interface/billing/sl_eob_invoice.php

   1 <?php
   2 /**
   3  * This provides for manual posting of EOBs.  It is invoked from
   4  * sl_eob_search.php.  For automated (X12 835) remittance posting
   5  * see sl_eob_process.php.
   6  *
   7  * @package   OpenEMR
   8  * @link      http://www.open-emr.org
   9  * @author    Rod Roark <rod@sunsetsystems.com>
  10  * @author    Roberto Vasquez <robertogagliotta@gmail.com>
  11  * @author    Terry Hill <terry@lillysystems.com>
  12  * @author    Jerry Padgett <sjpadgett@gmail.com>
  13  * @author    Stephen Waite <stephen.waite@cmsvt.com>
  14  * @author    Brady Miller <brady.g.miller@gmail.com>
  15  * @copyright Copyright (c) 2005-2016 Rod Roark <rod@sunsetsystems.com>
  16  * @copyright Copyright (c) 2018-2019 Stephen Waite <stephen.waite@cmsvt.com>
  17  * @copyright Copyright (c) 2019 Brady Miller <brady.g.miller@gmail.com>
  18  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  19  */
  20
  21
  22 require_once("../globals.php");
  23 require_once("$srcdir/patient.inc");
  24 require_once("$srcdir/forms.inc");
  25 require_once("$srcdir/invoice_summary.inc.php");
  26 require_once("../../custom/code_types.inc.php");
  27 require_once "$srcdir/user.inc";
  28
  29 use OpenEMR\Billing\SLEOB;
  30 use OpenEMR\Common\Logging\EventAuditLogger;
  31 use OpenEMR\Core\Header;
  32
  33 $debug = 0; // set to 1 for debugging mode
  34 $save_stay = $_REQUEST['form_save'] == '1' ? true : false;
  35 $from_posting = (0 + $_REQUEST['isPosting']) ? 1 : 0;
  36 $g_posting_adj_disable = $GLOBALS['posting_adj_disable'] ? 'checked' : '';
  37 if ($from_posting) {
  38     $posting_adj_disable = prevSetting('sl_eob_search.', 'posting_adj_disable', 'posting_adj_disable', $g_posting_adj_disable);
  39 } else {
  40     $posting_adj_disable = $g_posting_adj_disable;
  41 }
  42
  43 // If we permit deletion of transactions.  Might change this later.
  44 $ALLOW_DELETE = true;
  45
  46 $info_msg = "";
  47
  48 // Format money for display.
  49 //
  50 function bucks($amount)
  51 {
  52     if ($amount) {
  53         return sprintf("%.2f", $amount);
  54     }
  55 }
  56
  57 // Delete rows, with logging, for the specified table using the
  58 // specified WHERE clause.  Borrowed from deleter.php.
  59 //
  60 function row_delete($table, $where)
  61 {
  62     $tres = sqlStatement("SELECT * FROM " . escape_table_name($table) . " WHERE $where");
  63     $count = 0;
  64     while ($trow = sqlFetchArray($tres)) {
  65         $logstring = "";
  66         foreach ($trow as $key => $value) {
  67             if (!$value || $value == '0000-00-00 00:00:00') {
  68                 continue;
  69             }
  70
  71             if ($logstring) {
  72                 $logstring .= " ";
  73             }
  74
  75             $logstring .= $key . "='" . addslashes($value) . "'";
  76         }
  77
  78         EventAuditLogger::instance()->newEvent("delete", $_SESSION['authUser'], $_SESSION['authProvider'], 1, "$table: $logstring");
  79         ++$count;
  80     }
  81
  82     if ($count) { // Lets not echo the query for stay and save
  83         $query = "DELETE FROM " . escape_table_name($table) . " WHERE $where";
  84         sqlStatement($query);
  85     }
  86 }
  87
  88 ?>
  89 <html>
  90 <head>
  91     <?php Header::setupHeader(['datetime-picker', 'opener', 'no_dialog']); ?>
  92     <title><?php echo xlt('EOB Posting - Invoice') ?></title>
  93     <script language="JavaScript">
  94     var adjDisable = <?php echo js_escape($posting_adj_disable); ?>;
  95     // An insurance radio button is selected.
  96     function setins(istr) {
  97         return true;
  98     }
  99
 100     function goEncounterSummary(pid) {
 101         if(pid) {
 102             if(typeof opener.toEncSummary  === 'function') {
 103                 opener.toEncSummary(pid);
 104             }
 105         }
 106         window.close();
 107     }
 108     function doClose() {
 109         window.close();
 110     }
 111     // Compute an adjustment that writes off the balance:
 112     function writeoff(code) {
 113         var f = document.forms[0];
 114         var belement = f['form_line[' + code + '][bal]'];
 115         var pelement = f['form_line[' + code + '][pay]'];
 116         var aelement = f['form_line[' + code + '][adj]'];
 117         var relement = f['form_line[' + code + '][reason]'];
 118         var tmp = belement.value - pelement.value;
 119         aelement.value = Number(tmp).toFixed(2);
 120         if (aelement.value && !relement.value) relement.selectedIndex = 1;
 121         return false;
 122     }
 123
 124     // Onsubmit handler.  A good excuse to write some JavaScript.
 125     function validate(f) {
 126         let delcount = 0;
 127         let allempty = true;
 128
 129         for (var i = 0; i < f.elements.length; ++i) {
 130             let ename = f.elements[i].name;
 131             // Count deletes.
 132             if (ename.substring(0, 9) == 'form_del[') {
 133                 if (f.elements[i].checked) ++delcount;
 134                 continue;
 135             }
 136             let pfxlen = ename.indexOf('[pay]');
 137             if (pfxlen < 0) continue;
 138             let pfx = ename.substring(0, pfxlen);
 139             let code = pfx.substring(pfx.indexOf('[') + 1, pfxlen - 1);
 140             let cPay = parseFloat(f[pfx + '[pay]'].value).toFixed(2);
 141             let cAdjust = parseFloat(f[pfx + '[adj]'].value).toFixed(2);
 142
 143             if ((cPay != 0) || cAdjust != 0) {
 144                 allempty = false;
 145             }
 146             if(adjDisable) {
 147                 if ((cAdjust == 0 && f[pfx + '[reason]'].value)) {
 148                     allempty = false;
 149                 }
 150             }
 151             if ((cPay != 0) && isNaN(parseFloat(f[pfx + '[pay]'].value))) {
 152                 alert(<?php echo xlj('Payment value for code ') ?> + code + <?php echo xlj(' is not a number') ?>);
 153                 return false;
 154             }
 155             if ((cAdjust != 0) && isNaN(parseFloat(f[pfx + '[adj]'].value))) {
 156                 alert(<?php echo xlj('Adjustment value for code ') ?> + code + <?php echo xlj(' is not a number') ?>);
 157                 return false;
 158             }
 159             if ((cAdjust != 0) && !f[pfx + '[reason]'].value) {
 160                 alert(<?php echo xlj('Please select an adjustment reason for code ') ?> + code);
 161                 return false;
 162             }
 163 // TBD: validate the date format
 164         }
 165 // Check if save is clicked with nothing to post.
 166         if (allempty && delcount === 0) {
 167             alert(<?php echo xlj('Nothing to Post! Please review entries or use Cancel to exit transaction')?>);
 168             return false;
 169         }
 170 // Demand confirmation if deleting anything.
 171         if (delcount > 0) {
 172             if (!confirm(<?php echo xlj('Really delete'); ?> + ' ' + delcount +
 173                 ' ' + <?php echo xlj('transactions'); ?> + '?' +
 174                 ' ' + <?php echo xlj('This action will be logged'); ?> + '!')
 175             ) return false;
 176         }
 177
 178         return true;
 179     }
 180
 181     <!-- Get current date -->
 182
 183     function getFormattedToday() {
 184         let today = new Date();
 185         let dd = today.getDate();
 186         let mm = today.getMonth() + 1; //January is 0!
 187         let yyyy = today.getFullYear();
 188         if (dd < 10) {
 189             dd = '0' + dd
 190         }
 191         if (mm < 10) {
 192             mm = '0' + mm
 193         }
 194
 195         return (yyyy + '-' + mm + '-' + dd);
 196     }
 197
 198     <!-- Update Payment Fields -->
 199
 200     function updateFields(payField, adjField, balField, coPayField, isFirstProcCode) {
 201         let payAmount = 0.0;
 202         let adjAmount = 0.0;
 203         let balAmount = 0.0;
 204         let coPayAmount = 0.0;
 205
 206 // coPayFiled will be null if there is no co-pay entry in the fee sheet
 207         if (coPayField)
 208             coPayAmount = coPayField.value;
 209
 210 // if balance field is 0.00, its value comes back as null, so check for nul-ness first
 211         if (balField)
 212             balAmount = (balField.value) ? balField.value : 0;
 213         if (payField)
 214             payAmount = (payField.value) ? payField.value : 0;
 215
 216 //alert('balance = >' + balAmount +'<  payAmount = ' + payAmount + '  copay = ' + coPayAmount + '  isFirstProcCode = ' + isFirstProcCode);
 217
 218 // subtract the co-pay only from the first procedure code
 219         if (isFirstProcCode == 1)
 220             balAmount = parseFloat(balAmount) + parseFloat(coPayAmount);
 221         if (adjDisable) return;
 222
 223         adjAmount = balAmount - payAmount;
 224 // Assign rounded adjustment value back to TextField
 225         adjField.value = adjAmount = Math.round(adjAmount * 100) / 100;
 226     }
 227
 228     $(function () {
 229         $('.datepicker').datetimepicker({
 230             <?php $datetimepicker_timepicker = false; ?>
 231             <?php $datetimepicker_showseconds = false; ?>
 232             <?php $datetimepicker_formatInput = true; ?>
 233             <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 234             <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 235         });
 236     });
 237
 238     </script>
 239     <style>
 240         @media only screen and (max-width: 768px) {
 241             [class*="col-"] {
 242                 width: 100%;
 243                 text-align: left !Important;
 244             }
 245         }
 246
 247         .table {
 248             margin: auto;
 249             width: 99%;
 250         }
 251
 252         .table > tbody > tr > td {
 253             border-top: none;
 254         }
 255
 256         .last_detail {
 257             border-bottom: 1px black solid;
 258             margin-top: 2px;
 259         }
 260
 261         @media (min-width: 992px) {
 262             .modal-lg {
 263                 width: 1000px !Important;
 264             }
 265         }
 266
 267         /*.modalclass {
 268         overflow-x: hidden !Important;
 269         }
 270         .oe-ckbox-label{
 271         padding-left: 30px;
 272         font-weight: 500;
 273         }*/
 274     </style>
 275 </head>
 276 <body>
 277 <?php
 278 $trans_id = 0 + $_GET['id'];
 279 if (!$trans_id) {
 280     die(xlt("You cannot access this page directly."));
 281 }
 282
 283 // A/R case, $trans_id matches form_encounter.id.
 284 $ferow = sqlQuery("SELECT e.*, p.fname, p.mname, p.lname FROM form_encounter AS e, patient_data AS p WHERE e.id = ? AND p.pid = e.pid", array($trans_id));
 285 if (empty($ferow)) {
 286     die("There is no encounter with form_encounter.id = '" . text($trans_id) . "'.");
 287 }
 288 $patient_id = 0 + $ferow['pid'];
 289 $encounter_id = 0 + $ferow['encounter'];
 290 $svcdate = substr($ferow['date'], 0, 10);
 291 $form_payer_id = ($_POST['$form_payer_id']) ? (0 + $_POST['form_payer_id']) : 0;
 292 $form_reference = $_POST['form_reference'];
 293 $form_check_date = ($_POST['form_check_date']) ? DateToYYYYMMDD($_POST['form_check_date']) : date('Y-m-d');
 294 $form_deposit_date = ($_POST['form_deposit_date']) ? DateToYYYYMMDD($_POST['form_deposit_date']) : date('Y-m-d');
 295 $form_pay_total = ($_POST['form_pay_total']) ? (0 + $_POST['form_pay_total']) : 0;
 296
 297
 298 $payer_type = 0;
 299 if (preg_match('/^Ins(\d)/i', $_POST['form_insurance'], $matches)) {
 300     $payer_type = $matches[1];
 301 }
 302
 303 if (($_POST['form_save'] || $_POST['form_cancel'])) {
 304     if ($_POST['form_save']) {
 305         if (!verifyCsrfToken($_POST["csrf_token_form"])) {
 306             csrfNotVerified();
 307         }
 308
 309         if ($debug) {
 310             echo "<p><b>" . xlt("This module is in test mode. The database will not be changed.") . "</b><p>\n";
 311         }
 312
 313         $session_id = SLEOB::arGetSession($form_payer_id, $form_reference, $form_check_date, $form_deposit_date, $form_pay_total);
 314 // The sl_eob_search page needs its invoice links modified to invoke
 315 // javascript to load form parms for all the above and submit.
 316 // At the same time that page would be modified to work off the
 317 // openemr database exclusively.
 318 // And back to the sl_eob_invoice page, I think we may want to move
 319 // the source input fields from row level to header level.
 320
 321 // Handle deletes. row_delete() is borrowed from deleter.php.
 322         if ($ALLOW_DELETE && !$debug) {
 323             if (is_array($_POST['form_del'])) {
 324                 foreach ($_POST['form_del'] as $arseq => $dummy) {
 325                     row_delete("ar_activity", "pid = '" . add_escape_custom($patient_id) . "' AND " . "encounter = '" . add_escape_custom($encounter_id) . "' AND sequence_no = '" . add_escape_custom($arseq) . "'");
 326                 }
 327             }
 328         }
 329
 330         $paytotal = 0;
 331         foreach ($_POST['form_line'] as $code => $cdata) {
 332             $thispay = trim($cdata['pay']);
 333             $thisadj = trim($cdata['adj']);
 334             $thisins = trim($cdata['ins']);
 335             $thiscodetype = trim($cdata['code_type']);
 336             $reason = $cdata['reason'];
 337
 338 // Get the adjustment reason type.  Possible values are:
 339 // 1 = Charge adjustment
 340 // 2 = Coinsurance
 341 // 3 = Deductible
 342 // 4 = Other pt resp
 343 // 5 = Comment
 344             $reason_type = '1';
 345             if ($reason) {
 346                 $tmp = sqlQuery("SELECT option_value FROM list_options WHERE list_id = 'adjreason' AND activity = 1 AND option_id = ?", array($reason));
 347                 if (empty($tmp['option_value'])) {
 348 // This should not happen but if it does, apply old logic.
 349                     if (preg_match("/To copay/", $reason)) {
 350                         $reason_type = 2;
 351                     } elseif (preg_match("/To ded'ble/", $reason)) {
 352                         $reason_type = 3;
 353                     }
 354                     $info_msg .= xl("No adjustment reason type found for") . " \"$reason\". ";
 355                 } else {
 356                     $reason_type = $tmp['option_value'];
 357                 }
 358             }
 359
 360             if (!$thisins) {
 361                 $thisins = 0;
 362             }
 363
 364             if (0.0 + $thispay) {
 365                 SLEOB::arPostPayment($patient_id, $encounter_id, $session_id, $thispay, $code, $payer_type, '', $debug, '', $thiscodetype);
 366                 $paytotal += $thispay;
 367             }
 368
 369 // Be sure to record adjustment reasons, even for zero adjustments if
 370 // they happen to be comments.
 371             if ((0.0 + $thisadj) ||
 372                 ($reason && $reason_type == 5) ||
 373                 ($reason && ($reason_type > 1 && $reason_type < 6))) {
 374 // "To copay" and "To ded'ble" need to become a comment in a zero
 375 // adjustment, formatted just like sl_eob_process.php.
 376                 if ($reason_type == '2') {
 377                     $reason = $_POST['form_insurance'] . " coins: $thisadj";
 378                     $thisadj = 0;
 379                 } elseif ($reason_type == '3') {
 380                     $reason = $_POST['form_insurance'] . " dedbl: $thisadj";
 381                     $thisadj = 0;
 382                 } elseif ($reason_type == '4') {
 383                     $reason = $_POST['form_insurance'] . " ptresp: $thisadj $reason";
 384                     $thisadj = 0;
 385                 } elseif ($reason_type == '5') {
 386                     $reason = $_POST['form_insurance'] . " note: $thisadj $reason";
 387                     $thisadj = 0;
 388                 } else {
 389 // An adjustment reason including "Ins" is assumed to be assigned by
 390 // insurance, and in that case we identify which one by appending
 391 // Ins1, Ins2 or Ins3.
 392                     if (strpos(strtolower($reason), 'ins') != false) {
 393                         $reason .= ' ' . $_POST['form_insurance'];
 394                     }
 395                 }
 396                 SLEOB::arPostAdjustment($patient_id, $encounter_id, $session_id, $thisadj, $code, $payer_type, $reason, $debug, '', $thiscodetype);
 397             }
 398         }
 399
 400 // Maintain which insurances are marked as finished.
 401
 402         $form_done = 0 + $_POST['form_done'];
 403         $form_stmt_count = 0 + $_POST['form_stmt_count'];
 404         sqlStatement("UPDATE form_encounter SET last_level_closed = ?, stmt_count = ? WHERE pid = ? AND encounter = ?", array($form_done, $form_stmt_count, $patient_id, $encounter_id));
 405
 406         if ($_POST['form_secondary']) {
 407             SLEOB::arSetupSecondary($patient_id, $encounter_id, $debug);
 408         }
 409         echo "<script language='JavaScript'>\n";
 410         echo " if (opener.document.forms[0] != undefined) {\n";
 411         echo "   if (opener.document.forms[0].form_amount) {\n";
 412         echo "     var tmp = opener.document.forms[0].form_amount.value - " . attr($paytotal) . ";\n";
 413         echo "     opener.document.forms[0].form_amount.value = Number(tmp).toFixed(2);\n";
 414         echo "   }\n";
 415         echo " }\n";
 416     } else {
 417         echo "<script language='JavaScript'>\n";
 418     }
 419     if ($info_msg) {
 420         echo " alert(" . js_escape($info_msg) . ");\n";
 421     }
 422     if (!$debug && !$save_stay) {
 423         echo "doClose();\n";
 424     }
 425     echo "</script></body></html>\n";
 426     if (!$save_stay) {
 427         exit();
 428     }
 429 }
 430
 431 // Get invoice charge details.
 432 $codes = ar_get_invoice_summary($patient_id, $encounter_id, true);
 433 $pdrow = sqlQuery("select billing_note from patient_data where pid = ? limit 1", array($patient_id));
 434 ?>
 435
 436 <div class="container">
 437     <div class="row">
 438         <div class="page-header">
 439             <h2><?php echo xlt('EOB Invoice'); ?></h2>
 440         </div>
 441     </div>
 442     <div class="row">
 443         <form action='sl_eob_invoice.php?id=<?php echo attr_url($trans_id); ?>' method='post' onsubmit='return validate(this)'>
 444             <input type="hidden" name="csrf_token_form" value="<?php echo attr(collectCsrfToken()); ?>"/>
 445             <input type="hidden" name="isPosting" value="<?php echo attr($from_posting); ?>"/>
 446             <fieldset>
 447                 <legend><?php echo xlt('Invoice Actions'); ?></legend>
 448                 <div class="col-xs-12 oe-custom-line">
 449                     <div class="col-xs-3">
 450                         <label class="control-label" for="form_name"><?php echo xlt('Patient'); ?>:</label>
 451                         <input type="text" class="form-control" class="form-control" class="form-control" id='form_name'
 452                                name='form_name'
 453                                value="<?php echo attr($ferow['fname']) . ' ' . attr($ferow['mname']) . ' ' . attr($ferow['lname']); ?>"
 454                                disabled>
 455                     </div>
 456                     <div class="col-xs-3">
 457                         <label class="control-label" for="form_provider"><?php echo xlt('Provider'); ?>:</label>
 458                         <?php
 459                         $tmp = sqlQuery("SELECT fname, mname, lname " .
 460                             "FROM users WHERE id = ?", array($ferow['provider_id']));
 461                         $provider = text($tmp['fname']) . ' ' . text($tmp['mname']) . ' ' . text($tmp['lname']);
 462                         $tmp = sqlQuery("SELECT bill_date FROM billing WHERE " .
 463                             "pid = ? AND encounter = ? AND " .
 464                             "activity = 1 ORDER BY fee DESC, id ASC LIMIT 1", array($patient_id, $encounter_id));
 465                         $billdate = substr(($tmp['bill_date'] . "Not Billed"), 0, 10);
 466                         ?>
 467                         <input type="text" class="form-control" class="form-control" id='form_provider'
 468                                name='form_provider' value="<?php echo attr($provider); ?>" disabled>
 469                     </div>
 470                     <div class="col-xs-2">
 471                         <label class="control-label" for="form_invoice"><?php echo xlt('Invoice'); ?>:</label>
 472                         <input type="text" class="form-control" class="form-control" id='form_provider'
 473                                name='form_provider' value='<?php echo attr($patient_id) . "." . attr($encounter_id); ?>'
 474                                disabled>
 475                     </div>
 476                     <div class="col-xs-2">
 477                         <label class="control-label" for="svc_date"><?php echo xlt('Svc Date'); ?>:</label>
 478                         <input type="text" class="form-control" class="form-control" id='svc_date' name='form_provider'
 479                                value='<?php echo attr($svcdate); ?>' disabled>
 480                     </div>
 481                     <div class="col-xs-2">
 482                         <label class="control-label" for="insurance_name"><?php echo xlt('Insurance'); ?>:</label>
 483                         <?php
 484                         for ($i = 1; $i <= 3; ++$i) {
 485                             $payerid = SLEOB::arGetPayerID($patient_id, $svcdate, $i);
 486                             if ($payerid) {
 487                                 $tmp = sqlQuery("SELECT name FROM insurance_companies WHERE id = ?", array($payerid));
 488                                 $insurance .= "$i: " . $tmp['name'] . "\n";
 489                             }
 490                         }
 491                         ?>
 492                         <textarea name="insurance_name" id="insurance_name" class="form-control" cols="5" rows="2"
 493                                   readonly><?php echo attr($insurance); ?></textarea>
 494                     </div>
 495                 </div>
 496                 <div class="col-xs-12 oe-custom-line">
 497                     <div class="col-xs-3">
 498                         <label class="control-label" for="form_stmt_count"><?php echo xlt('Statements Sent'); ?>
 499                             :</label>
 500                         <input type='text' name='form_stmt_count' id='form_stmt_count' class="form-control"
 501                                value='<?php echo attr((0 + $ferow['stmt_count'])); ?>'/>
 502                     </div>
 503                     <div class="col-xs-3">
 504                         <label class="control-label" for="form_reference"><?php echo xlt('Check/EOB No.'); ?>:</label>
 505                         <input type='text' name='form_reference' id='form_reference' class="form-control" value=''/>
 506                     </div>
 507                     <div class="col-xs-2">
 508                         <label class="control-label" for="form_check_date"><?php echo xlt('Check/EOB Date'); ?>:</label>
 509                         <input type='text' name='form_check_date' class='form-control datepicker' value=''/>
 510                     </div>
 511                     <div class="col-xs-2">
 512                         <label class="control-label" for="form_deposit_date"><?php echo xlt('Deposit Date'); ?>:</label>
 513                         <input type='text' name='form_deposit_date' id='form_deposit_date' class='form-control datepicker' value=''/>
 514                         <input type='hidden' name='form_payer_id' value=''/>
 515                         <input type='hidden' name='form_orig_reference' value=''/>
 516                         <input type='hidden' name='form_orig_check_date' value=''/>
 517                         <input type='hidden' name='form_orig_deposit_date' value=''/>
 518                         <input type='hidden' name='form_pay_total' value=''/>
 519                     </div>
 520                 </div>
 521                 <div class="col-xs-12 oe-custom-line">
 522                     <div class="col-xs-4">
 523                         <label class="control-label" for="type_code"><?php echo xlt('Now posting for'); ?>:</label>
 524                         <div style="padding-left:15px">
 525                             <?php
 526                                 $last_level_closed = 0 + $ferow['last_level_closed'];
 527                             ?>
 528                             <label class="radio-inline">
 529                                 <input <?php echo $last_level_closed === 0 ? attr('checked') : ''; ?> name='form_insurance' onclick='setins("Ins1")' type='radio'
 530                                        value='Ins1'><?php echo xlt('Ins1') ?>
 531                             </label>
 532                             <label class="radio-inline">
 533                                 <input <?php echo $last_level_closed === 1 ? attr('checked') : ''; ?> name='form_insurance' onclick='setins("Ins2")' type='radio'
 534                                        value='Ins2'><?php echo xlt('Ins2') ?>
 535                             </label>
 536                             <label class="radio-inline">
 537                                 <input <?php echo $last_level_closed === 2 ? attr('checked') : ''; ?> name='form_insurance' onclick='setins("Ins3")' type='radio'
 538                                        value='Ins3'><?php echo xlt('Ins3') ?>
 539                             </label>
 540                             <label class="radio-inline">
 541                                 <input <?php echo $last_level_closed === 3 ? attr('checked') : ''; ?> name='form_insurance' onclick='setins("Pt")' type='radio'
 542                                        value='Pt'><?php echo xlt('Patient') ?>
 543                             </label>
 544                             <?php
 545                             // TBD: I think the following is unused and can be removed.
 546                             ?>
 547                             <input name='form_eobs' type='hidden' value='<?php echo attr($arrow['shipvia']) ?>'/>
 548                         </div>
 549                     </div>
 550                     <div class="col-xs-4">
 551                         <label class="control-label" for=""><?php echo xlt('Done with'); ?>:</label>
 552                         <div style="padding-left:15px">
 553                             <?php
 554                             // Write a checkbox for each insurance.  It is to be checked when
 555                             // we no longer expect any payments from that company for the claim.
 556                             $last_level_closed = 0 + $ferow['last_level_closed'];
 557                             foreach (array(0 => 'None', 1 => 'Ins1', 2 => 'Ins2', 3 => 'Ins3') as $key => $value) {
 558                                 if ($key && !SLEOB::arGetPayerID($patient_id, $svcdate, $key)) {
 559                                     continue;
 560                                 }
 561                                 $checked = ($last_level_closed == $key) ? " checked" : "";
 562                                 echo "<label class='radio-inline'>";
 563                                 echo "<input type='radio' name='form_done' value='" . attr($key) . "'$checked />" . text($value);
 564                                 echo "</label>";
 565                             }
 566                             ?>
 567                         </div>
 568                     </div>
 569                     <div class="col-xs-4">
 570                         <label class="control-label" for=""><?php echo xlt('Secondary billing'); ?>:</label>
 571                         <div style="padding-left:15px">
 572                             <label class="checkbox-inline">
 573                                 <input name="form_secondary" type="checkbox"
 574                                        value="1"><?php echo xlt('Needs secondary billing') ?>
 575                             </label>
 576                         </div>
 577                     </div>
 578                 </div>
 579
 580             </fieldset>
 581             <fieldset>
 582                 <legend><?php echo xlt('Invoice Details'); ?></legend>
 583                 <div class="table-responsive">
 584                     <table class="table table-condensed">
 585                         <thead>
 586                         <tr>
 587                             <th><?php echo xlt('Code') ?></th>
 588                             <th align="right"><?php echo xlt('Charge') ?></th>
 589                             <th align="right"><?php echo xlt('Balance') ?>&nbsp;</th>
 590                             <th><?php echo xlt('By/Source') ?></th>
 591                             <th><?php echo xlt('Date') ?></th>
 592                             <th><?php echo xlt('Pay') ?></th>
 593                             <th><?php echo xlt('Adjust') ?></th>
 594                             <th>&nbsp;</th>
 595                             <th><?php echo xlt('Reason') ?></th>
 596                             <?php
 597                             if ($ALLOW_DELETE) { ?>
 598                                 <th><?php echo xlt('Del') ?></th>
 599                                 <?php
 600                             } ?>
 601                         </tr>
 602                         </thead>
 603                         <?php
 604                         $firstProcCodeIndex = -1;
 605                         $encount = 0;
 606                         foreach ($codes as $code => $cdata) {
 607                             ++$encount;
 608                             $dispcode = $code;
 609
 610                             // remember the index of the first entry whose code is not "CO-PAY", i.e. it's a legitimate proc code
 611                             if ($firstProcCodeIndex == -1 && strcmp($code, "CO-PAY") != 0) {
 612                                 $firstProcCodeIndex = $encount;
 613                             }
 614
 615                             // this sorts the details more or less chronologically:
 616                             ksort($cdata['dtl']);
 617                             foreach ($cdata['dtl'] as $dkey => $ddata) {
 618                                 $ddate = substr($dkey, 0, 10);
 619                                 if (preg_match('/^(\d\d\d\d)(\d\d)(\d\d)\s*$/', $ddate, $matches)) {
 620                                     $ddate = $matches[1] . '-' . $matches[2] . '-' . $matches[3];
 621                                 }
 622                                 $tmpchg = "";
 623                                 $tmpadj = "";
 624                                 if ($ddata['chg'] != 0) {
 625                                     if (isset($ddata['rsn'])) {
 626                                         $tmpadj = 0 - $ddata['chg'];
 627                                     } else {
 628                                         $tmpchg = $ddata['chg'];
 629                                     }
 630                                 }
 631                                 ?>
 632                                 <tr>
 633                                     <td class="detail"
 634                                         style="background:<?php echo $dispcode ? 'lightyellow' : ''; ?>"><?php echo text($dispcode);
 635                                         $dispcode = "" ?></td>
 636                                     <td class="detail" class="detail"><?php echo text(bucks($tmpchg)); ?></td>
 637                                     <td class="detail" class="detail">&nbsp;</td>
 638                                     <td class="detail">
 639                                         <?php
 640                                         if (isset($ddata['plv'])) {
 641                                             if (!$ddata['plv']) {
 642                                                 echo 'Pt/';
 643                                             } else {
 644                                                 echo 'Ins' . text($ddata['plv']) . '/';
 645                                             }
 646                                         }
 647                                         echo text($ddata['src']);
 648                                         ?>
 649                                     </td>
 650                                     <td class="detail"><?php echo text($ddate); ?></td>
 651                                     <td class="detail"><?php echo text(bucks($ddata['pmt'])); ?></td>
 652                                     <td class="detail"><?php echo text(bucks($tmpadj)); ?></td>
 653                                     <td class="detail">&nbsp;</td>
 654                                     <td class="detail"><?php echo text($ddata['rsn']); ?></td>
 655                                     <?php
 656                                     if ($ALLOW_DELETE) { ?>
 657                                         <td class="detail">
 658                                             <?php
 659                                             if (!empty($ddata['arseq'])) { ?>
 660                                                 <input name="form_del[<?php echo attr($ddata['arseq']); ?>]"
 661                                                        type="checkbox">
 662                                                 <?php
 663                                             } else {
 664                                                 ?> &nbsp;
 665                                                 <?php
 666                                             } ?>
 667                                         </td>
 668                                     <?php } ?>
 669                                 </tr>
 670                             <?php } // end of prior detail line ?>
 671                             <tr>
 672                                 <td class="last_detail"><?php echo text($dispcode);
 673                                     $dispcode = "" ?></td>
 674                                 <td class="last_detail">&nbsp;</td>
 675                                 <td class="last_detail">
 676                                     <input name="form_line[<?php echo attr($code); ?>][bal]" type="hidden"
 677                                            value="<?php echo attr(bucks($cdata['bal'])); ?>">
 678                                     <input name="form_line[<?php echo attr($code); ?>][ins]" type="hidden"
 679                                            value="<?php echo attr($cdata['ins']); ?>">
 680                                     <input name="form_line[<?php echo attr($code); ?>][code_type]" type="hidden"
 681                                            value="<?php echo attr($cdata['code_type']); ?>"> <?php echo text(sprintf("%.2f", $cdata['bal'])); ?>
 682                                     &nbsp;
 683                                 </td>
 684                                 <td class="last_detail"></td>
 685                                 <td class="last_detail"></td>
 686                                 <td class="last_detail">
 687                                     <input name="form_line[<?php echo attr($code); ?>][pay]"
 688                                            onkeyup="updateFields(document.forms[0]['form_line[<?php echo attr($code); ?>][pay]'], document.forms[0]['form_line[<?php echo attr($code); ?>][adj]'], document.forms[0]['form_line[<?php echo attr($code); ?>][bal]'], document.forms[0]['form_line[CO-PAY][bal]'], <?php echo ($firstProcCodeIndex == $encount) ? 1 : 0 ?>)"
 689                                            onfocus="this.select()" autofocus size="10" type="text" class="form-control"
 690                                            value="0.00"></td>
 691                                 <td class="last_detail">
 692                                     <input name="form_line[<?php echo attr($code); ?>][adj]" size="10" type="text"
 693                                            class="form-control"
 694                                            value='<?php echo attr($totalAdjAmount ? $totalAdjAmount : '0.00'); ?>'
 695                                            onclick="this.select()">
 696                                 </td>
 697                                 <td class="last_detail" align="center"><a href=""
 698                                                                           onclick="return writeoff(<?php echo attr_js($code); ?>)">WO</a>
 699                                 </td>
 700                                 <td class="last_detail">
 701                                     <select class="form-control" name="form_line[<?php echo attr($code); ?>][reason]">
 702                                         <?php
 703                                         // Adjustment reasons are now taken from the list_options table.
 704                                         echo "    <option value=''></option>\n";
 705                                         $ores = sqlStatement("SELECT option_id, title, is_default FROM list_options " .
 706                                             "WHERE list_id = 'adjreason' AND activity = 1 ORDER BY seq, title");
 707                                         while ($orow = sqlFetchArray($ores)) {
 708                                             echo "    <option value='" . attr($orow['option_id']) . "'";
 709                                             if ($orow['is_default']) {
 710                                                 echo " selected";
 711                                             }
 712                                             echo ">" . text($orow['title']) . "</option>\n";
 713                                         }
 714                                         ?>
 715                                     </select>
 716                                     <?php
 717                                     // TBD: Maybe a comment field would be good here, for appending
 718                                     // to the reason.
 719                                     ?>
 720                                 </td>
 721                                 <?php if ($ALLOW_DELETE) { ?>
 722                                     <td class="last_detail">&nbsp;</td>
 723                                 <?php } ?>
 724                             </tr>
 725                         <?php } // end of code ?>
 726                     </table>
 727                 </div>
 728             </fieldset>
 729             <?php //can change position of buttons by creating a class 'position-override' and adding rule text-align:center or right as the case may be in individual stylesheets ?>
 730             <div class="form-group clearfix">
 731                 <div class="col-sm-12 text-left position-override" id="search-btn">
 732                     <div class="btn-group" role="group">
 733                         <button type='submit' class="btn btn-default btn-save" name='form_save' id="btn-save-stay"
 734                             onclick="this.value='1';"><?php echo xlt("Save Current"); ?></button>
 735                         <button type='submit' class="btn btn-default btn-save" name='form_save' id="btn-save"
 736                             onclick="this.value='2';"><?php echo xlt("Save & Exit"); ?></button>
 737                         <button type='button' class="btn btn-link btn-cancel btn-separate-left" name='form_cancel'
 738                             id="btn-cancel" onclick='doClose()'><?php echo xlt("Close"); ?></button>
 739                     </div>
 740                     <?php if ($GLOBALS['new_tabs_layout'] && $from_posting) { ?>
 741                         <button type='button' class="btn btn-default btn-view pull-right" name='form_goto' id="btn-goto"
 742                             onclick="goEncounterSummary(<?php echo attr_js($patient_id) ?>)"><?php echo xlt("Past Encounters"); ?></button>
 743                     <?php } ?>
 744                 </div>
 745             </div>
 746         </form>
 747     </div>
 748 </div><!--End of container div-->
 749 <?php if ($from_posting) { ?>
 750 <script language="JavaScript">
 751     var f1 = opener.document.forms[0];
 752     var f2 = document.forms[0];
 753     if (f1.form_source) {
 754         <?php
 755         // These support creation and lookup of ar_session table entries:
 756         echo "  f2.form_reference.value         = f1.form_source.value;\n";
 757         echo "  f2.form_check_date.value        = f1.form_paydate.value;\n";
 758         echo "  //f2.form_deposit_date.value      = f1.form_deposit_date.value;\n";
 759         echo "  if (f1.form_deposit_date.value != '')\n";
 760         echo "     f2.form_deposit_date.value      = f1.form_deposit_date.value;\n";
 761         echo "  else\n";
 762         echo "     f2.form_deposit_date.value      = getFormattedToday();\n";
 763         echo "  f2.form_payer_id.value          = f1.form_payer_id.value;\n";
 764         echo "  f2.form_pay_total.value         = f1.form_amount.value;\n";
 765         echo "  f2.form_orig_reference.value    = f1.form_source.value;\n";
 766         echo "  f2.form_orig_check_date.value   = f1.form_paydate.value;\n";
 767         echo "  f2.form_orig_deposit_date.value = f1.form_deposit_date.value;\n";
 768
 769         // While I'm thinking about it, some notes about eob sessions.
 770         // If they do not have all of the session key fields in the search
 771         // page, then show a warning at the top of the invoice page.
 772         // Also when they go to save the invoice page and a session key
 773         // field has changed, alert them to that and allow a cancel.
 774
 775         // Another point... when posting EOBs, the incoming payer ID might
 776         // not match the payer ID for the patient's insurance.  This is
 777         // because the same payer might be entered more than once into the
 778         // insurance_companies table.  I don't think it matters much.
 779         ?>
 780     }
 781     setins("Ins1");
 782 </script>
 783 <?php } ?>
 784 </body>
 785 </html>