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     "*" . $claim->billingFacilityZip() .
 149     "~\n";
 150
 151   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 152   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 153     ++$edicount;
 154     $out .= "REF" .
 155       "*EI" .
 156       "*" . $claim->billingFacilityETIN() .
 157       "~\n";
 158   }
 159
 160   ++$edicount;
 161   $out .= "REF" .
 162     "*" . $claim->providerNumberType() .
 163     "*" . $claim->providerNumber() .
 164     "~\n";
 165
 166   ++$edicount;
 167   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 168     "*87" .
 169     "*2" .
 170     "*" . $claim->billingFacilityName() .
 171     "*" .
 172     "*" .
 173     "*" .
 174     "*";
 175   if ($claim->billingFacilityNPI())
 176     $out .= "*XX*" . $claim->billingFacilityNPI();
 177   else
 178     $out .= "*24*" . $claim->billingFacilityETIN();
 179   $out .= "~\n";
 180
 181   ++$edicount;
 182   $out .= "N3" .
 183     "*" . $claim->billingFacilityStreet() .
 184     "~\n";
 185
 186   ++$edicount;
 187   $out .= "N4" .
 188     "*" . $claim->billingFacilityCity() .
 189     "*" . $claim->billingFacilityState() .
 190     "*" . $claim->billingFacilityZip() .
 191     "~\n";
 192
 193   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 194     ++$edicount;
 195     $out .= "REF" .
 196       "*EI" .
 197       "*" . $claim->billingFacilityETIN() .
 198       "~\n";
 199   }
 200
 201   $PatientHL = 0;
 202
 203   ++$edicount;
 204   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 205     "*$HLcount" .
 206     "*$HLBillingPayToProvider" .
 207     "*22" .
 208     "*$PatientHL" .
 209     "~\n";
 210
 211   $HLSubscriber = $HLcount++;
 212
 213   ++$edicount;
 214   $out .= "SBR" .       // Subscriber Information
 215     "*" . $claim->payerSequence() .
 216     "*" . $claim->insuredRelationship() .
 217     "*" . $claim->groupNumber() .
 218     "*" . $claim->groupName() .
 219     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 220     "*" .
 221     "*" .
 222     "*" .
 223     "*" . $claim->claimType() . // Zirmed replaces this
 224     "~\n";
 225
 226   ++$edicount;
 227   $out .= "NM1" .       // Loop 2010BA Subscriber
 228     "*IL" .
 229     "*1" .
 230     "*" . $claim->insuredLastName() .
 231     "*" . $claim->insuredFirstName() .
 232     "*" . $claim->insuredMiddleName() .
 233     "*" .
 234     "*" .
 235     "*MI" .
 236     "*" . $claim->policyNumber() .
 237     "~\n";
 238
 239   ++$edicount;
 240   $out .= "N3" .
 241     "*" . $claim->insuredStreet() .
 242     "~\n";
 243
 244   ++$edicount;
 245   $out .= "N4" .
 246     "*" . $claim->insuredCity() .
 247     "*" . $claim->insuredState() .
 248     "*" . $claim->insuredZip() .
 249     "~\n";
 250
 251   ++$edicount;
 252   $out .= "DMG" .
 253     "*D8" .
 254     "*" . $claim->insuredDOB() .
 255     "*" . $claim->insuredSex() .
 256     "~\n";
 257
 258   ++$edicount;
 259   $out .= "NM1" .       // Loop 2010BB Payer
 260     "*PR" .
 261     "*2" .
 262     "*" . $claim->payerName() .
 263     "*" .
 264     "*" .
 265     "*" .
 266     "*" .
 267     "*PI" .
 268     "*" . $claim->payerID() . // Zirmed ignores this if using Payer Name Matching.
 269     "~\n";
 270
 271   // if (!$claim->payerID()) {
 272   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 273   // }
 274
 275   ++$edicount;
 276   $out .= "N3" .
 277     "*" . $claim->payerStreet() .
 278     "~\n";
 279
 280   ++$edicount;
 281   $out .= "N4" .
 282     "*" . $claim->payerCity() .
 283     "*" . $claim->payerState() .
 284     "*" . $claim->payerZip() .
 285     "~\n";
 286
 287   if (! $claim->isSelfOfInsured()) {
 288     ++$edicount;
 289     $out .= "HL" .        // Loop 2000C Patient Information
 290       "*$HLcount" .
 291       "*$HLSubscriber" .
 292       "*23" .
 293       "*0" .
 294       "~\n";
 295
 296     $HLcount++;
 297
 298     ++$edicount;
 299     $out .= "PAT" .
 300       "*" . $claim->insuredRelationship() .
 301       "~\n";
 302
 303     ++$edicount;
 304     $out .= "NM1" .       // Loop 2010CA Patient
 305       "*QC" .
 306       "*1" .
 307       "*" . $claim->patientLastName() .
 308       "*" . $claim->patientFirstName() .
 309       "*" . $claim->patientMiddleName() .
 310       "~\n";
 311
 312     ++$edicount;
 313     $out .= "N3" .
 314       "*" . $claim->patientStreet() .
 315       "~\n";
 316
 317     ++$edicount;
 318     $out .= "N4" .
 319       "*" . $claim->patientCity() .
 320       "*" . $claim->patientState() .
 321       "*" . $claim->patientZip() .
 322       "~\n";
 323
 324     ++$edicount;
 325     $out .= "DMG" .
 326       "*D8" .
 327       "*" . $claim->patientDOB() .
 328       "*" . $claim->patientSex() .
 329       "~\n";
 330   } // end of patient different from insured
 331
 332   $proccount = $claim->procCount();
 333
 334   $clm_total_charges = 0;
 335   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 336     $clm_total_charges += $claim->cptCharges($prockey);
 337   }
 338
 339   if (!$clm_total_charges) {
 340     $log .= "*** This claim has no charges!\n";
 341   }
 342
 343   ++$edicount;
 344   $out .= "CLM" .       // Loop 2300 Claim
 345     "*$pid-$encounter" .
 346     "*" . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 347     "*" .
 348     "*" .
 349     "*" . $claim->facilityPOS() . "::1" .
 350     "*Y" .
 351     "*A" .
 352     "*Y" .
 353     "*Y" .
 354     "*C" .
 355     "~\n";
 356
 357   ++$edicount;
 358   $out .= "DTP" .       // Date of Onset
 359     "*431" .
 360     "*D8" .
 361     "*" . $claim->onsetDate() .
 362     "~\n";
 363
 364   if (strcmp($claim->facilityPOS(),'21') == 0) {
 365     ++$edicount;
 366     $out .= "DTP" .     // Date of Hospitalization
 367       "*435" .
 368       "*D8" .
 369       "*" . $claim->onsetDate() .
 370       "~\n";
 371   }
 372
 373   $patientpaid = $claim->patientPaidAmount();
 374   if ($patientpaid != 0) {
 375     ++$edicount;
 376     $out .= "AMT" .     // Patient paid amount. Page 220.
 377       "*F5" .
 378       "*" . $patientpaid .
 379       "~\n";
 380   }
 381
 382   if ($claim->priorAuth()) {
 383     ++$edicount;
 384     $out .= "REF" .     // Prior Authorization Number
 385       "*G1" .
 386       "*" . $claim->priorAuth() .
 387       "~\n";
 388   }
 389
 390   if ($claim->cliaCode()) {
 391     // Required by Medicare when in-house labs are done.
 392     ++$edicount;
 393     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 394       "*X4" .
 395       "*" . $claim->cliaCode() .
 396       "~\n";
 397   }
 398
 399   $da = $claim->diagArray();
 400   ++$edicount;
 401   $out .= "HI";         // Health Diagnosis Codes
 402   $diag_type_code = 'BK';
 403   foreach ($da as $diag) {
 404     $out .= "*$diag_type_code:" . $diag;
 405     $diag_type_code = 'BF';
 406   }
 407   $out .= "~\n";
 408
 409   if ($claim->referrerLastName()) {
 410     // Medicare requires referring provider's name and UPIN.
 411     ++$edicount;
 412     $out .= "NM1" .     // Loop 2310A Referring Provider
 413       "*DN" .
 414       "*1" .
 415       "*" . $claim->referrerLastName() .
 416       "*" . $claim->referrerFirstName() .
 417       "*" . $claim->referrerMiddleName() .
 418       "*" .
 419       "*";
 420     if ($claim->referrerNPI()) { $out .=
 421       "*XX" .
 422       "*" . $claim->referrerNPI();
 423     } else { $out .=
 424       "*34" .
 425       "*" . $claim->referrerSSN();
 426     }
 427     $out .= "~\n";
 428
 429     ++$edicount;
 430     $out .= "REF" .     // Referring Provider Secondary Identification
 431       "*1G" .
 432       "*" . $claim->referrerUPIN() .
 433       "~\n";
 434   }
 435
 436   ++$edicount;
 437   $out .= "NM1" .       // Loop 2310B Rendering Provider
 438     "*82" .
 439     "*1" .
 440     "*" . $claim->providerLastName() .
 441     "*" . $claim->providerFirstName() .
 442     "*" . $claim->providerMiddleName() .
 443     "*" .
 444     "*";
 445   if ($claim->providerNPI()) { $out .=
 446     "*XX" .
 447     "*" . $claim->providerNPI();
 448   } else { $out .=
 449     "*34" .
 450     "*" . $claim->providerSSN();
 451     $log .= "*** Rendering provider has no NPI.\n";
 452   }
 453   $out .= "~\n";
 454
 455   ++$edicount;
 456   $out .= "PRV" .       // Rendering Provider Information
 457     "*PE" .
 458     "*ZZ" .
 459     "*207Q00000X" .
 460     "~\n";
 461
 462   // REF*1C is required here for the Medicare provider number if NPI was
 463   // specified in NM109.  Not sure if other payers require anything here.
 464   if ($claim->providerNumber()) {
 465     ++$edicount;
 466     $out .= "REF" .
 467       "*" . $claim->providerNumberType() .
 468       "*" . $claim->providerNumber() .
 469       "~\n";
 470   }
 471
 472   ++$edicount;
 473   $out .= "NM1" .       // Loop 2310D Service Location
 474     "*77" .
 475     "*2" .
 476     "*" . $claim->facilityName() .
 477     "*" .
 478     "*" .
 479     "*" .
 480     "*";
 481   if ($claim->facilityNPI()) { $out .=
 482     "*XX*" . $claim->facilityNPI();
 483   } else { $out .=
 484     "*24*" . $claim->facilityETIN();
 485     $log .= "*** Service location has no NPI.\n";
 486   }
 487   $out .= "~\n";
 488
 489   ++$edicount;
 490   $out .= "N3" .
 491     "*" . $claim->facilityStreet() .
 492     "~\n";
 493
 494   ++$edicount;
 495   $out .= "N4" .
 496     "*" . $claim->facilityCity() .
 497     "*" . $claim->facilityState() .
 498     "*" . $claim->facilityZip() .
 499     "~\n";
 500
 501   $prev_pt_resp = $clm_total_charges; // for computation below
 502
 503   // Loops 2320 and 2330*, other subscriber/payer information.
 504   //
 505   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 506
 507     ++$edicount;
 508     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 509       "*" . $claim->payerSequence($ins) .
 510       "*" . $claim->insuredRelationship($ins) .
 511       "*" . $claim->groupNumber($ins) .
 512       "*" . $claim->groupName($ins) .
 513       "*" .
 514       "*" .
 515       "*" .
 516       "*" .
 517       "*" . $claim->claimType($ins) .
 518       "~\n";
 519
 520     // Things that apply only to previous payers, not future payers.
 521     //
 522     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 523
 524       // Generate claim-level adjustments.
 525       $aarr = $claim->payerAdjustments($ins);
 526       foreach ($aarr as $a) {
 527         ++$edicount;
 528         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 529           "*" . $a[1] .
 530           "*" . $a[2] .
 531           "*" . $a[3] .
 532           "~\n";
 533       }
 534
 535       $payerpaid = $claim->payerTotals($ins);
 536       ++$edicount;
 537       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 538         "*D" .
 539         "*" . $payerpaid[1] .
 540         "~\n";
 541
 542       // Patient responsibility amount as of this previous payer.
 543       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 544       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 545
 546       ++$edicount;
 547       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 548         "*F2" .
 549         "*" . sprintf('%.2f', $prev_pt_resp) .
 550         "~\n";
 551
 552     } // End of things that apply only to previous payers.
 553
 554     ++$edicount;
 555     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 556       "*D8" .
 557       "*" . $claim->insuredDOB($ins) .
 558       "*" . $claim->insuredSex($ins) .
 559       "~\n";
 560
 561     ++$edicount;
 562     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 563       "*" .
 564       "*" .
 565       "*Y" .
 566       "*B" .
 567       "*" .
 568       "*Y" .
 569       "~\n";
 570
 571     ++$edicount;
 572     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 573       "*IL" .
 574       "*1" .
 575       "*" . $claim->insuredLastName($ins) .
 576       "*" . $claim->insuredFirstName($ins) .
 577       "*" . $claim->insuredMiddleName($ins) .
 578       "*" .
 579       "*" .
 580       "*MI" .
 581       "*" . $claim->policyNumber($ins) .
 582       "~\n";
 583
 584     ++$edicount;
 585     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 586       "*PR" .
 587       "*2" .
 588       "*" . $claim->payerName($ins) .
 589       "*" .
 590       "*" .
 591       "*" .
 592       "*" .
 593       "*PI" .
 594       "*" . $claim->payerID($ins) .
 595       "~\n";
 596
 597     // if (!$claim->payerID($ins)) {
 598     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 599     // }
 600
 601   } // End loops 2320/2330*.
 602
 603   $loopcount = 0;
 604
 605   // Procedure loop starts here.
 606   //
 607   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 608     ++$loopcount;
 609
 610     ++$edicount;
 611     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 612       "*$loopcount" .
 613       "~\n";
 614
 615     ++$edicount;
 616     $out .= "SV1" .     // Professional Service. Page 400.
 617       "*HC:" . $claim->cptKey($prockey) .
 618       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 619       "*UN" .
 620       "*" . $claim->cptUnits($prockey) .
 621       "*" .
 622       "*" .
 623       "*" . $claim->diagIndex($prockey) .
 624       "~\n";
 625
 626     if (!$claim->cptCharges($prockey)) {
 627       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 628     }
 629
 630     if (!$claim->diagIndex($prockey)) {
 631       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 632     }
 633
 634     ++$edicount;
 635     $out .= "DTP" .     // Date of Service. Page 435.
 636       "*472" .
 637       "*D8" .
 638       "*" . $claim->serviceDate() .
 639       "~\n";
 640
 641     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 642     // with HCPCS codes.
 643     //
 644     $ndc = $claim->cptNDCID($prockey);
 645     if ($ndc) {
 646       ++$edicount;
 647       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 648         "*4" .
 649         "*N4" .
 650         "*" . $ndc .
 651         "~\n";
 652
 653       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 654         $log .= "*** NDC code '$ndc' has invalid format!\n";
 655       }
 656
 657       ++$edicount;
 658       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 659       if (!$tmpunits) $tmpunits = 1;
 660       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 661         "*" .
 662         "*" .
 663         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 664         "*" . $claim->cptNDCQuantity($prockey) .
 665         "*" . $claim->cptNDCUOM($prockey) .
 666         "~\n";
 667     }
 668
 669     // Loop 2430, adjudication by previous payers.
 670     //
 671     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 672       if ($claim->payerSequence($ins) > $claim->payerSequence())
 673         continue; // payer is future, not previous
 674
 675       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 676       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 677
 678       if ($payerpaid[1] == 0 && !count($aarr)) {
 679         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 680           "' has no payments or adjustments from previous payer!\n";
 681         continue;
 682       }
 683
 684       ++$edicount;
 685       $out .= "SVD" . // Service line adjudication. Page 554.
 686         "*" . $claim->payerID($ins) .
 687         "*" . $payerpaid[1] .
 688         "*HC:" . $claim->cptKey($prockey) .
 689         "*" .
 690         "*" . $claim->cptUnits($prockey) .
 691         "~\n";
 692
 693       $tmpdate = $payerpaid[0];
 694       foreach ($aarr as $a) {
 695         ++$edicount;
 696         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 697           "*" . $a[1] .
 698           "*" . $a[2] .
 699           "*" . $a[3] .
 700           "~\n";
 701         if (!$tmpdate) $tmpdate = $a[0];
 702       }
 703
 704       if ($tmpdate) {
 705         ++$edicount;
 706         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 707           "*573" .
 708           "*D8" .
 709           "*$tmpdate" .
 710           "~\n";
 711       }
 712     } // end loop 2430
 713   } // end this procedure
 714
 715   ++$edicount;
 716   $out .= "SE" .        // SE Trailer
 717     "*$edicount" .
 718     "*0021" .
 719     "~\n";
 720
 721   $out .= "GE" .        // GE Trailer
 722     "*1" .
 723     "*1" .
 724     "~\n";
 725
 726   $out .= "IEA" .       // IEA Trailer
 727     "*1" .
 728     "*000000001" .
 729     "~\n";
 730
 731   $log .= "\n";
 732   return $out;
 733 }
 734 ?>