library/gen_x12_837.inc.php

   1 <?php
   2 // Copyright (C) 2007-2009 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, $encounter_claim=false) {
  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     "*" . $claim->x12gsisa05() .
  30     "*" . $claim->x12gssenderid() .
  31     "*" . $claim->x12gsisa07() .
  32     "*" . $claim->x12gsreceiverid() .
  33     "*030911" .
  34     "*1630" .
  35     "*U" .
  36     "*00401" .
  37     "*000000001" .
  38     "*" . $claim->x12gsisa14() .
  39     "*" . $claim->x12gsisa15() .
  40     "*:" .
  41     "~\n";
  42
  43   $out .= "GS" .
  44     "*HC" .
  45     "*" . $claim->x12gsgs02() .
  46     "*" . trim($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', $today) .
  66     "*1023" .
  67     ($encounter_claim ? "*RP" : "*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     "*" . $claim->billingFacilityName() .
  81     "*" .
  82     "*" .
  83     "*" .
  84     "*" .
  85     "*46";
  86    if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
  87     $out  .=  "*" . $claim->clearingHouseETIN();
  88    } else {
  89     $out  .=  "*" . $claim->billingFacilityETIN();
  90    }
  91     $out .= "~\n";
  92
  93   ++$edicount;
  94   $out .= "PER" .
  95     "*IC" .
  96     "*" . $claim->billingContactName() .
  97     "*TE" .
  98     "*" . $claim->billingContactPhone();
  99   if ($claim->x12gsper06()) {
 100     $out .= "*ED*" . $claim->x12gsper06();
 101   }
 102   $out .= "~\n";
 103
 104   ++$edicount;
 105   $out .= "NM1" .       // Loop 1000B Receiver
 106     "*40" .
 107     "*2" .
 108     "*" . $claim->clearingHouseName() .
 109     "*" .
 110     "*" .
 111     "*" .
 112     "*" .
 113     "*46" .
 114     "*" . $claim->clearingHouseETIN() .
 115     "~\n";
 116
 117   $HLcount = 1;
 118
 119   ++$edicount;
 120   $out .= "HL" .        // Loop 2000A Billing/Pay-To Provider HL Loop
 121     "*$HLcount" .
 122     "*" .
 123     "*20" .
 124     "*1" .
 125     "~\n";
 126
 127   $HLBillingPayToProvider = $HLcount++;
 128
 129   ++$edicount;
 130   $out .= "NM1" .       // Loop 2010AA Billing Provider
 131     "*85" .
 132     "*2" .
 133     "*" . $claim->billingFacilityName() .
 134     "*" .
 135     "*" .
 136     "*" .
 137     "*";
 138   if ($claim->billingFacilityNPI()) {
 139     $out .= "*XX*" . $claim->billingFacilityNPI();
 140   } else {
 141     $log .= "*** Billing facility has no NPI.\n";
 142     $out .= "*24*" . $claim->billingFacilityETIN();
 143   }
 144   $out .= "~\n";
 145
 146   ++$edicount;
 147   $out .= "N3" .
 148     "*" . $claim->billingFacilityStreet() .
 149     "~\n";
 150
 151   ++$edicount;
 152   $out .= "N4" .
 153     "*" . $claim->billingFacilityCity() .
 154     "*" . $claim->billingFacilityState() .
 155     "*" . $claim->billingFacilityZip() .
 156     "~\n";
 157
 158   // Add a REF*EI*<ein> segment if NPI was specified in the NM1 above.
 159   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 160     ++$edicount;
 161     $out .= "REF" ;
 162         if($claim->federalIdType()){
 163       $out .= "*" . $claim->federalIdType();
 164         }
 165         else{
 166           $out .= "*EI";//For dealing with the situation before adding selection for TaxId type In facility ie default to EIN.
 167         }
 168       $out .=  "*" . $claim->billingFacilityETIN() .
 169       "~\n";
 170   }
 171
 172   if ($claim->providerNumberType() && $claim->providerNumber()) {
 173     ++$edicount;
 174     $out .= "REF" .
 175       "*" . $claim->providerNumberType() .
 176       "*" . $claim->providerNumber() .
 177       "~\n";
 178   }
 179   else if ($claim->providerNumber()) {
 180     $log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
 181   }
 182
 183   ++$edicount;
 184   $out .= "NM1" .       // Loop 2010AB Pay-To Provider
 185     "*87" .
 186     "*2" .
 187     "*" . $claim->billingFacilityName() .
 188     "*" .
 189     "*" .
 190     "*" .
 191     "*";
 192   if ($claim->billingFacilityNPI())
 193     $out .= "*XX*" . $claim->billingFacilityNPI();
 194   else
 195     $out .= "*24*" . $claim->billingFacilityETIN();
 196   $out .= "~\n";
 197
 198   ++$edicount;
 199   $out .= "N3" .
 200     "*" . $claim->billingFacilityStreet() .
 201     "~\n";
 202
 203   ++$edicount;
 204   $out .= "N4" .
 205     "*" . $claim->billingFacilityCity() .
 206     "*" . $claim->billingFacilityState() .
 207     "*" . $claim->billingFacilityZip() .
 208     "~\n";
 209
 210   if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
 211     ++$edicount;
 212     $out .= "REF" .
 213       "*EI" .
 214       "*" . $claim->billingFacilityETIN() .
 215       "~\n";
 216   }
 217
 218   $PatientHL = 0;
 219
 220   ++$edicount;
 221   $out .= "HL" .        // Loop 2000B Subscriber HL Loop
 222     "*$HLcount" .
 223     "*$HLBillingPayToProvider" .
 224     "*22" .
 225     "*$PatientHL" .
 226     "~\n";
 227
 228   $HLSubscriber = $HLcount++;
 229
 230   if (!$claim->payerSequence()) {
 231     $log .= "*** Error: Insurance information is missing!\n";
 232   }
 233   ++$edicount;
 234   $out .= "SBR" .       // Subscriber Information
 235     "*" . $claim->payerSequence() .
 236     "*" . $claim->insuredRelationship() .
 237     "*" . $claim->groupNumber() .
 238     "*" . $claim->groupName() .
 239     "*" . $claim->insuredTypeCode() . // applies for secondary medicare
 240     "*" .
 241     "*" .
 242     "*" .
 243     "*" . $claim->claimType() . // Zirmed replaces this
 244     "~\n";
 245
 246   ++$edicount;
 247   $out .= "NM1" .       // Loop 2010BA Subscriber
 248     "*IL" .
 249     "*1" .
 250     "*" . $claim->insuredLastName() .
 251     "*" . $claim->insuredFirstName() .
 252     "*" . $claim->insuredMiddleName() .
 253     "*" .
 254     "*" .
 255     "*MI" .
 256     "*" . $claim->policyNumber() .
 257     "~\n";
 258
 259   ++$edicount;
 260   $out .= "N3" .
 261     "*" . $claim->insuredStreet() .
 262     "~\n";
 263
 264   ++$edicount;
 265   $out .= "N4" .
 266     "*" . $claim->insuredCity() .
 267     "*" . $claim->insuredState() .
 268     "*" . $claim->insuredZip() .
 269     "~\n";
 270
 271   ++$edicount;
 272   $out .= "DMG" .
 273     "*D8" .
 274     "*" . $claim->insuredDOB() .
 275     "*" . $claim->insuredSex() .
 276     "~\n";
 277
 278   ++$edicount;
 279   $out .= "NM1" .       // Loop 2010BB Payer
 280     "*PR" .
 281     "*2" .
 282     "*" . $claim->payerName() .
 283     "*" .
 284     "*" .
 285     "*" .
 286     "*" .
 287     "*PI" .
 288     // Zirmed ignores this if using payer name matching:
 289     "*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
 290     "~\n";
 291
 292   // if (!$claim->payerID()) {
 293   //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
 294   // }
 295
 296   ++$edicount;
 297   $out .= "N3" .
 298     "*" . $claim->payerStreet() .
 299     "~\n";
 300
 301   ++$edicount;
 302   $out .= "N4" .
 303     "*" . $claim->payerCity() .
 304     "*" . $claim->payerState() .
 305     "*" . $claim->payerZip() .
 306     "~\n";
 307
 308   if (! $claim->isSelfOfInsured()) {
 309     ++$edicount;
 310     $out .= "HL" .        // Loop 2000C Patient Information
 311       "*$HLcount" .
 312       "*$HLSubscriber" .
 313       "*23" .
 314       "*0" .
 315       "~\n";
 316
 317     $HLcount++;
 318
 319     ++$edicount;
 320     $out .= "PAT" .
 321       "*" . $claim->insuredRelationship() .
 322       "~\n";
 323
 324     ++$edicount;
 325     $out .= "NM1" .       // Loop 2010CA Patient
 326       "*QC" .
 327       "*1" .
 328       "*" . $claim->patientLastName() .
 329       "*" . $claim->patientFirstName() .
 330       "*" . $claim->patientMiddleName() .
 331       "~\n";
 332
 333     ++$edicount;
 334     $out .= "N3" .
 335       "*" . $claim->patientStreet() .
 336       "~\n";
 337
 338     ++$edicount;
 339     $out .= "N4" .
 340       "*" . $claim->patientCity() .
 341       "*" . $claim->patientState() .
 342       "*" . $claim->patientZip() .
 343       "~\n";
 344
 345     ++$edicount;
 346     $out .= "DMG" .
 347       "*D8" .
 348       "*" . $claim->patientDOB() .
 349       "*" . $claim->patientSex() .
 350       "~\n";
 351   } // end of patient different from insured
 352
 353   $proccount = $claim->procCount();
 354
 355   $clm_total_charges = 0;
 356   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 357     $clm_total_charges += $claim->cptCharges($prockey);
 358   }
 359
 360   if (!$clm_total_charges) {
 361     $log .= "*** This claim has no charges!\n";
 362   }
 363
 364   ++$edicount;
 365   $out .= "CLM" .       // Loop 2300 Claim
 366     "*$pid-$encounter" .
 367     "*"  . sprintf("%.2f",$clm_total_charges) . // Zirmed computes and replaces this
 368     "*"  .
 369     "*"  .
 370     "*"  . $claim->facilityPOS() . "::" . $claim->frequencyTypeCode() .
 371     "*Y" .
 372     "*A" .
 373     "*"  . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
 374     "*Y" .
 375     "*C" .
 376     "~\n";
 377
 378   ++$edicount;
 379   $out .= "DTP" .       // Date of Onset
 380     "*431" .
 381     "*D8" .
 382     "*" . $claim->onsetDate() .
 383     "~\n";
 384
 385   if (strcmp($claim->facilityPOS(),'21') == 0) {
 386     ++$edicount;
 387     $out .= "DTP" .     // Date of Hospitalization
 388       "*435" .
 389       "*D8" .
 390       "*" . $claim->onsetDate() .
 391       "~\n";
 392   }
 393
 394   $patientpaid = $claim->patientPaidAmount();
 395   if ($patientpaid != 0) {
 396     ++$edicount;
 397     $out .= "AMT" .     // Patient paid amount. Page 220.
 398       "*F5" .
 399       "*" . $patientpaid .
 400       "~\n";
 401   }
 402
 403   if ($claim->priorAuth()) {
 404     ++$edicount;
 405     $out .= "REF" .     // Prior Authorization Number
 406       "*G1" .
 407       "*" . $claim->priorAuth() .
 408       "~\n";
 409   }
 410
 411   if ($claim->cliaCode() and $claim->claimType() === 'MB') {
 412     // Required by Medicare when in-house labs are done.
 413     ++$edicount;
 414     $out .= "REF" .     // Clinical Laboratory Improvement Amendment Number
 415       "*X4" .
 416       "*" . $claim->cliaCode() .
 417       "~\n";
 418   }
 419
 420   // Note: This would be the place to implement the NTE segment for loop 2300.
 421
 422   // Diagnoses, up to 8 per HI segment.
 423   $da = $claim->diagArray();
 424   $diag_type_code = 'BK';
 425   $tmp = 0;
 426   foreach ($da as $diag) {
 427     if ($tmp % 8 == 0) {
 428       if ($tmp) $out .= "~\n";
 429       ++$edicount;
 430       $out .= "HI";         // Health Diagnosis Codes
 431     }
 432     $out .= "*$diag_type_code:" . $diag;
 433     $diag_type_code = 'BF';
 434     ++$tmp;
 435   }
 436   if ($tmp) $out .= "~\n";
 437
 438   if ($claim->referrerLastName()) {
 439     // Medicare requires referring provider's name and UPIN.
 440     ++$edicount;
 441     $out .= "NM1" .     // Loop 2310A Referring Provider
 442       "*DN" .
 443       "*1" .
 444       "*" . $claim->referrerLastName() .
 445       "*" . $claim->referrerFirstName() .
 446       "*" . $claim->referrerMiddleName() .
 447       "*" .
 448       "*";
 449     if ($claim->referrerNPI()) { $out .=
 450       "*XX" .
 451       "*" . $claim->referrerNPI();
 452     } else { $out .=
 453       "*34" .
 454       "*" . $claim->referrerSSN();
 455     }
 456     $out .= "~\n";
 457
 458     if ($claim->referrerTaxonomy()) {
 459       ++$edicount;
 460       $out .= "PRV" .
 461         "*RF" . // ReFerring provider
 462         "*ZZ" .
 463         "*" . $claim->referrerTaxonomy() .
 464         "~\n";
 465     }
 466
 467     if ($claim->referrerUPIN()) {
 468       ++$edicount;
 469       $out .= "REF" .   // Referring Provider Secondary Identification
 470         "*1G" .
 471         "*" . $claim->referrerUPIN() .
 472         "~\n";
 473     }
 474   }
 475
 476   ++$edicount;
 477   $out .= "NM1" .       // Loop 2310B Rendering Provider
 478     "*82" .
 479     "*1" .
 480     "*" . $claim->providerLastName() .
 481     "*" . $claim->providerFirstName() .
 482     "*" . $claim->providerMiddleName() .
 483     "*" .
 484     "*";
 485   if ($claim->providerNPI()) { $out .=
 486     "*XX" .
 487     "*" . $claim->providerNPI();
 488   } else { $out .=
 489     "*34" .
 490     "*" . $claim->providerSSN();
 491     $log .= "*** Rendering provider has no NPI.\n";
 492   }
 493   $out .= "~\n";
 494
 495   if ($claim->providerTaxonomy()) {
 496     ++$edicount;
 497     $out .= "PRV" .
 498       "*PE" . // PErforming provider
 499       "*ZZ" .
 500       "*" . $claim->providerTaxonomy() .
 501       "~\n";
 502   }
 503
 504   // REF*1C is required here for the Medicare provider number if NPI was
 505   // specified in NM109.  Not sure if other payers require anything here.
 506   // --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
 507
 508    if (trim($claim->x12gsreceiverid()) != '470819582') { // if NOT ECLAIMS EDI
 509       if ($claim->providerNumber()) {
 510         ++$edicount;
 511         $out .= "REF" .
 512           "*" . $claim->providerNumberType() .
 513           "*" . $claim->providerNumber() .
 514           "~\n";
 515       }
 516    }
 517
 518   // Loop 2310D is omitted in the case of home visits (POS=12).
 519   if ($claim->facilityPOS() != 12) {
 520     ++$edicount;
 521     $out .= "NM1" .       // Loop 2310D Service Location
 522       "*77" .
 523       "*2";
 524     if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 525       "*" . $claim->facilityName();
 526     }
 527     if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
 528       "*" .
 529       "*" .
 530       "*" .
 531       "*";
 532       if ($claim->facilityNPI()) { $out .=
 533         "*XX*" . $claim->facilityNPI();
 534       } else { $out .=
 535         "*24*" . $claim->facilityETIN();
 536         $log .= "*** Service location has no NPI.\n";
 537       }
 538     }
 539     $out .= "~\n";
 540     if ($claim->facilityStreet()) {
 541       ++$edicount;
 542       $out .= "N3" .
 543         "*" . $claim->facilityStreet() .
 544         "~\n";
 545     }
 546     if ($claim->facilityState()) {
 547       ++$edicount;
 548       $out .= "N4" .
 549         "*" . $claim->facilityCity() .
 550         "*" . $claim->facilityState() .
 551         "*" . $claim->facilityZip() .
 552         "~\n";
 553     }
 554   }
 555
 556   // Loop 2310E, Supervising Provider
 557   //
 558   if ($claim->supervisorLastName()) {
 559     ++$edicount;
 560     $out .= "NM1" .
 561       "*DQ" . // Supervising Physician
 562       "*1" .  // Person
 563       "*" . $claim->supervisorLastName() .
 564       "*" . $claim->supervisorFirstName() .
 565       "*" . $claim->supervisorMiddleName() .
 566       "*" .   // NM106 not used
 567       "*";    // Name Suffix
 568     if ($claim->supervisorNPI()) { $out .=
 569       "*XX" .
 570       "*" . $claim->supervisorNPI();
 571     } else { $out .=
 572       "*34" .
 573       "*" . $claim->supervisorSSN();
 574     }
 575     $out .= "~\n";
 576
 577     if ($claim->supervisorNumber()) {
 578       ++$edicount;
 579       $out .= "REF" .
 580         "*" . $claim->supervisorNumberType() .
 581         "*" . $claim->supervisorNumber() .
 582         "~\n";
 583     }
 584   }
 585
 586   $prev_pt_resp = $clm_total_charges; // for computation below
 587
 588   // Loops 2320 and 2330*, other subscriber/payer information.
 589   //
 590   for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 591
 592     $tmp1 = $claim->claimType($ins);
 593     $tmp2 = 'C1'; // Here a kludge. See page 321.
 594     if ($tmp1 === 'CI') $tmp2 = 'C1';
 595     if ($tmp1 === 'AM') $tmp2 = 'AP';
 596     if ($tmp1 === 'HM') $tmp2 = 'HM';
 597     if ($tmp1 === 'MB') $tmp2 = 'MB';
 598     if ($tmp1 === 'MC') $tmp2 = 'MC';
 599     if ($tmp1 === '09') $tmp2 = 'PP';
 600     ++$edicount;
 601     $out .= "SBR" . // Loop 2320, Subscriber Information - page 318
 602       "*" . $claim->payerSequence($ins) .
 603       "*" . $claim->insuredRelationship($ins) .
 604       "*" . $claim->groupNumber($ins) .
 605       "*" . $claim->groupName($ins) .
 606       "*" . $tmp2 .
 607       "*" .
 608       "*" .
 609       "*" .
 610       "*" . $claim->claimType($ins) .
 611       "~\n";
 612
 613     // Things that apply only to previous payers, not future payers.
 614     //
 615     if ($claim->payerSequence($ins) < $claim->payerSequence()) {
 616
 617       // Generate claim-level adjustments.
 618       $aarr = $claim->payerAdjustments($ins);
 619       foreach ($aarr as $a) {
 620         ++$edicount;
 621         $out .= "CAS" . // Previous payer's claim-level adjustments. Page 323.
 622           "*" . $a[1] .
 623           "*" . $a[2] .
 624           "*" . $a[3] .
 625           "~\n";
 626       }
 627
 628       $payerpaid = $claim->payerTotals($ins);
 629       ++$edicount;
 630       $out .= "AMT" . // Previous payer's paid amount. Page 332.
 631         "*D" .
 632         "*" . $payerpaid[1] .
 633         "~\n";
 634
 635       // Patient responsibility amount as of this previous payer.
 636       $prev_pt_resp -= $payerpaid[1]; // reduce by payments
 637       $prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
 638
 639       ++$edicount;
 640       $out .= "AMT" . // Allowed amount per previous payer. Page 334.
 641         "*B6" .
 642         "*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
 643         "~\n";
 644
 645       ++$edicount;
 646       $out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
 647         "*F2" .
 648         "*" . sprintf('%.2f', $prev_pt_resp) .
 649         "~\n";
 650
 651     } // End of things that apply only to previous payers.
 652
 653     ++$edicount;
 654     $out .= "DMG" . // Other subscriber demographic information. Page 342.
 655       "*D8" .
 656       "*" . $claim->insuredDOB($ins) .
 657       "*" . $claim->insuredSex($ins) .
 658       "~\n";
 659
 660     ++$edicount;
 661     $out .= "OI" .  // Other Insurance Coverage Information. Page 344.
 662       "*" .
 663       "*" .
 664       "*Y" .
 665       "*B" .
 666       "*" .
 667       "*Y" .
 668       "~\n";
 669
 670     ++$edicount;
 671     $out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 350.
 672       "*IL" .
 673       "*1" .
 674       "*" . $claim->insuredLastName($ins) .
 675       "*" . $claim->insuredFirstName($ins) .
 676       "*" . $claim->insuredMiddleName($ins) .
 677       "*" .
 678       "*" .
 679       "*MI" .
 680       "*" . $claim->policyNumber($ins) .
 681       "~\n";
 682
 683     ++$edicount;
 684     $out .= "N3" .
 685       "*" . $claim->insuredStreet($ins) .
 686       "~\n";
 687
 688     ++$edicount;
 689     $out .= "N4" .
 690       "*" . $claim->insuredCity($ins) .
 691       "*" . $claim->insuredState($ins) .
 692       "*" . $claim->insuredZip($ins) .
 693       "~\n";
 694
 695     ++$edicount;
 696     $out .= "NM1" . // Loop 2330B Payer info for other insco. Page 359.
 697       "*PR" .
 698       "*2" .
 699       "*" . $claim->payerName($ins) .
 700       "*" .
 701       "*" .
 702       "*" .
 703       "*" .
 704       "*PI" .
 705       "*" . $claim->payerID($ins) .
 706       "~\n";
 707
 708     // if (!$claim->payerID($ins)) {
 709     //   $log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
 710     // }
 711
 712     // Payer address (N3 and N4) are added below so that Gateway EDI can
 713     // auto-generate secondary claims.  These do NOT appear in my copy of
 714     // the spec!  -- Rod 2008-06-12
 715
 716     if (trim($claim->x12gsreceiverid()) == '431420764') { // if Gateway EDI
 717       ++$edicount;
 718       $out .= "N3" .
 719         "*" . $claim->payerStreet($ins) .
 720         "~\n";
 721       //
 722       ++$edicount;
 723       $out .= "N4" .
 724         "*" . $claim->payerCity($ins) .
 725         "*" . $claim->payerState($ins) .
 726         "*" . $claim->payerZip($ins) .
 727         "~\n";
 728     } // end Gateway EDI
 729
 730   } // End loops 2320/2330*.
 731
 732   $loopcount = 0;
 733
 734   // Procedure loop starts here.
 735   //
 736   for ($prockey = 0; $prockey < $proccount; ++$prockey) {
 737     ++$loopcount;
 738
 739     ++$edicount;
 740     $out .= "LX" .      // Loop 2400 LX Service Line. Page 398.
 741       "*$loopcount" .
 742       "~\n";
 743
 744     ++$edicount;
 745     $out .= "SV1" .     // Professional Service. Page 400.
 746       "*HC:" . $claim->cptKey($prockey) .
 747       "*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
 748       "*UN" .
 749       "*" . $claim->cptUnits($prockey) .
 750       "*" .
 751       "*" .
 752       "*";
 753     $dia = $claim->diagIndexArray($prockey);
 754     $i = 0;
 755     foreach ($dia as $dindex) {
 756       if ($i) $out .= ':';
 757       $out .= $dindex;
 758       if (++$i >= 4) break;
 759     }
 760     $out .= "~\n";
 761
 762     if (!$claim->cptCharges($prockey)) {
 763       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
 764     }
 765
 766     if (empty($dia)) {
 767       $log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
 768     }
 769
 770     ++$edicount;
 771     $out .= "DTP" .     // Date of Service. Page 435.
 772       "*472" .
 773       "*D8" .
 774       "*" . $claim->serviceDate() .
 775       "~\n";
 776
 777     // AMT*AAE segment for Approved Amount from previous payer.
 778     // Medicare secondaries seem to require this.
 779     //
 780     for ($ins = $claim->payerCount() - 1; $ins > 0; --$ins) {
 781       if ($claim->payerSequence($ins) > $claim->payerSequence())
 782         continue; // payer is future, not previous
 783       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 784       ++$edicount;
 785       $out .= "AMT" . // Approved amount per previous payer. Page 485.
 786         "*AAE" .
 787         "*" . sprintf('%.2f', $claim->cptCharges($prockey) - $payerpaid[2]) .
 788         "~\n";
 789       break;
 790     }
 791
 792     // Loop 2410, Drug Information. Medicaid insurers seem to want this
 793     // with HCPCS codes.
 794     //
 795     $ndc = $claim->cptNDCID($prockey);
 796     if ($ndc) {
 797       ++$edicount;
 798       $out .= "LIN" . // Drug Identification. Page 500+ (Addendum pg 71).
 799         "*" .         // Per addendum, LIN01 is not used.
 800         "*N4" .
 801         "*" . $ndc .
 802         "~\n";
 803
 804       if (!preg_match('/^\d\d\d\d\d-\d\d\d\d-\d\d$/', $ndc, $tmp)) {
 805         $log .= "*** NDC code '$ndc' has invalid format!\n";
 806       }
 807
 808       ++$edicount;
 809       $tmpunits = $claim->cptNDCQuantity($prockey) * $claim->cptUnits($prockey);
 810       if (!$tmpunits) $tmpunits = 1;
 811       $out .= "CTP" . // Drug Pricing. Page 500+ (Addendum pg 74).
 812         "*" .
 813         "*" .
 814         "*" . sprintf('%.2f', $claim->cptCharges($prockey) / $tmpunits) .
 815         "*" . $claim->cptNDCQuantity($prockey) .
 816         "*" . $claim->cptNDCUOM($prockey) .
 817         "~\n";
 818     }
 819
 820     // Loop 2420A, Rendering Provider (service-specific).
 821     // Used if the rendering provider for this service line is different
 822     // from that in loop 2310B.
 823     //
 824     if ($claim->providerNPI() != $claim->providerNPI($prockey)) {
 825       ++$edicount;
 826       $out .= "NM1" .       // Loop 2310B Rendering Provider
 827         "*82" .
 828         "*1" .
 829         "*" . $claim->providerLastName($prockey) .
 830         "*" . $claim->providerFirstName($prockey) .
 831         "*" . $claim->providerMiddleName($prockey) .
 832         "*" .
 833         "*";
 834       if ($claim->providerNPI($prockey)) { $out .=
 835         "*XX" .
 836         "*" . $claim->providerNPI($prockey);
 837       } else { $out .=
 838         "*34" .
 839         "*" . $claim->providerSSN($prockey);
 840         $log .= "*** Rendering provider has no NPI.\n";
 841       }
 842       $out .= "~\n";
 843
 844       if ($claim->providerTaxonomy($prockey)) {
 845         ++$edicount;
 846         $out .= "PRV" .
 847           "*PE" . // PErforming provider
 848           "*ZZ" .
 849           "*" . $claim->providerTaxonomy($prockey) .
 850           "~\n";
 851       }
 852
 853       // REF*1C is required here for the Medicare provider number if NPI was
 854       // specified in NM109.  Not sure if other payers require anything here.
 855       if ($claim->providerNumber($prockey)) {
 856         ++$edicount;
 857         $out .= "REF" .
 858           "*" . $claim->providerNumberType($prockey) .
 859           "*" . $claim->providerNumber($prockey) .
 860           "~\n";
 861       }
 862     }
 863
 864     // Loop 2430, adjudication by previous payers.
 865     //
 866     for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 867       if ($claim->payerSequence($ins) > $claim->payerSequence())
 868         continue; // payer is future, not previous
 869
 870       $payerpaid = $claim->payerTotals($ins, $claim->cptKey($prockey));
 871       $aarr = $claim->payerAdjustments($ins, $claim->cptKey($prockey));
 872
 873       if ($payerpaid[1] == 0 && !count($aarr)) {
 874         $log .= "*** Procedure '" . $claim->cptKey($prockey) .
 875           "' has no payments or adjustments from previous payer!\n";
 876         continue;
 877       }
 878
 879       ++$edicount;
 880       $out .= "SVD" . // Service line adjudication. Page 554.
 881         "*" . $claim->payerID($ins) .
 882         "*" . $payerpaid[1] .
 883         "*HC:" . $claim->cptKey($prockey) .
 884         "*" .
 885         "*" . $claim->cptUnits($prockey) .
 886         "~\n";
 887
 888       $tmpdate = $payerpaid[0];
 889       foreach ($aarr as $a) {
 890         ++$edicount;
 891         $out .= "CAS" . // Previous payer's line level adjustments. Page 558.
 892           "*" . $a[1] .
 893           "*" . $a[2] .
 894           "*" . $a[3] .
 895           "~\n";
 896         if (!$tmpdate) $tmpdate = $a[0];
 897       }
 898
 899       if ($tmpdate) {
 900         ++$edicount;
 901         $out .= "DTP" . // Previous payer's line adjustment date. Page 566.
 902           "*573" .
 903           "*D8" .
 904           "*$tmpdate" .
 905           "~\n";
 906       }
 907     } // end loop 2430
 908   } // end this procedure
 909
 910   ++$edicount;
 911   $out .= "SE" .        // SE Trailer
 912     "*$edicount" .
 913     "*0021" .
 914     "~\n";
 915
 916   $out .= "GE" .        // GE Trailer
 917     "*1" .
 918     "*1" .
 919     "~\n";
 920
 921   $out .= "IEA" .       // IEA Trailer
 922     "*1" .
 923     "*000000001" .
 924     "~\n";
 925
 926   $log .= "\n";
 927   return $out;
 928 }
 929 ?>