638       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 639         "*4" .
 640         "*N4" .
 641         "*" . $ndc .
 642         "~\n";
 643
 644       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 645         $log .= "*** NDC code '$ndc' has invalid format!\n";
 646       }
 647
 648       ++$edicount;
 649       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 650         "*" .
 651         "*" .
 652         "*0" . // dummy price, required by HIPAA
 653         "*" . $claim->cptNDCQuantity($prockey) .
 654         "*" . $claim->cptNDCUOM($prockey) .
 655         "~\n";
 656     }
 657
 658     // Loop 2430, adjudication by previous payers.
 659     //
 660     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 661       if ($claim->payerSequence($ins) > $claim->payerSequence())
 662         continue; // payer is future, not previous
 663
 664       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 665       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 666
 667       if ($payerpaid[1] == 0 && !count($aarr)) {
 668         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 669           "' has no payments or adjustments from previous payer!\n";
 670         continue;
 671       }
 672
 673       ++$edicount;
 674       $out .= "SVD" . // Service line adjudication. Page 554.
 675         "*" . $claim->payerID($ins) .
 676         "*" . $payerpaid[1] .
 677         "*HC:" . $claim->cptKey($prockey) .
 678         "*" .
 679         "*" . $claim->cptUnits($prockey) .
 680         "~\n";
 681
 682       $tmpdate = $payerpaid[0];
 683       foreach ($aarr as $a) {
 684         ++$edicount;
 685         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 686           "*" . $a[1] .
 687           "*" . $a[2] .
 688           "*" . $a[3] .
 689           "~\n";
 690         if (!$tmpdate) $tmpdate = $a[0];
 691       }
 692
 693       if ($tmpdate) {
 694         ++$edicount;
 695         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 696           "*573" .
 697           "*D8" .
 698           "*$tmpdate" .
 699           "~\n";
 700       }
 701     } // end loop 2430
 702   } // end this procedure
 703
 704   ++$edicount;
 705   $out .= "SE" .        // SE Trailer
 706     "*$edicount" .
 707     "*0021" .
 708     "~\n";
 709
 710   $out .= "GE" .        // GE Trailer
 711     "*1" .
 712     "*1" .
 713     "~\n";
 714
 715   $out .= "IEA" .       // IEA Trailer
 716     "*1" .
 717     "*000000001" .
 718     "~\n";
 719
 720   $log .= "\n";
 721   return $out;
 722 }
 723 ?>