library/gen_x12_837i.inc.php

   1 <?php
   2 /**
   3  * X12 837I
   4  *
   5  * @package OpenEMR
   6  * @link    https://www.open-emr.org
   7  * @author  Jerry Padgett <sjpadgett@gmail.com>
   8  * @copyright Copyright (c) 2017 Jerry Padgett <sjpadgett@gmail.com>
   9  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  10  */
  11
  12 use OpenEMR\Billing\Claim;
  13
  14 function x12date($frmdate)
  15 {
  16     return ('20' . substr($frmdate, 4, 2) . substr($frmdate, 0, 2) . substr($frmdate, 2, 2));
  17 }
  18
  19 $ub04id = array();
  20 function generate_x12_837I($pid, $encounter, &$log, $ub04id)
  21 {
  22     $today = time();
  23     $out = '';
  24     $claim = new Claim($pid, $encounter);
  25     $edicount = 0;
  26
  27     $log .= "Generating 837I claim $pid-$encounter for " .
  28     $claim->patientFirstName()  . ' ' .
  29     $claim->patientMiddleName() . ' ' .
  30     $claim->patientLastName()   . ' on ' .
  31     date('Y-m-d H:i', $today) . ".\n";
  32     $out .= "ISA" .
  33         "*" . $claim->x12gsisa01() .
  34         "*" . $claim->x12gsisa02() .
  35         "*" . $claim->x12gsisa03() .
  36         "*" . $claim->x12gsisa04() .
  37         "*" . $claim->x12gsisa05() .
  38         "*" . $claim->x12gssenderid() .
  39         "*" . $claim->x12gsisa07() .
  40         "*" . $claim->x12gsreceiverid() .
  41         // date of transmission "*030911" .
  42     "*" . date('Ymd', $today) .
  43     //Time of transmission "*1630" .
  44     "*" . date('Hi', $today) .
  45     "*" . "^"  .
  46     "*" . "00501" .
  47     "*" . "000000001" .
  48     "*" . $claim->x12gsisa14() .
  49     "*" . $claim->x12gsisa15() .
  50     "*:" .
  51     "~\n";
  52     $out .= "GS" .
  53         "*HC" .
  54         "*" . $claim->x12gsgs02() .
  55         "*" . trim($claim->x12gs03()) .
  56         "*" . date('Ymd', $today) .
  57         "*" . date('Hi', $today) .
  58         "*1" .
  59         "*X" .
  60         // "*" . $claim->x12gsversionstring() .
  61     "*" . "005010X223A2".
  62     "~\n";
  63     ++$edicount;
  64     $out .= "ST" .
  65     "*" . "837" .
  66     "*" . "0021" .
  67     // "*" . $claim->x12gsversionstring() .
  68     "*" . "005010X223A2".
  69     "~\n";
  70     ++$edicount;
  71     $out .= "BHT" .
  72         "*" . "0019" .                             // 0019 is required here
  73         "*" . "00" .                               // 00 = original transmission
  74         "*" . "0123" .                             // reference identification
  75         "*" . date('Ymd', $today) .           // transaction creation date
  76         "*" . date('Hi', $today) .            // transaction creation time
  77         ($encounter_claim ? "*RP" : "*CH") .  // RP = reporting, CH = chargeable
  78         "~\n";
  79
  80         ++$edicount;
  81         //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
  82         $billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
  83     if ($billingFacilityName == '') {
  84         $log .= "*** billing facility name in 1000A loop is empty\n";
  85     }
  86         $out .= "NM1" .       // Loop 1000A Submitter stays in the 837I
  87         "*" . "41" .
  88         "*" . "2" .
  89         "*" . $billingFacilityName .
  90         "*" .
  91         "*" .
  92         "*" .
  93         "*" .
  94         "*" . "46";
  95
  96         $out  .=  "*" . $claim->billingFacilityETIN();
  97         $out .= "~\n";
  98         ++$edicount;
  99
 100         $out .= "PER" .
 101             "*IC" .
 102             "*" . $claim->billingContactName() .
 103             "*TE" .
 104             "*" . $claim->billingContactPhone();
 105         $out .= "~\n";
 106
 107         ++$edicount;
 108
 109         $out .= "NM1" .       // Loop 1000B Receiver stays in the 837I
 110             "*" . "40" .
 111             "*" . "2" .
 112             "*" . $claim->clearingHouseName() .
 113             "*" .
 114             "*" .
 115             "*" .
 116             "*" .
 117             "*" . "46" .
 118             "*" . $claim->clearingHouseETIN() .
 119             "~\n";
 120         $HLcount = 1;
 121         ++$edicount;
 122
 123         $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 124             "*" . "$HLcount" .
 125             "*" .
 126             "*" . "20" .
 127             "*" . "1" .              // 1 indicates there are child segments
 128             "~\n";
 129         $HLBillingPayToProvider = $HLcount++;
 130         // Situational PRV segment (for provider taxonomy code) omitted here.
 131         // Situational CUR segment (foreign currency information) omitted here.
 132         ++$edicount;
 133         //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
 134         $billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
 135         $out .= "NM1" .       // Loop 2010AA Billing Provider stays in the 837I
 136             "*" . "85" .
 137             "*" . "2" .
 138             "*" . $billingFacilityName .
 139             "*" .
 140             "*" .
 141             "*" .
 142             "*";
 143     if ($claim->billingFacilityNPI()) {
 144         $out .= "*XX*" . $claim->billingFacilityNPI();
 145     } else {
 146         $log .= "*** Billing facility has no NPI.\n";
 147         $out .= "*XX*";
 148     }
 149         $out .= "~\n";
 150         ++$edicount;
 151         $out .= "N3" .
 152             "*" . $claim->billingFacilityStreet() .
 153             "~\n";
 154         ++$edicount;
 155         $out .= "N4" .
 156             "*" . $claim->billingFacilityCity() .
 157             "*" . $claim->billingFacilityState() .
 158             "*" . $claim->x12Zip($claim->billingFacilityZip()) .
 159             "~\n";
 160     if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 161         ++$edicount;
 162         $out .= "REF";
 163         if ($claim->federalIdType()) {
 164             $out .= "*" . $claim->federalIdType();
 165         } else {
 166             $out .= "*EI"; // For dealing with the situation before adding TaxId type In facility.
 167         }
 168         $out .= "*" . $claim->billingFacilityETIN() . "~\n";
 169     } else {
 170         $log .= "*** No billing facility NPI and/or ETIN.\n";
 171     }
 172     if ($claim->providerNumberType() && $claim->providerNumber() && !$claim->billingFacilityNPI()) {
 173         ++$edicount;
 174         $out .= "REF" .
 175             "*" . $claim->providerNumberType() .
 176             "*" . $claim->providerNumber() .
 177             "~\n";
 178     } else if ($claim->providerNumber() && !$claim->providerNumberType()) {
 179         $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 180     }
 181         // Situational PER*1C segment.
 182         ++$edicount;
 183         $out .= "PER" .
 184             "*" . "IC" .
 185             "*" . $claim->billingContactName() .
 186             "*" . "TE" .
 187             "*" . $claim->billingContactPhone();
 188         $out .= "~\n";
 189
 190         // This is also excluded in the 837I
 191         // Loop 2010AC Pay-To Plan Name omitted.  Includes:
 192         // NM1*PE, N3, N4, REF*2U, REF*EI
 193         $PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
 194         $HLSubscriber = $HLcount++;
 195         ++$edicount;
 196
 197         // loop 2000B
 198         $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 199             "*$HLSubscriber" .
 200             "*$HLBillingPayToProvider" .
 201             "*" . "22" .
 202             "*$PatientHL" .
 203             "~\n";
 204     if (!$claim->payerSequence()) {
 205         $log .= "*** Error: Insurance information is missing!\n";
 206     }
 207         ++$edicount;
 208
 209         //SBR01 is either a P or S    SBR02 for care is always 18 "patient"  SBR09 is always MA
 210         $out .= "SBR" .       // Subscriber Information
 211             "*" . $claim->payerSequence() .
 212             "*" . ($claim->isSelfOfInsured() ? '18' : '') .
 213             "*" . $claim->groupNumber() .
 214             "*" . (($claim->groupNumber()) ? '' : $claim->groupName()) .
 215             "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 216             "*" .
 217             "*" .
 218             "*" .
 219             "*" . $claim->claimType() . // Zirmed replaces this
 220             "~\n";
 221         // 2000C Segment PAT omitted.
 222         ++$edicount;
 223         $out .= "NM1" .       // Loop 2010BA Subscriber  same in 837I
 224             "*IL" .
 225             "*" . "1" . // 1 = person, 2 = non-person
 226             "*" . $claim->insuredLastName() .
 227             "*" . $claim->insuredFirstName() .
 228             "*" . $claim->insuredMiddleName() .
 229             "*" .
 230             "*" . // Name Suffix
 231             "*MI" .
 232             // "MI" = Member Identification Number
 233         // "II" = Standard Unique Health Identifier, "Required if the
 234         //        HIPAA Individual Patient Identifier is mandated use."
 235         //        Here we presume that is not true yet.
 236         "*" . $claim->policyNumber() .
 237         "~\n";
 238         // For 5010, further subscriber info is sent only if they are the patient.
 239     if ($claim->isSelfOfInsured()) {
 240         ++$edicount;
 241         $out .= "N3" .
 242             "*" . $claim->insuredStreet() .
 243             "~\n";
 244         ++$edicount;
 245         $out .= "N4" .
 246             "*" . $claim->insuredCity() .
 247             "*" . $claim->insuredState() .
 248             "*" . $claim->x12Zip($claim->insuredZip()) .
 249             "~\n";
 250         ++$edicount;
 251         $out .= "DMG" .
 252             "*D8" .
 253             "*" . $claim->insuredDOB() .
 254             "*" . $claim->insuredSex() .
 255             "~\n";
 256     }
 257         // Segment REF*SY (Subscriber Secondary Identification) omitted.
 258         // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 259         // Segment PER*IC (Property and Casualty Subscriber Contact Information) omitted.
 260         ++$edicount;
 261         $payerName = substr($claim->payerName(), 0, 60);
 262         $out .= "NM1" .       // Loop 2010BB Payer
 263             "*PR" .
 264             "*" . "2" .
 265             "*" . $payerName .
 266             "*" .
 267             "*" .
 268             "*" .
 269             "*" .
 270             "*" . "PI" .
 271             "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 272             "~\n";
 273     if (!$claim->payerID()) {
 274         $log .= "*** Payer ID is missing for payer '" . $claim->payerName() . "'.\n";
 275     }
 276
 277         ++$edicount;
 278         $out .= "N3" .
 279             "*" . $claim->payerStreet() .
 280             "~\n";
 281         ++$edicount;
 282         $out .= "N4" .
 283             "*" . $claim->payerCity() .
 284             "*" . $claim->payerState() .
 285             "*" . $claim->x12Zip($claim->payerZip()) .
 286             "~\n";
 287
 288         // Segment REF (Payer Secondary Identification) omitted.
 289         // Segment REF (Billing Provider Secondary Identification) omitted.
 290
 291
 292     if (! $claim->isSelfOfInsured()) {
 293         ++$edicount;
 294         $out .= "HL" .        // Loop 2000C Patient Information
 295             "*" . "$HLcount" .
 296             "*$HLSubscriber" .
 297             "*23" .
 298             "*0" .
 299             "~\n";
 300         $HLcount++;
 301         ++$edicount;
 302         $out .= "PAT" .
 303             "*" . $claim->insuredRelationship() .
 304             "~\n";
 305         ++$edicount;
 306         $out .= "NM1" .       // Loop 2010CA Patient may need this elsed in to the loop 2000C
 307             "*QC" .
 308             "*1" .
 309             "*" . $claim->patientLastName() .
 310             "*" . $claim->patientFirstName();
 311         if ($claim->patientMiddleName() !== '') {
 312             $out .= "*" . $claim->patientMiddleName();
 313         }
 314             $out .= "~\n";
 315             ++$edicount;
 316             $out .= "N3" .
 317                 "*" . $claim->patientStreet() .
 318                 "~\n";
 319             ++$edicount;
 320             $out .= "N4" .
 321                 "*" . $claim->patientCity() .
 322                 "*" . $claim->patientState() .
 323                 "*" . $claim->x12Zip($claim->patientZip()) .
 324                 "~\n";
 325             ++$edicount;
 326             $out .= "DMG" .
 327                 "*D8" .
 328                 "*" . $claim->patientDOB() .
 329                 "*" . $claim->patientSex() .
 330                 "~\n";
 331             // Segment REF*Y4 (Property and Casualty Claim Number) omitted.
 332             // Segment REF (Property and Casualty Patient Identifier) omitted.
 333             // Segment PER (Property and Casualty Patient Contact Information) omitted.
 334     } // end of patient different from insured
 335         $proccount = $claim->procCount();
 336         $clm_total_charges = 0;
 337     for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 338         $clm_total_charges += $claim->cptCharges($prockey);
 339     }
 340     if (!$clm_total_charges) {
 341         $log .= "*** This claim has no charges!\n";
 342     }
 343         ++$edicount;
 344         $out .= "CLM" .       // Loop 2300 Claim
 345             "*" . $pid . "-" . $encounter .
 346             "*"  . sprintf("%.2f", $clm_total_charges) . // Zirmed computes and replaces this
 347             "*"  .
 348             "*"  ;
 349     // Service location this need to be bill type from ub form type_of_bill
 350     if (strlen($ub04id[7]) >= 3) {
 351         $out .= "*" . substr($ub04id[7], 1, 1) . ":" . substr($ub04id[7], 2, 1) . ":" . substr($ub04id[7], 3, 1);
 352     }
 353
 354     $out .= "*" .
 355         "*" . "A" .
 356         "*" . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 357         "*" . "Y" .
 358         "~\n";
 359     // discharge hour
 360     if ($ub04id[29]) {
 361         ++ $edicount;
 362         $out .= "DTP" . // Loop 2300
 363         "*" . "096" .
 364         "*" . "TM" .
 365         "*" . $ub04id[29] .
 366         "~\n";
 367     }
 368
 369     // Statment Dates
 370     // DTP 434 RD8 (Statment from OR to date)
 371
 372     if ($ub04id[13]) {
 373         ++ $edicount;
 374
 375         $tmp = x12date($ub04id[13]);
 376         $tmp1 = x12date($ub04id[14]);
 377         $out .= "DTP" . // Loop 2300
 378         "*434" . "*" . "RD8" . "*" . $tmp . '-' . $tmp1 . "~\n";
 379     }
 380
 381     if ($ub04id[13]) {
 382         ++ $edicount;
 383         $tmp = x12date($ub04id[25]);
 384         $out .= "DTP" . // Loop 2300
 385         "*435" . "*" . "DT" . "*" . $tmp . $ub04id[26] . "~\n";
 386     }
 387
 388     if (strlen(trim($ub04id[13])) == 0) {
 389         $log .= "*** Error: No Admission Date Entered!\n";
 390     }
 391
 392     // Repricer Received Date
 393     // DTP 050 D8 (Admission Date and Hour from form)
 394
 395     // Institutional Claim Code
 396     // CL1 (Admission Type Code) (Admission Source Code) (Patient Status Code)
 397
 398     if ($ub04id[27] != "014X") { // Type of bill
 399         ++ $edicount;
 400         $out .= "CL1" . // Loop 2300
 401         "*" . $ub04id[27] . "*" . $ub04id[28] . "*" . $ub04id[30] . "~\n";
 402     }
 403
 404     // Segment PWK (Claim Supplemental Information) omitted.
 405
 406     // Segment CN1 (Contract Information) omitted.
 407
 408     // Patient Estimated Amount Due
 409     // Check logic
 410
 411     // $patientpaid = $claim->patientPaidAmount();
 412     // if ($patientpaid != 0) {
 413     // ++$edicount;
 414     // $out .= "AMT" . // Patient paid amount. Page 190/220.
 415     // "*F5" .
 416     // "*" . $patientpaid .
 417     // "~\n";
 418     // }
 419
 420     // Segment REF*4N (Service Authorization Exception Code) omitted.
 421     // Segment REF*9F (Referral Number) omitted.
 422
 423     // Prior Authorization
 424     //
 425     if ($claim->priorAuth()) {
 426         ++ $edicount;
 427         $out .= "REF" . // Prior Authorization Number
 428         "*G1" . "*" . $claim->priorAuth() . "~\n";
 429     }
 430
 431     // Segment REF*F8 (Payer Claim Control Number) omitted.
 432
 433     // This may be needed for the UB04 Claim if so change the 'MB' to 'MA'
 434     // if ($claim->cliaCode() && ($CMS_5010 || $claim->claimType() === 'MB')) {
 435     // Required by Medicare when in-house labs are done.
 436     // ++$edicount;
 437     // $out .= "REF" . // Clinical Laboratory Improvement Amendment Number
 438     // "*X4" .
 439     // "*" . $claim->cliaCode() .
 440     // "~\n";
 441     // }
 442
 443     // Segment REF*9A (Repriced Claim Number) omitted.
 444     // Segment REF*9C (Adjusted Repriced Claim Number) omitted.
 445     // Segment REF*LX (Investigational Device Exemption Number) omitted.
 446     // Segment REF*S9 (Claim Identifier for Transmission Intermediaries) omitted.
 447     // Segment REF*LU (Auto Accident State) omitted.
 448     // Segment REF*EA (Medical Record Number) omitted.
 449     // Segment REF*P4 (Demonstration Project Identifier) omitted.
 450     // Segment REF*G4 (Peer Review Organization PRO Approval Number) omitted.
 451     // Segment K3 (File Information) omitted.
 452
 453     if ($claim->additionalNotes()) {
 454         // Claim Note
 455         // Has a list of valid codes. Required when PROVIDER deems necessary
 456
 457         // Billing note.
 458         // Check to verify I am getting this information on the ub04 form
 459
 460         ++ $edicount;
 461         $out .= "NTE" . // comments box 19
 462         "*" . "ADD" . "*" . $claim->additionalNotes() . "~\n";
 463     }
 464
 465     // Segment CRC (EPSDT Referral) omitted.
 466     // Diagnoses, up to $max_per_seg per HI segment. Check this
 467     $max_per_seg = 18;
 468     $da = $claim->diagArray();
 469     $diag_type_code = 'ABK'; // ICD10
 470     $tmp = 0;
 471     foreach ($da as $diag) {
 472         if ($tmp == 1) {
 473             continue;
 474         }
 475         if ($tmp % $max_per_seg == 0) {
 476             if ($tmp) {
 477                 $out .= "~\n";
 478             }
 479             ++ $edicount;
 480             $out .= "HI"; // Health Diagnosis Codes
 481         }
 482         $out .= "*" . $diag_type_code . ":" . $diag;
 483         if ($claim->diagtype == "ICD9") {
 484             $diag_type_code = 'BF';
 485         } else {
 486             $diag_type_code = 'ABF';
 487         }
 488
 489         ++ $tmp;
 490     }
 491     if ($tmp) {
 492         $out .= "~\n";
 493     }
 494
 495     // Segment HI*BI (Occurrence Span Information).
 496     // HI BI (Occurrence Span Code 1) RD8 (Occurrence Span Code Associated Date)
 497     if ($ub04id[52]) {
 498         $max_per_seg = 4;
 499         $diag_type_code = 'BI';
 500         $tmp = 0;
 501         $os = 52;
 502         for ($i = 0; $i <= 3;) {
 503             if ($tmp % $max_per_seg == 0) {
 504                 if ($tmp) {
 505                     $out .= "~\n";
 506                 }
 507                 ++ $edicount;
 508                 $out .= "HI"; // Health Diagnosis Codes
 509             }
 510             if ($ub04id[$os]) {
 511                 $out .= "*" . $diag_type_code . ":" . $ub04id[$os ++] . ":" . x12date($ub04id[$os ++]) . ":" . x12date($ub04id[$os ++]);
 512                 $diag_type_code = 'BI';
 513             }
 514             if ($os >= 57) {
 515                 $os = 67;
 516             }
 517             ++ $tmp;
 518             ++ $i;
 519         }
 520         if ($tmp) {
 521             $out .= "~\n";
 522         }
 523     }
 524
 525     // Segment HI*BH (Occurrence Information).
 526     // HI BH (Occurrence Code 1) D8 (Occurrence Code Associated Date)
 527
 528     if ($ub04id[44]) {
 529         $max_per_seg = 8;
 530         $diag_type_code = 'BH';
 531         $tmp = 0;
 532         $os = 44;
 533         for ($i = 0; $i <= 7;) {
 534             if ($tmp % $max_per_seg == 0) {
 535                 if ($tmp) {
 536                     $out .= "~\n";
 537                 }
 538                 ++ $edicount;
 539                 $out .= "HI"; // Health Diagnosis Codes
 540             }
 541             if ($ub04id[$os]) {
 542                 $out .= "*" . $diag_type_code . ":" . $ub04id[$os] . ":D8" . ":" . x12date($ub04id[$os ++]);
 543                 $diag_type_code = 'BH';
 544             }
 545             if ($os >= 51) {
 546                 $os = 59;
 547             }
 548             ++ $tmp;
 549             ++ $i;
 550         }
 551         if ($tmp) {
 552             $out .= "~\n";
 553         }
 554     }
 555
 556     // Segment HI*BE (Value Information).
 557     // HI BE (Value Code 1) *.* (Value Code Amount)
 558
 559     if ($ub04id[74]) {
 560         $max_per_seg = 12;
 561         $diag_type_code = 'BE';
 562         $os = 74;
 563         $tmp = 0;
 564         for ($i = 0; $i <= 11;) {
 565             if ($tmp % $max_per_seg == 0) {
 566                 if ($tmp) {
 567                     $out .= "~\n";
 568                 }
 569                 ++ $edicount;
 570                 $out .= "HI"; // Health Diagnosis Codes
 571             }
 572             if ($ub04id[$os]) {
 573                 // if ($i=1) {
 574                 $out .= "*" . $diag_type_code . ":" . $ub04id[$os ++] . ":" . ":" . x12date($ub04id[$os ++]);
 575                 $diag_type_code = 'BE';
 576                 // }
 577             }
 578             ++ $tmp;
 579             ++ $i;
 580         }
 581         if ($tmp) {
 582             $out .= "~\n";
 583         }
 584     }
 585
 586     // Segment HI*BG (Condition Information).
 587     // HI BG (Condition Code 1)
 588
 589     if ($ub04id[31]) {
 590         $max_per_seg = 11;
 591         $diag_type_code = 'BG';
 592         $os = 31;
 593         $tmp = 0;
 594         for ($i = 0; $i <= 10;) {
 595             if ($tmp % $max_per_seg == 0) {
 596                 if ($tmp) {
 597                     $out .= "~\n";
 598                 }
 599                 ++ $edicount;
 600                 $out .= "HI"; // Health Diagnosis Codes
 601             }
 602             if ($ub04id[$os]) {
 603                 // if ($i=1) {
 604                 $out .= "*" . $diag_type_code . ":" . $ub04id[$os ++];
 605                 $diag_type_code = 'BG';
 606                 // }
 607             }
 608
 609             ++ $tmp;
 610             ++ $i;
 611         }
 612         if ($tmp) {
 613             $out .= "~\n";
 614         }
 615     }
 616
 617     // Segment HI*TC (Treatment Code Information).
 618     // HI TC (Treatment Code 1)
 619     /* 63a. TREATMENT AUTHORIZATION CODES - PRIMARY PLAN */
 620     if ($ub04id[319]) {
 621         $max_per_seg = 3;
 622         $diag_type_code = 'TC';
 623         $tmp = 0;
 624
 625         for ($i = 0; $i <= 2;) {
 626             if ($tmp % $max_per_seg == 0) {
 627                 if ($tmp) {
 628                     $out .= "~\n";
 629                 }
 630                 ++ $edicount;
 631                 $out .= "HI"; // Health Diagnosis Codes
 632             }
 633
 634             if ($ub04id[319]) {
 635                 $out .= "*" . $diag_type_code . ":" . $ub04id[319];
 636                 $diag_type_code = 'TC';
 637             }
 638             if ($i = 1) {
 639                 if ($ub04id[322]) {
 640                     $out .= "*" . $diag_type_code . ":" . $ub04id[322];
 641                     $diag_type_code = 'TC';
 642                 }
 643             }
 644             if ($i = 2) {
 645                 if ($ub04id[325]) {
 646                     $out .= "*" . $diag_type_code . ":" . $ub04id[325];
 647                     $diag_type_code = 'TC';
 648                 }
 649             }
 650
 651             ++ $tmp;
 652             ++ $i;
 653         }
 654         if ($tmp) {
 655             $out .= "~\n";
 656         }
 657     }
 658
 659     // Segment HCP (Claim Pricing/Repricing Information) omitted.
 660
 661     // This needs to allow Attending Physician 2310A, Operating Physician Name 2310B, Other Operating Physician Name 2310C
 662     // and Rendering Provider Name (Rendering Provider Name is futher down)
 663
 664     if ($ub04id[388]) {
 665         ++ $edicount;
 666         // Loop 2310A Attending Physician
 667         $out .= "NM1" . "*71" . "*1" . "*" . $ub04id[388] . "*" . $ub04id[389] . "*" . "*";
 668         if ($ub04id[379]) { // NPI
 669             $out .= "*" . "XX" . "*" . $ub04id[379];
 670         } else {
 671             $out .= "*" . "*";
 672             $log .= "*** Attending Physician has no NPI.\n";
 673         }
 674         $out .= "~\n";
 675
 676         if ($ub04id[380]) {
 677             ++ $edicount;
 678             $out .= "REF" . // Attending Physician Secondary Identification
 679             "*" . $ub04id[380] . "*" . $ub04id[381] . "~\n";
 680         }
 681     }
 682
 683     // 2310B
 684
 685     if ($ub04id[400]) {
 686         ++ $edicount;
 687
 688         $out .= "NM1" . // Loop 2310B operating Physician
 689         "*72" . "*1" . "*" . $ub04id[400] . "*" . $ub04id[400] . "*" . "*";
 690         if ($ub04id[390]) {
 691             $out .= "*" . "XX" . "*" . $ub04id[390];
 692         } else {
 693             $out .= "*" . "*";
 694             $log .= "*** Operating Physician has no NPI qualifier.\n";
 695         }
 696         $out .= "~\n";
 697
 698         if ($ub04id[391]) {
 699             ++ $edicount;
 700             $out .= "REF" . // operating Physician Secondary Identification
 701             "*" . $claim->$ub04id[391] . "*" . $ub04id[392] . "~\n";
 702         }
 703     }
 704
 705     // 2310C
 706
 707     if ($ub04id[413]) {
 708         ++ $edicount;
 709
 710         $out .= "NM1" . // Loop 2310C other operating Physician
 711         "*73" . "*1" . "*" . $ub04id[413] . "*" . $ub04id[414] . "*" . "*";
 712         if ($ub04id[405]) {
 713             $out .= "*" . $ub04id[405] . "*" . $ub04id[406];
 714         } else {
 715             $out .= "*" . "*";
 716             $log .= "*** Other Operating Physician has no NPI.\n";
 717         }
 718         $out .= "~\n";
 719
 720         if ($ub04id[407]) {
 721             ++ $edicount;
 722             $out .= "REF" . // other operating Physician Secondary Identification
 723             "*" . $ub04id[407] . "*" . $ub04id[408] . "~\n";
 724         }
 725     }
 726     if ($ub04id[427]) {
 727         ++ $edicount;
 728
 729         $out .= "NM1" . // Loop 2310C other operating Physician
 730         "*73" . "*1" . "*" . $ub04id[427] . "*" . $ub04id[428] . "*" . "*";
 731         if ($ub04id[420]) {
 732             $out .= "*" . $ub04id[419] . "*" . $ub04id[420];
 733         } else {
 734             $out .= "*" . "*";
 735             $log .= "*** Other Operating Physician has no NPI.\n";
 736         }
 737         $out .= "~\n";
 738
 739         if ($ub04id[422]) {
 740             ++ $edicount;
 741             $out .= "REF" . // other operating Physician Secondary Identification
 742             "*" . $ub04id[422] . "*" . $ub04id[421] . "~\n";
 743         }
 744     }
 745     /*
 746      * Per the implementation guide lines, only include this information if it is different
 747      * than the Loop 2010AA information
 748      */
 749     if ($claim->providerNPIValid() && $claim->billingFacilityNPI() !== $claim->providerNPI()) {
 750         ++ $edicount;
 751         $out .= "NM1" . // Loop 2310D Rendering Provider
 752         "*82" . "*1" . "*" . $claim->providerLastName() . "*" . $claim->providerFirstName() . "*" . $claim->providerMiddleName() . "*" . "*";
 753         if ($claim->providerNPI()) {
 754             $out .= "*XX" . "*" . $claim->providerNPI();
 755         } else {
 756             $log .= "*** Rendering provider has no NPI.\n";
 757         }
 758         $out .= "~\n";
 759
 760         // End of Loop 2310D
 761     } else {
 762         // This loop can only get skipped if we are generating a 5010 claim
 763         if (! ($claim->providerNPIValid())) {
 764             //If the loop was skipped because the provider NPI was invalid, generate a warning for the log.
 765             $log .= "*** Skipping 2310B because " . $claim->providerLastName() . "," . $claim->providerFirstName() . " has invalid NPI.\n";
 766         }
 767         /*
 768          * Skipping this segment because the providerNPI and the billingFacilityNPI are identical
 769          * is a normal condition, so no need to warn.
 770          */
 771     }
 772
 773     // 5010 spec says nothing here if NPI was specified.
 774     //
 775     if (! $claim->providerNPI() && in_array($claim->providerNumberType(), array('0B', '1G', 'G2', 'LU'))) {
 776         if ($claim->providerNumber()) {
 777             ++ $edicount;
 778             $out .= "REF" . "*" . $claim->providerNumberType() . "*" . $claim->providerNumber() . "~\n";
 779         }
 780     }
 781
 782     // Loop 2310D is omitted in the case of home visits (POS=12).
 783     if ($claim->facilityPOS() != 12 && ($claim->facilityNPI() != $claim->billingFacilityNPI())) {
 784         ++ $edicount;
 785
 786         // Service Facility Name
 787
 788         $out .= "NM1" . // Loop 2310E Service Location
 789         "*77" . "*2";
 790         $facilityName = substr($claim->facilityName(), 0, 60);
 791         if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) {
 792             $out .= "*" . $facilityName;
 793         }
 794         if ($claim->facilityNPI() || $claim->facilityETIN()) {
 795             $out .= "*" . "*" . "*" . "*";
 796             if ($claim->facilityNPI()) {
 797                 $out .= "*XX*" . $claim->facilityNPI();
 798             } else {
 799                 $log .= "*** Service location has no NPI.\n";
 800             }
 801         }
 802         $out .= "~\n";
 803         if ($claim->facilityStreet()) {
 804             ++ $edicount;
 805             $out .= "N3" . "*" . $claim->facilityStreet() . "~\n";
 806         }
 807         if ($claim->facilityState()) {
 808             ++ $edicount;
 809             $out .= "N4" . "*" . $claim->facilityCity() . "*" . $claim->facilityState() . "*" . $claim->x12Zip($claim->facilityZip()) . "~\n";
 810         }
 811     }
 812
 813     // Segment REF (Service Facility Location Secondary Identification) omitted.
 814     // Segment PER (Service Facility Contact Information) omitted.
 815
 816     // Loop 2310F Referring Provider
 817
 818     if ($claim->referrerLastName()) {
 819         // Medicare requires referring provider's name and UPIN.
 820         ++ $edicount;
 821
 822         $out .= "NM1" . // Loop 2310F Referring Provider this needs to change position
 823         "*DN" . "*1" . "*" . $claim->referrerLastName() . "*" . $claim->referrerFirstName() . "*" . $claim->referrerMiddleName() . "*" . "*";
 824         if ($claim->referrerNPI()) {
 825             $out .= "*XX" . "*" . $claim->referrerNPI();
 826         } else {
 827             $log .= "*** Referrer has no NPI.\n";
 828         }
 829         $out .= "~\n";
 830     }
 831
 832     // Loop 2310E, Supervising Provider
 833     // Omitted
 834
 835     // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
 836     // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
 837
 838     $prev_pt_resp = $clm_total_charges; // for computation below
 839
 840     // Loops 2320 and 2330*, other subscriber/payer information.
 841     // Remember that insurance index 0 is always for the payer being billed
 842     // by this claim, and 1 and above are always for the "other" payers.
 843     //
 844     for ($ins = 1; $ins < $claim->payerCount(); ++ $ins) {
 845         $tmp1 = $claim->claimType($ins);
 846         $tmp2 = 'C1'; // Here a kludge. See page 321.
 847         if ($tmp1 === 'CI') {
 848             $tmp2 = 'C1';
 849         }
 850         if ($tmp1 === 'AM') {
 851             $tmp2 = 'AP';
 852         }
 853         if ($tmp1 === 'HM') {
 854             $tmp2 = 'HM';
 855         }
 856         if ($tmp1 === 'MB') {
 857             $tmp2 = 'MB';
 858         }
 859         if ($tmp1 === 'MA') {
 860             $tmp2 = 'MA';
 861         }
 862         if ($tmp1 === 'MC') {
 863             $tmp2 = 'MC';
 864         }
 865         if ($tmp1 === '09') {
 866             $tmp2 = 'PP';
 867         }
 868         ++ $edicount;
 869
 870         $out .= "SBR" . // Loop 2320, Subscriber Information - page 297/318
 871         "*" . $claim->payerSequence($ins) .
 872         "*" . $claim->insuredRelationship($ins) .
 873         "*" . $claim->groupNumber($ins) .
 874         "*" . (($claim->groupNumber($ins)) ? '' : $claim->groupName($ins)) .
 875         "*" . ($claim->insuredTypeCode($ins) ? $claim->insuredTypeCode($ins) : $tmp2) .
 876         "*" .
 877         "*" .
 878         "*" .
 879         "*" . $claim->claimType($ins) .
 880         "~\n";
 881
 882         // Things that apply only to previous payers, not future payers.
 883         //
 884         if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 885             // Generate claim-level adjustments.
 886             $aarr = $claim->payerAdjustments($ins);
 887             foreach ($aarr as $a) {
 888                 ++ $edicount;
 889                 $out .= "CAS" . // Previous payer's claim-level adjustments. Page 301/323.
 890                 "*" . $a[1] . "*" . $a[2] . "*" . $a[3] . "~\n";
 891             }
 892
 893             $payerpaid = $claim->payerTotals($ins);
 894             ++ $edicount;
 895             $out .= "AMT" . // Previous payer's paid amount. Page 307/332.
 896             "*D" . "*" . $payerpaid[1] . "~\n";
 897
 898             // Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
 899             // Segment AMT*EAF (Remaining Patient Liability) omitted.
 900         } // End of things that apply only to previous payers.
 901
 902         ++ $edicount;
 903         $out .= "OI" . // Other Insurance Coverage Information. Page 310/344.
 904         "*" . "*" . "*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
 905         // For this next item, the 5010 example in the spec does not match its
 906         // description. So this might be wrong.
 907         "*" .
 908         "*" .
 909         "*" .
 910         "Y" .
 911         "~\n";
 912
 913         // Segment MOA (Medicare Outpatient Adjudication) omitted.
 914         ++$edicount;
 915         $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
 916             "*" . "IL" .
 917             "*" . "1" .
 918             "*" . $claim->insuredLastName($ins) .
 919             "*" . $claim->insuredFirstName($ins) .
 920             "*" . $claim->insuredMiddleName($ins) .
 921             "*" .
 922             "*" .
 923             "*" . "MI" .
 924             "*" . $claim->policyNumber($ins) .
 925             "~\n";
 926
 927         ++$edicount;
 928         $out .= "N3" .
 929             "*" . $claim->insuredStreet($ins) .
 930             "~\n";
 931
 932         ++$edicount;
 933         $out .= "N4" .
 934             "*" . $claim->insuredCity($ins) .
 935             "*" . $claim->insuredState($ins) .
 936             "*" . $claim->x12Zip($claim->insuredZip($ins)) .
 937             "~\n";
 938
 939         // Segment REF (Other Subscriber Secondary Identification) omitted.
 940         ++$edicount;
 941         $payerName = substr($claim->payerName($ins), 0, 60);
 942         $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 322/359.
 943             "*" . "PR" .
 944             "*" . "2" .
 945             "*" . $payerName .
 946             "*" .
 947             "*" .
 948             "*" .
 949             "*" .
 950             "*" . "PI" .
 951             "*" . $claim->payerID($ins) .
 952             "~\n";
 953
 954         if (!$claim->payerID($ins)) {
 955             $log .= "*** Payer ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 956         }
 957
 958         ++$edicount;
 959         $out .= "N3" .
 960             "*" . $claim->payerStreet($ins) .
 961             "~\n";
 962
 963         ++$edicount;
 964         $out .= "N4" .
 965             "*" . $claim->payerCity($ins) .
 966             "*" . $claim->payerState($ins) .
 967             "*" . $claim->x12Zip($claim->payerZip($ins)) .
 968             "~\n";
 969
 970         // Segment DTP*573 (Claim Check or Remittance Date) omitted.
 971         // Segment REF (Other Payer Secondary Identifier) omitted.
 972         // Segment REF*G1 (Other Payer Prior Authorization Number) omitted.
 973         // Segment REF*9F (Other Payer Referral Number) omitted.
 974         // Segment REF*T4 (Other Payer Claim Adjustment Indicator) omitted.
 975         // Segment REF*F8 (Other Payer Claim Control Number) omitted.
 976         // 2330C-I loops Omitted
 977     } // End loops 2320/2330*.
 978
 979     $loopcount = 0;
 980
 981     // Procedure loop starts here.
 982     //
 983
 984     for ($tlh = 0; $tlh < $proccount; ++ $tlh) {
 985         $tmp = $claim->procs[$tlh][code_text];
 986
 987         if ($claim->procs[$tlh][code_type] == 'HCPCS') {
 988             $tmpcode = '3';
 989         } else {
 990             $tmpcode = '1';
 991         }
 992         $getrevcd = $claim->cptCode($tlh);
 993         $sql = "SELECT * FROM codes WHERE code_type = ? and code = ? ORDER BY revenue_code DESC";
 994         $revcode[$tlh] = sqlQuery($sql, array(
 995             $tmpcode,
 996             $getrevcd
 997         ));
 998     }
 999
1000
1001     for ($prockey = 0; $prockey < $proccount; ++ $prockey) {
1002         $os = 99 + ($loopcount * 8); // Form revenue code offset
1003         $dosos = 102 + ($loopcount * 8); // Procedure date of service form start offset-add 8 for loop
1004         ++ $loopcount;
1005
1006         ++ $edicount;
1007         $out .= "LX" . // Loop 2400 LX Service Line. Page 398.
1008         "*" . "$loopcount" . "~\n";
1009
1010         ++ $edicount;
1011
1012         // Revenue code from form
1013         //
1014         $tmp = $ub04id[$os]; //$revcode[$prockey][revenue_code];
1015         if (empty($tmp)) {
1016             $log .= "*** Error: Missing Revenue Code for " . $claim->cptKey($prockey) . "!\n";
1017         }
1018         // Institutional Service Line.
1019         //
1020         $out .= "SV2" .  "*" . $tmp . // revenue code
1021
1022         "*" . "HC:" . $claim->cptKey($prockey) . "*" . sprintf('%.2f', $claim->cptCharges($prockey)) . "*UN" . "*" . $claim->cptUnits($prockey) . "*" . "*" . "*";
1023
1024         $out .= "~\n";
1025
1026         if (! $claim->cptCharges($prockey)) {
1027             $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
1028         }
1029
1030         // Segment SV5 (Durable Medical Equipment Service) omitted.
1031         // Segment PWK (Line Supplemental Information) omitted.
1032         // Segment PWK (Durable Medical Equipment Certificate of Medical Necessity Indicator) omitted.
1033         // Segment CR1 (Ambulance Transport Information) omitted.
1034         // Segment CR3 (Durable Medical Equipment Certification) omitted.
1035         // Segment CRC (Ambulance Certification) omitted.
1036         // Segment CRC (Hospice Employee Indicator) omitted.
1037         // Segment CRC (Condition Indicator / Durable Medical Equipment) omitted.
1038
1039         ++ $edicount;
1040
1041         $out .= "DTP" . // Date of Service. Needs to be when service preformed.
1042             "*" . "472" . "*" . "D8" . "*" . $ub04id[$dosos] . "~\n"; //$claim->serviceDate()
1043
1044         $testnote = rtrim($claim->cptNotecodes($prockey));
1045         if (! empty($testnote)) {
1046             ++ $edicount;
1047             $out .= "NTE" . // Explain Unusual Circumstances.
1048             "*ADD" . "*" . $claim->cptNotecodes($prockey) . "~\n";
1049         }
1050
1051         // Segment DTP*471 (Prescription Date) omitted.
1052         // Segment DTP*607 (Revision/Recertification Date) omitted.
1053         // Segment DTP*463 (Begin Therapy Date) omitted.
1054         // Segment DTP*461 (Last Certification Date) omitted.
1055         // Segment DTP*304 (Last Seen Date) omitted.
1056         // Segment DTP (Test Date) omitted.
1057         // Segment DTP*011 (Shipped Date) omitted.
1058         // Segment DTP*455 (Last X-Ray Date) omitted.
1059         // Segment DTP*454 (Initial Treatment Date) omitted.
1060         // Segment QTY (Ambulance Patient Count) omitted.
1061         // Segment QTY (Obstetric Anesthesia Additional Units) omitted.
1062         // Segment MEA (Test Result) omitted.
1063         // Segment CN1 (Contract Information) omitted.
1064         // Segment REF*9B (Repriced Line Item Reference Number) omitted.
1065         // Segment REF*9D (Adjusted Repriced Line Item Reference Number) omitted.
1066         // Segment REF*G1 (Prior Authorization) omitted.
1067         // Segment REF*6R (Line Item Control Number) omitted.
1068         // (Really oughta have this for robust 835 posting!)
1069         // Segment REF*EW (Mammography Certification Number) omitted.
1070         // Segment REF*X4 (CLIA Number) omitted.
1071         // Segment REF*F4 (Referring CLIA Facility Identification) omitted.
1072         // Segment REF*BT (Immunization Batch Number) omitted.
1073         // Segment REF*9F (Referral Number) omitted.
1074         // Segment AMT*GT (Sales Tax Amount) omitted.
1075         // Segment AMT*F4 (Postage Claimed Amount) omitted.
1076         // Segment K3 (File Information) omitted.
1077         // Segment NTE (Line Note) omitted.
1078         // Segment NTE (Third Party Organization Notes) omitted.
1079         // Segment PS1 (Purchased Service Information) omitted.
1080         // Segment HCP (Line Pricing/Repricing Information) omitted.
1081
1082         // Loop 2410, Drug Information. Medicaid insurers seem to want this
1083         // with HCPCS codes.
1084         //
1085         $ndc = $claim->cptNDCID($prockey);
1086
1087         if ($ndc) {
1088             ++$edicount;
1089             $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
1090                 "*" .         // Per addendum, LIN01 is not used.
1091                 "*" . "N4" .
1092                 "*" . $ndc .
1093                 "~\n";
1094
1095             if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp) && !preg_match('/^\d{11}$/', $ndc)) {
1096                 $log .= "*** NDC code '$ndc' has invalid format!\n";
1097             }
1098
1099             ++$edicount;
1100             $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
1101                 "*" .
1102                 "*" .
1103                 "*" .
1104                 "*" . $claim->cptNDCQuantity($prockey) .
1105                 "*" . $claim->cptNDCUOM($prockey) .
1106                 // Note: 5010 documents "ME" (Milligrams) as an additional unit of measure.
1107             "~\n";
1108         }
1109
1110         // Segment REF (Prescription or Compound Drug Association Number) omitted.
1111
1112         // Loop 2420A, Rendering Provider (service-specific). (Operating Physician Name for 837I)
1113         // Used if the rendering provider for this service line is different
1114         // from that in loop 2310B.
1115         //
1116         if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
1117             ++$edicount;
1118             $out .= "NM1" .       // Loop 2310B Rendering Provider
1119                 "*" . "82" .
1120                 "*" . "1" .
1121                 "*" . $claim->providerLastName($prockey) .
1122                 "*" . $claim->providerFirstName($prockey) .
1123                 "*" . $claim->providerMiddleName($prockey) .
1124                 "*" .
1125                 "*";
1126             if ($claim->providerNPI($prockey)) {
1127                 $out .=
1128                 "*" . "XX" .
1129                 "*" . $claim->providerNPI($prockey);
1130             } else {
1131                 $log .= "*** Rendering provider has no NPI.\n";
1132             }
1133             $out .= "~\n";
1134
1135             if ($claim->providerTaxonomy($prockey)) {
1136                 ++$edicount;
1137                 $out .= "PRV" .
1138                     "*" . "PE" . // PErforming provider
1139                     "*" . "PXC" .
1140                     "*" . $claim->providerTaxonomy($prockey) .
1141                     "~\n";
1142             }
1143
1144             // Segment PRV*PE (Rendering Provider Specialty Information) omitted.
1145             // Segment REF (Rendering Provider Secondary Identification) omitted.
1146             // Segment NM1 (Purchased Service Provider Name) omitted.
1147             // Segment REF (Purchased Service Provider Secondary Identification) omitted.
1148             // Segment NM1,N3,N4 (Service Facility Location) omitted.
1149             // Segment REF (Service Facility Location Secondary Identification) omitted.
1150             // Segment NM1 (Supervising Provider Name) omitted.
1151             // Segment REF (Supervising Provider Secondary Identification) omitted.
1152             // Segment NM1,N3,N4 (Ordering Provider) omitted.
1153             // Segment REF (Ordering Provider Secondary Identification) omitted.
1154             // Segment PER (Ordering Provider Contact Information) omitted.
1155             // Segment NM1 (Referring Provider Name) omitted.
1156             // Segment REF (Referring Provider Secondary Identification) omitted.
1157             // Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
1158             // Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
1159
1160             // REF*1C is required here for the Medicare provider number if NPI was
1161             // specified in NM109. Not sure if other payers require anything here.
1162             if ($claim->providerNumberType($prockey) == "G2") {
1163                 ++$edicount; $out .= "REF" . "*" . $claim->providerNumberType($prockey) .
1164                 "*" . $claim->providerNumber($prockey) . "~\n";
1165             }
1166         } // provider exception
1167
1168         // Loop 2430, adjudication by previous payers.
1169         //
1170         for ($ins = 1; $ins < $claim->payerCount(); ++ $ins) {
1171             if ($claim->payerSequence($ins) > $claim->payerSequence()) {
1172                 continue; // payer is future, not previous
1173             }
1174
1175             $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
1176             $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
1177
1178             if ($payerpaid[1] == 0 && ! count($aarr)) {
1179                 $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no payments or adjustments from previous payer!\n";
1180                 continue;
1181             }
1182
1183             ++ $edicount;
1184             $out .= "SVD" . // Service line adjudication. Page 554.
1185             "*" . $claim->payerID($ins) . "*" . $payerpaid[1] . "*HC:" . $claim->cptKey($prockey) . "*" . "*" . $claim->cptUnits($prockey) . "~\n";
1186
1187             $tmpdate = $payerpaid[0];
1188             foreach ($aarr as $a) {
1189                 ++ $edicount;
1190                 $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
1191                 "*" . $a[1] . "*" . $a[2] . "*" . $a[3] . "~\n";
1192                 if (! $tmpdate) {
1193                     $tmpdate = $a[0];
1194                 }
1195             }
1196
1197             if ($tmpdate) {
1198                 ++ $edicount;
1199                 $out .= "DTP" . // Previous payer's line adjustment date. Page 493/566.
1200                 "*573" . "*D8" . "*$tmpdate" . "~\n";
1201             }
1202
1203             // Segment AMT*EAF (Remaining Patient Liability) omitted.
1204             // Segment LQ (Form Identification Code) omitted.
1205             // Segment FRM (Supporting Documentation) omitted.
1206         } // end loop 2430
1207     } // end this procedure
1208
1209     ++ $edicount;
1210     $out .= "SE" . // SE Trailer
1211     "*$edicount" . "*0021" . "~\n";
1212
1213     $out .= "GE" . // GE Trailer
1214     "*1" . "*1" . "~\n";
1215
1216     $out .= "IEA" . // IEA Trailer
1217     "*1" . "*000000001" . "~\n";
1218
1219     // Remove any trailing empty fields (delimiters) from each segment.
1220     $out = preg_replace('/\*+~/', '~', $out);
1221
1222     $log .= "\n";
1223     return $out;
1224 }