interface/cmsportal/insurance_form.php

   1 <?php
   2 /**
   3  * Insurance form posting for the WordPress Patient Portal.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Rod Roark <rod@sunsetsystems.com>
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2014 Rod Roark <rod@sunsetsystems.com>
  10  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14
  15 require_once("../globals.php");
  16 require_once("$srcdir/patient.inc");
  17 require_once("$srcdir/options.inc.php");
  18 require_once("portal.inc.php");
  19
  20 // Consider this a step towards converting the insurance form to layout-based.
  21 // Faking it here makes things easier.
  22 // Also note that some fields like SSN and most of the subscriber employer
  23 // items have been omitted because they are not relevant for claims.
  24 //
  25 $insurance_layout = array(
  26   array('field_id'     => 'type',
  27         'title'        => 'Type',
  28         'uor'          => '2',
  29         'data_type'    => '1',
  30         'list_id'      => 'insurance_types',
  31         'edit_options' => '',
  32        ),
  33   array('field_id'     => 'date',
  34         'title'        => 'Effective Date',
  35         'uor'          => '2',
  36         'data_type'    => '4',               // Text-date
  37         'list_id'      => '',
  38         'edit_options' => '',
  39        ),
  40   array('field_id'     => 'provider',
  41         'title'        => 'Provider',
  42         'uor'          => '2',
  43         'data_type'    => '16',              // Insurance Providers
  44         'list_id'      => '',
  45         'edit_options' => '',
  46        ),
  47   array('field_id'     => 'plan_name',
  48         'title'        => 'Plan Name',
  49         'uor'          => '1',
  50         'data_type'    => '2',               // Text
  51         'list_id'      => '',
  52         'edit_options' => '',
  53        ),
  54   array('field_id'     => 'policy_number',
  55         'title'        => 'Policy Number',
  56         'uor'          => '1',
  57         'data_type'    => '2',               // Text
  58         'list_id'      => '',
  59         'edit_options' => '',
  60        ),
  61   array('field_id'     => 'group_number',
  62         'title'        => 'Group Number',
  63         'uor'          => '1',
  64         'data_type'    => '2',               // Text
  65         'list_id'      => '',
  66         'edit_options' => '',
  67        ),
  68   array('field_id'     => 'subscriber_employer',
  69         'title'        => 'Group Name',
  70         'uor'          => '1',
  71         'data_type'    => '2',               // Text
  72         'list_id'      => '',
  73         'edit_options' => '',
  74        ),
  75   array('field_id'     => 'subscriber_lname',
  76         'title'        => 'Subscriber Last Name',
  77         'uor'          => '2',
  78         'data_type'    => '2',               // Text
  79         'list_id'      => '',
  80         'edit_options' => '',
  81        ),
  82   array('field_id'     => 'subscriber_fname',
  83         'title'        => 'Subscriber First Name',
  84         'uor'          => '1',
  85         'data_type'    => '2',               // Text
  86         'list_id'      => '',
  87         'edit_options' => '',
  88        ),
  89   array('field_id'     => 'subscriber_mname',
  90         'title'        => 'Subscriber Middle Name',
  91         'uor'          => '1',
  92         'data_type'    => '2',               // Text
  93         'list_id'      => '',
  94         'edit_options' => '',
  95        ),
  96   array('field_id'     => 'subscriber_DOB',
  97         'title'        => 'Subscriber DOB',
  98         'uor'          => '2',
  99         'data_type'    => '4',               // Text-date
 100         'list_id'      => '',
 101         'edit_options' => '',
 102        ),
 103   array('field_id'     => 'subscriber_sex',
 104         'title'        => 'Subscriber Sex',
 105         'uor'          => '2',
 106         'data_type'    => '1',               // List
 107         'list_id'      => 'sex',
 108         'edit_options' => '',
 109        ),
 110   array('field_id'     => 'subscriber_relationship',
 111         'title'        => 'Subscriber Relationship',
 112         'uor'          => '2',
 113         'data_type'    => '1',               // List
 114         'list_id'      => 'sub_relation',
 115         'edit_options' => '',
 116        ),
 117   array('field_id'     => 'subscriber_street',
 118         'title'        => 'Subscriber Street',
 119         'uor'          => '1',
 120         'data_type'    => '2',               // Text
 121         'list_id'      => '',
 122         'edit_options' => '',
 123        ),
 124   array('field_id'     => 'subscriber_city',
 125         'title'        => 'Subscriber City',
 126         'uor'          => '1',
 127         'data_type'    => '2',               // Text
 128         'list_id'      => '',
 129         'edit_options' => '',
 130        ),
 131   array('field_id'     => 'subscriber_state',
 132         'title'        => 'Subscriber State',
 133         'uor'          => '1',
 134         'data_type'    => '1',               // List
 135         'list_id'      => 'state',
 136         'edit_options' => '',
 137        ),
 138   array('field_id'     => 'subscriber_postal_code',
 139         'title'        => 'Subscriber Zip',
 140         'uor'          => '1',
 141         'data_type'    => '2',               // Text
 142         'list_id'      => '',
 143         'edit_options' => '',
 144        ),
 145   array('field_id'     => 'subscriber_phone',
 146         'title'        => 'Subscriber Phone',
 147         'uor'          => '1',
 148         'data_type'    => '2',               // Text
 149         'list_id'      => '',
 150         'edit_options' => '',
 151        ),
 152 );
 153
 154 $postid = intval($_REQUEST['postid']);
 155
 156 if ($_POST['bn_save']) {
 157     $newdata = array();
 158     $ptid = intval($_POST['ptid']);
 159     foreach ($insurance_layout as $frow) {
 160         $data_type = $frow['data_type'];
 161         $field_id  = $frow['field_id'];
 162         $newdata[$field_id] = get_layout_form_value($frow);
 163     }
 164
 165     newInsuranceData(
 166         $ptid,
 167         $newdata['type'],
 168         $newdata['provider'],
 169         $newdata['policy_number'],
 170         $newdata['group_number'],
 171         $newdata['plan_name'],
 172         $newdata['subscriber_lname'],
 173         $newdata['subscriber_mname'],
 174         $newdata['subscriber_fname'],
 175         $newdata['subscriber_relationship'],
 176         '',                                    // subscriber_ss
 177         $newdata['subscriber_DOB'],
 178         $newdata['subscriber_street'],
 179         $newdata['subscriber_postal_code'],
 180         $newdata['subscriber_city'],
 181         $newdata['subscriber_state'],
 182         '',                                    // subscriber_country
 183         $newdata['subscriber_phone'],
 184         $newdata['subscriber_employer'],
 185         '',                                    // subscriber_employer_street
 186         '',                                    // subscriber_employer_city
 187         '',                                    // subscriber_employer_postal_code
 188         '',                                    // subscriber_employer_state
 189         '',                                    // subscriber_employer_country
 190         '',                                    // copay
 191         $newdata['subscriber_sex'],
 192         $newdata['date'],
 193         'TRUE',                                // accept_assignment
 194         ''                                     // policy_type
 195     );
 196   // Finally, delete the request from the portal.
 197     $result = cms_portal_call(array('action' => 'delpost', 'postid' => $postid));
 198     if ($result['errmsg']) {
 199         die(text($result['errmsg']));
 200     }
 201
 202     echo "<html><body><script language='JavaScript'>\n";
 203     echo "if (top.restoreSession) top.restoreSession(); else opener.top.restoreSession();\n";
 204     echo "document.location.href = 'list_requests.php';\n";
 205     echo "</script></body></html>\n";
 206     exit();
 207 }
 208
 209 // Get the portal request data.
 210 if (!$postid) {
 211     die(xlt('Request ID is missing!'));
 212 }
 213
 214 $result = cms_portal_call(array('action' => 'getpost', 'postid' => $postid));
 215 if ($result['errmsg']) {
 216     die(text($result['errmsg']));
 217 }
 218
 219 // Look up the patient in OpenEMR.
 220 $ptid = lookup_openemr_patient($result['post']['user']);
 221 ?>
 222 <html>
 223 <head>
 224 <?php html_header_show(); ?>
 225 <link rel=stylesheet href="<?php echo $css_header; ?>" type="text/css">
 226 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.min.css">
 227
 228 <style>
 229
 230 tr.head   { font-size:10pt; background-color:#cccccc; text-align:center; }
 231 tr.detail { font-size:10pt; background-color:#ddddff; }
 232 td input  { background-color:transparent; }
 233
 234 </style>
 235
 236 <script type="text/javascript" src="../../library/textformat.js?v=<?php echo $v_js_includes; ?>"></script>
 237 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-1-7-2/jquery.min.js"></script>
 238 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.full.min.js"></script>
 239
 240 <script language="JavaScript">
 241
 242 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 243
 244 function myRestoreSession() {
 245  if (top.restoreSession) top.restoreSession(); else opener.top.restoreSession();
 246  return true;
 247 }
 248
 249 // This capitalizes the first letter of each word in the passed input
 250 // element.  It also strips out extraneous spaces.
 251 // Copied from demographics_full.php.
 252 function capitalizeMe(elem) {
 253  var a = elem.value.split(' ');
 254  var s = '';
 255  for(var i = 0; i < a.length; ++i) {
 256   if (a[i].length > 0) {
 257    if (s.length > 0) s += ' ';
 258    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 259   }
 260  }
 261  elem.value = s;
 262 }
 263
 264 function validate() {
 265  var f = document.forms[0];
 266  // TBD
 267  return true;
 268 }
 269
 270 $(document).ready(function() {
 271     $('.datepicker').datetimepicker({
 272         <?php $datetimepicker_timepicker = false; ?>
 273         <?php $datetimepicker_showseconds = false; ?>
 274         <?php $datetimepicker_formatInput = true; ?>
 275         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 276         <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 277     });
 278     $('.datetimepicker').datetimepicker({
 279         <?php $datetimepicker_timepicker = true; ?>
 280         <?php $datetimepicker_showseconds = false; ?>
 281         <?php $datetimepicker_formatInput = true; ?>
 282         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 283         <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 284     });
 285 });
 286
 287 </script>
 288 </head>
 289
 290 <body class="body_top">
 291 <center>
 292
 293 <form method='post' action='insurance_form.php' onsubmit='return validate()'>
 294
 295 <input type='hidden' name='ptid'   value='<?php echo attr($ptid);   ?>' />
 296 <input type='hidden' name='postid' value='<?php echo attr($postid); ?>' />
 297
 298 <table width='100%' cellpadding='1' cellspacing='2'>
 299  <tr class='head'>
 300   <th align='left'><?php echo xlt('Field'); ?></th>
 301   <th align='left'><?php echo xlt('Current Value'); ?></th>
 302   <th align='left'><?php echo xlt('New Value'); ?></th>
 303  </tr>
 304
 305 <?php
 306 $insrow = getInsuranceData($pid, $result['fields']['type']);
 307
 308 foreach ($insurance_layout as $lorow) {
 309     $data_type  = $lorow['data_type'];
 310     $field_id   = $lorow['field_id'];
 311
 312     $list_id = $lorow['list_id'];
 313     $field_title = $lorow['title'];
 314
 315     $currvalue  = '';
 316     if (isset($insrow[$field_id])) {
 317         $currvalue = $insrow[$field_id];
 318     }
 319
 320     $newvalue = '';
 321     if (isset($result['fields'][$field_id])) {
 322         $newvalue = trim($result['fields'][$field_id]);
 323     }
 324
 325   // Translate $newvalue for certain field types including lists.
 326     if ($newvalue !== '') {
 327         if ($list_id) {
 328             $tmp = sqlQuery(
 329                 "SELECT option_id FROM list_options WHERE " .
 330                 "list_id = ? AND title = ? AND activity = 1 ORDER BY option_id LIMIT 1",
 331                 array($list_id, $newvalue)
 332             );
 333             if (isset($tmp['option_id'])) {
 334                 $newvalue = $tmp['option_id'];
 335             }
 336         }
 337
 338         // Some data types like insurance provider are pretty hopeless, so let the display
 339         // logic generate a "Fix me" message and the user can translate it.
 340     }
 341
 342     echo " <tr class='detail'>\n";
 343     echo "  <td class='bold'>" . text($field_title) . "</td>\n";
 344     echo "  <td>";
 345     echo generate_display_field($lorow, $currvalue);
 346     echo "</td>\n";
 347     echo "  <td>";
 348     generate_form_field($lorow, $newvalue);
 349     echo "</td>\n";
 350     echo " </tr>\n";
 351 }
 352 ?>
 353
 354 </table>
 355
 356 <p>
 357 <input type='submit' name='bn_save' value='<?php echo xla('Save and Delete Request'); ?>' />
 358 &nbsp;
 359 <input type='button' value='<?php echo xla('Back'); ?>' onclick="window.history.back()" />
 360 <!-- Was: onclick="myRestoreSession();location='list_requests.php'" -->
 361 </p>
 362
 363 </form>
 364
 365 <script language="JavaScript">
 366
 367 // Fix inconsistently formatted phone numbers from the database.
 368 var f = document.forms[0];
 369 if (f.form_phone) phonekeyup(f.form_phone, mypcc);
 370
 371 // This is a by-product of generate_form_field().
 372 <?php echo $date_init; ?>
 373
 374 </script>
 375
 376 <!-- include support for the list-add selectbox feature -->
 377 <?php include $GLOBALS['fileroot'] . "/library/options_listadd.inc"; ?>
 378
 379 </center>
 380 </body>
 381 </html>