library/gen_hcfa_1500.inc.php

   1 <?php
   2 /*
   3  * This program creates the HCFA 1500 claim form.
   4  *
   5  * @package OpenEMR
   6  * @author Rod Roark <rod@sunsetsystems.com>
   7  * @author Stephen Waite <stephen.waite@cmsvt.com>
   8  * @copyright Copyright (c) 2011 Rod Roark <rod@sunsetsystems.com>
   9  * @copyright Copyright (C) 2018 Stephen Waite <stephen.waite@cmsvt.com>
  10  * @link http://www.open-emr.org
  11  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once("gen_hcfa_1500_02_12.inc.php");
  15 require_once(dirname(__FILE__) . "/invoice_summary.inc.php");
  16
  17 use OpenEMR\Billing\Claim;
  18
  19 $hcfa_curr_line = 1;
  20 $hcfa_curr_col = 1;
  21 $hcfa_data = '';
  22 $hcfa_proc_index = 0;
  23
  24 /**
  25  * take the data element and place it at the correct coordinates on the page
  26  *
  27  * @global int $hcfa_curr_line
  28  * @global type $hcfa_curr_col
  29  * @global type $hcfa_data
  30  * @param type $line
  31  * @param type $col
  32  * @param type $maxlen
  33  * @param type $data
  34  * @param type $strip   regular expression for what to strip from the data. period and has are the defaults
  35  *                      02/12 version needs to include periods in the diagnoses hence the need to override
  36  */
  37 function put_hcfa($line, $col, $maxlen, $data, $strip = '/[.#]/')
  38 {
  39     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data;
  40     if ($line < $hcfa_curr_line) {
  41         die("Data item at ($line, $col) precedes current line.");
  42     }
  43
  44     while ($hcfa_curr_line < $line) {
  45         $hcfa_data .= "\n";
  46         ++$hcfa_curr_line;
  47         $hcfa_curr_col = 1;
  48     }
  49
  50     if ($col < $hcfa_curr_col) {
  51         die("Data item at ($line, $col) precedes current column.");
  52     }
  53
  54     while ($hcfa_curr_col < $col) {
  55         $hcfa_data .= " ";
  56         ++$hcfa_curr_col;
  57     }
  58
  59     $data = preg_replace($strip, '', strtoupper($data));
  60     $len = min(strlen($data), $maxlen);
  61     $hcfa_data .= substr($data, 0, $len);
  62     $hcfa_curr_col += $len;
  63 }
  64
  65 function gen_hcfa_1500($pid, $encounter, &$log)
  66 {
  67     global $hcfa_data, $hcfa_proc_index;
  68
  69     $hcfa_data = '';
  70     $hcfa_proc_index = 0;
  71
  72     $today = time();
  73     $claim = new Claim($pid, $encounter);
  74
  75     $log .= "Generating HCFA claim $pid-$encounter for " .
  76     $claim->patientFirstName()  . ' ' .
  77     $claim->patientMiddleName() . ' ' .
  78     $claim->patientLastName()   . ' on ' .
  79     date('Y-m-d H:i', $today) . ".\n";
  80
  81     while ($hcfa_proc_index < $claim->procCount()) {
  82         if ($hcfa_proc_index) {
  83             $hcfa_data .= "\014"; // append form feed for new page
  84         }
  85
  86         gen_hcfa_1500_page($pid, $encounter, $log, $claim);
  87     }
  88
  89     $log .= "\n";
  90     return $hcfa_data;
  91 }
  92
  93 function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim)
  94 {
  95     global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
  96
  97     $hcfa_curr_line = 1;
  98     $hcfa_curr_col = 1;
  99
 100     // According to:
 101     // http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
 102     // Medicare interprets sections 9 and 11 of the claim form in its own
 103     // special way.  This flag tells us to do that.  However I'm not 100%
 104     // sure that it applies nationwide, and if you find that it is not right
 105     // for you then set it to false.  -- Rod 2009-03-26
 106     $new_medicare_logic = $claim->claimType() == 'MB';
 107
 108     // Payer name, attn, street.
 109     put_hcfa(2, 41, 31, $claim->payerName());
 110     put_hcfa(3, 41, 31, $claim->payerAttn());
 111     put_hcfa(4, 41, 31, $claim->payerStreet());
 112
 113     // Payer city, state, zip.
 114     $tmp = $claim->payerCity() ? ($claim->payerCity() . ', ') : '';
 115     put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
 116
 117     // Box 1. Insurance Type
 118     // claimTypeRaw() gets the integer value from insurance_companies.ins_type_code.
 119     // Previous version of this code called claimType() which maps ins_type_code to
 120     // a 2-character code and that was not specific enough.
 121     $ct = $claim->claimTypeRaw();
 122     $tmpcol = 45;                    // Other
 123     if ($ct == 2) {
 124         $tmpcol =  1; // Medicare
 125     } else if ($ct == 3) {
 126         $tmpcol =  8; // Medicaid
 127     } else if ($ct == 5) {
 128         $tmpcol = 15; // TriCare (formerly CHAMPUS)
 129     } else if ($ct == 4) {
 130         $tmpcol = 24; // Champus VA
 131     } else if ($ct == 6) {
 132         $tmpcol = 31; // Group Health Plan (only BCBS?)
 133     } else if ($ct == 7) {
 134         $tmpcol = 39; // FECA
 135     }
 136
 137     put_hcfa(8, $tmpcol, 1, 'X');
 138
 139     // Box 1a. Insured's ID Number
 140     put_hcfa(8, 50, 17, $claim->policyNumber());
 141
 142     // Box 2. Patient's Name
 143     $tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
 144     if ($claim->patientMiddleName()) {
 145         $tmp .= ', ' . substr($claim->patientMiddleName(), 0, 1);
 146     }
 147
 148     put_hcfa(10, 1, 28, $tmp);
 149
 150     // Box 3. Patient's Birth Date and Sex
 151     $tmp = $claim->patientDOB();
 152     put_hcfa(10, 31, 2, substr($tmp, 4, 2));
 153     put_hcfa(10, 34, 2, substr($tmp, 6, 2));
 154     put_hcfa(10, 37, 4, substr($tmp, 0, 4));
 155     put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
 156
 157     // Box 4. Insured's Name
 158     $tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
 159     if ($claim->insuredMiddleName()) {
 160         $tmp .= ', ' . substr($claim->insuredMiddleName(), 0, 1);
 161     }
 162
 163     put_hcfa(10, 50, 28, $tmp);
 164
 165     // Box 5. Patient's Address
 166     put_hcfa(12, 1, 28, $claim->patientStreet());
 167
 168     // Box 6. Patient Relationship to Insured
 169     $tmp = $claim->insuredRelationship();
 170     $tmpcol = 47;                         // Other
 171     if ($tmp === '18') {
 172         $tmpcol = 33; // self
 173     } else if ($tmp === '01') {
 174         $tmpcol = 38; // spouse
 175     } else if ($tmp === '19') {
 176         $tmpcol = 42; // child
 177     }
 178
 179     put_hcfa(12, $tmpcol, 1, 'X');
 180
 181     // Box 7. Insured's Address
 182     put_hcfa(12, 50, 28, $claim->insuredStreet());
 183
 184     // Box 5 continued. Patient's City and State
 185     put_hcfa(14, 1, 20, $claim->patientCity());
 186     put_hcfa(14, 26, 2, $claim->patientState());
 187
 188     // Box 8. Reserved for NUCC Use in 02/12
 189
 190     // Box 7 continued. Insured's City and State
 191     put_hcfa(14, 50, 20, $claim->insuredCity());
 192     put_hcfa(14, 74, 2, $claim->insuredState());
 193
 194     // Box 5 continued. Patient's Zip Code and Telephone
 195     put_hcfa(16, 1, 10, $claim->patientZip());
 196     $tmp = $claim->patientPhone();
 197     put_hcfa(16, 15, 3, substr($tmp, 0, 3));
 198     put_hcfa(16, 19, 7, substr($tmp, 3));
 199
 200     // Box 7 continued. Insured's Zip Code and Telephone
 201     put_hcfa(16, 50, 10, $claim->insuredZip());
 202     $tmp = $claim->insuredPhone();
 203     put_hcfa(16, 65, 3, substr($tmp, 0, 3));
 204     put_hcfa(16, 69, 7, substr($tmp, 3));
 205
 206     // Box 9. Other Insured's Name
 207     if ($new_medicare_logic) {
 208         // TBD: Medigap stuff? How do we know if this is a Medigap transfer?
 209     } else {
 210         if ($claim->payerCount() > 1) {
 211             $tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
 212             if ($claim->insuredMiddleName(1)) {
 213                 $tmp .= ', ' . substr($claim->insuredMiddleName(1), 0, 1);
 214             }
 215
 216             put_hcfa(18, 1, 28, $tmp);
 217         }
 218     }
 219
 220     // Box 11. Insured's Group Number
 221     if ($new_medicare_logic) {
 222         // If this is Medicare secondary then we need the primary's policy number
 223         // here, otherwise the word "NONE".
 224         $tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
 225     } else {
 226         $tmp = $claim->groupNumber();
 227     }
 228
 229     put_hcfa(18, 50, 30, $tmp);
 230
 231     // Box 9a. Other Insured's Policy or Group Number
 232     if ($new_medicare_logic) {
 233         // TBD: Medigap stuff?
 234     } else {
 235         if ($claim->payerCount() > 1) {
 236             put_hcfa(20, 1, 28, $claim->policyNumber(1));
 237         }
 238     }
 239
 240     // Box 10a. Employment Related
 241     put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
 242
 243     // Box 11a. Insured's Birth Date and Sex
 244     if ($new_medicare_logic) {
 245         $tmpdob = $tmpsex = '';
 246         if ($claim->payerSequence() != 'P') {
 247             $tmpdob = $claim->insuredDOB(1);
 248             $tmpsex = $claim->insuredSex(1);
 249         }
 250     } else {
 251         $tmpdob = $claim->insuredDOB();
 252         $tmpsex = $claim->insuredSex();
 253     }
 254
 255     if ($tmpdob) {
 256         put_hcfa(20, 53, 2, substr($tmpdob, 4, 2));
 257         put_hcfa(20, 56, 2, substr($tmpdob, 6, 2));
 258         put_hcfa(20, 59, 4, substr($tmpdob, 0, 4));
 259     }
 260
 261     if ($tmpsex) {
 262         put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
 263     }
 264
 265     // Box 9b. Reserved for NUCC Use in 02/12
 266
 267     // Box 10b. Auto Accident
 268     put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
 269     if ($claim->isRelatedAuto()) {
 270         put_hcfa(22, 45, 2, $claim->autoAccidentState());
 271     }
 272
 273     // Box 11b. Insured's Employer/School Name
 274     if ($new_medicare_logic) {
 275         $tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
 276     } else {
 277         $tmp = $claim->groupName();
 278     }
 279
 280     put_hcfa(22, 50, 30, $tmp);
 281
 282     // Box 9c. Reserved for NUCC Use in 02/12
 283
 284     // Box 10c. Other Accident
 285     put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
 286
 287     // Box 11c. Insurance Plan Name or Program Name
 288     if ($new_medicare_logic) {
 289         $tmp = '';
 290         if ($claim->payerSequence() != 'P') {
 291             $tmp = $claim->planName(1);
 292             if (!$tmp) {
 293                 $tmp = $claim->payerName(1);
 294             }
 295         }
 296     } else {
 297         $tmp = $claim->planName();
 298     }
 299
 300     put_hcfa(24, 50, 30, $tmp);
 301
 302     // Box 9d. Other Insurance Plan Name or Program Name
 303     if ($new_medicare_logic) {
 304         // TBD: Medigap stuff?
 305     } else {
 306         if ($claim->payerCount() > 1) {
 307             put_hcfa(26, 1, 28, $claim->planName(1));
 308         }
 309     }
 310
 311     // Box 10d. Claim Codes  medicaid_referral_code
 312
 313     if ($claim->epsdtFlag()) {
 314         put_hcfa(26, 34, 2, $claim->medicaidReferralCode());
 315     }
 316
 317     // Box 11d. Is There Another Health Benefit Plan
 318
 319     if (!$new_medicare_logic) {
 320         put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
 321     }
 322
 323     // Box 12. Patient's or Authorized Person's Signature
 324     put_hcfa(29, 7, 17, 'Signature on File');
 325     // Note: Date does not apply unless the person physically signs the form.
 326
 327     // Box 13. Insured's or Authorized Person's Signature
 328     put_hcfa(29, 55, 17, 'Signature on File');
 329
 330     // Box 14. Date of Current Illness/Injury/Pregnancy
 331     // this will cause onsetDate in Encounter summary to override misc billing so not perfect yet but fine for now
 332     $tmp = ($claim->onsetDate()) ? $claim->onsetDate() : $claim->miscOnsetDate();
 333     if (!empty($tmp)) {
 334         put_hcfa(32, 2, 2, substr($tmp, 4, 2));
 335         put_hcfa(32, 5, 2, substr($tmp, 6, 2));
 336         put_hcfa(32, 8, 4, substr($tmp, 0, 4));
 337         // Include Box 14 Qualifier
 338         put_hcfa(32, 16, 3, $claim->box14Qualifier());
 339     }
 340
 341     // Box 15. First Date of Same or Similar Illness, if applicable
 342     $tmp = $claim->dateInitialTreatment();
 343     if (!empty($tmp)) {
 344         // Only include the Box 15 qualifier if using version 02/12 and there is a Box 15 date.
 345         put_hcfa(32, 31, 3, $claim->box15Qualifier());
 346     }
 347
 348     put_hcfa(32, 37, 2, substr($tmp, 4, 2));
 349     put_hcfa(32, 40, 2, substr($tmp, 6, 2));
 350     put_hcfa(32, 43, 4, substr($tmp, 0, 4));
 351
 352     // Box 16. Dates Patient Unable to Work in Current Occupation
 353     if ($claim->isUnableToWork()) {
 354         $tmp = $claim->offWorkFrom();
 355         put_hcfa(32, 54, 2, substr($tmp, 4, 2));
 356         put_hcfa(32, 57, 2, substr($tmp, 6, 2));
 357         put_hcfa(32, 60, 4, substr($tmp, 0, 4));
 358         $tmp = $claim->offWorkTo();
 359         put_hcfa(32, 68, 2, substr($tmp, 4, 2));
 360         put_hcfa(32, 71, 2, substr($tmp, 6, 2));
 361         put_hcfa(32, 74, 4, substr($tmp, 0, 4));
 362     }
 363
 364     // Referring provider stuff.  Reports are that for primary care providers,
 365     // Medicare forbids an entry here and other payers require one.
 366     // There is still confusion over this.
 367     if ($claim->referrerLastName() || $claim->billingProviderLastName() &&
 368         (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB')) {
 369         // Box 17a. Referring Provider Alternate Identifier
 370         // Commented this out because UPINs are obsolete, leaving the code as an
 371         // example in case some other identifier needs to be supported.
 372         /*****************************************************************
 373         if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
 374             put_hcfa(33, 30,  2, '1G');
 375             put_hcfa(33, 33, 15, $claim->referrerUPIN());
 376         }
 377         *****************************************************************/
 378         if ($claim->claimType() == 'MC') {
 379             put_hcfa(33, 30, 2, 'ZZ');
 380             put_hcfa(33, 33, 14, $claim->referrerTaxonomy());
 381         }
 382
 383         // Box 17. Name of Referring Provider or Other Source
 384         if (strlen($claim->billingProviderLastName()) !=0) {
 385             $tmp2 = $claim->billingProviderLastName() . ', ' . $claim->billingProviderFirstName();
 386             if ($claim->billingProviderMiddleName()) {
 387                 $tmp2 .= ', ' . substr($claim->billingProviderMiddleName(), 0, 1);
 388             }
 389
 390             put_hcfa(34, 1, 3, $claim->billing_options['provider_qualifier_code']);
 391             put_hcfa(34, 4, 25, $tmp2);
 392             if ($claim->billingProviderNPI()) {
 393                 put_hcfa(34, 33, 15, $claim->billingProviderNPI());
 394             }
 395         } else {
 396             $tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
 397             if ($claim->referrerMiddleName()) {
 398                 $tmp .= ', ' . substr($claim->referrerMiddleName(), 0, 1);
 399             }
 400
 401             put_hcfa(34, 1, 3, 'DN');
 402             put_hcfa(34, 4, 25, $tmp);
 403             if ($claim->referrerNPI()) {
 404                 put_hcfa(34, 33, 15, $claim->referrerNPI());
 405             }
 406         }
 407     }
 408
 409     // Box 18. Hospitalization Dates Related to Current Services
 410     if ($claim->isHospitalized()) {
 411         $tmp = $claim->hospitalizedFrom();
 412         put_hcfa(34, 54, 2, substr($tmp, 4, 2));
 413         put_hcfa(34, 57, 2, substr($tmp, 6, 2));
 414         put_hcfa(34, 60, 4, substr($tmp, 0, 4));
 415         $tmp = $claim->hospitalizedTo();
 416         put_hcfa(34, 68, 2, substr($tmp, 4, 2));
 417         put_hcfa(34, 71, 2, substr($tmp, 6, 2));
 418         put_hcfa(34, 74, 4, substr($tmp, 0, 4));
 419     }
 420
 421     // Box 19. Reserved for Local Use
 422     put_hcfa(36, 1, 48, $claim->additionalNotes());
 423
 424     // Box 20. Outside Lab
 425     put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
 426     if ($claim->isOutsideLab()) {
 427         // Note here that put_hcfa strips the decimal point, as required.
 428         // We right-justify this amount (ending in col. 69).
 429         put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
 430     }
 431
 432     // Box 21. Diagnoses
 433     process_diagnoses_02_12($claim, $log);
 434
 435     $proccount = $claim->procCount(); // number of procedures
 436
 437     // Charges, adjustments and payments are accumulated by line item so that
 438     // each page of a multi-page claim will stand alone.  Payments include the
 439     // co-pay for the first page only.
 440     $clm_total_charges = 0;
 441     $clm_amount_adjusted = 0;
 442     $clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
 443
 444     // Procedure loop starts here.
 445     for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
 446         $dia = $claim->diagIndexArray($hcfa_proc_index);
 447
 448         if (!$claim->cptCharges($hcfa_proc_index)) {
 449             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 450             "' has no charges!\n";
 451         }
 452
 453         if (empty($dia)) {
 454             $log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) .
 455             "' is not justified!\n";
 456         }
 457
 458         $clm_total_charges += $claim->cptCharges($hcfa_proc_index);
 459
 460         // Compute prior payments and "hard" adjustments.
 461         for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
 462             if ($claim->payerSequence($ins) > $claim->payerSequence()) {
 463                 continue; // skip future payers
 464             }
 465
 466             $payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
 467             $clm_amount_paid += $payerpaid[1];
 468             $clm_amount_adjusted += $payerpaid[2];
 469         }
 470
 471         ++$svccount;
 472         $lino = $svccount * 2 + 41;
 473
 474         // Drug Information. Medicaid insurers want this with HCPCS codes.
 475         //
 476         $ndc = $claim->cptNDCID($hcfa_proc_index);
 477         if ($ndc) {
 478             if (preg_match('/^(\d\d\d\d\d)-(\d\d\d\d)-(\d\d)$/', $ndc, $tmp)) {
 479                 $ndc = $tmp[1] . $tmp[2] . $tmp[3];
 480             } else if (preg_match('/^\d{11}$/', $ndc)) {
 481             } else {
 482                 $log .= "*** NDC code '$ndc' has invalid format!\n";
 483             }
 484
 485             put_hcfa($lino, 1, 50, "N4$ndc   " . $claim->cptNDCUOM($hcfa_proc_index) .
 486             $claim->cptNDCQuantity($hcfa_proc_index));
 487         }
 488
 489         //Note Codes.
 490         put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
 491
 492         // 24i and 24j Top. ID Qualifier and Rendering Provider ID
 493         if ($claim->supervisorNumber()) {
 494             // If there is a supervising provider and that person has a
 495             // payer-specific provider number, then we assume that the SP
 496             // must be identified on the claim and this is how we do it
 497             // (but the NPI of the actual rendering provider appears below).
 498             // BCBS of TN indicated they want it this way.  YMMV.  -- Rod
 499             put_hcfa($lino, 65, 2, $claim->supervisorNumberType());
 500             put_hcfa($lino, 68, 10, $claim->supervisorNumber());
 501         } else if ($claim->providerNumber($hcfa_proc_index)) {
 502             put_hcfa($lino, 65, 2, $claim->providerNumberType($hcfa_proc_index));
 503             put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
 504         } else if ($claim->claimType() == 'MC') {
 505             put_hcfa($lino, 65, 2, 'ZZ');
 506             put_hcfa($lino, 68, 14, $claim->providerTaxonomy());
 507         }
 508
 509         ++$lino;
 510
 511         // 24a. Date of Service
 512         $tmp = $claim->serviceDate();
 513         put_hcfa($lino, 1, 2, substr($tmp, 4, 2));
 514         put_hcfa($lino, 4, 2, substr($tmp, 6, 2));
 515         put_hcfa($lino, 7, 2, substr($tmp, 2, 2));
 516         put_hcfa($lino, 10, 2, substr($tmp, 4, 2));
 517         put_hcfa($lino, 13, 2, substr($tmp, 6, 2));
 518         put_hcfa($lino, 16, 2, substr($tmp, 2, 2));
 519
 520         // 24b. Place of Service
 521         put_hcfa($lino, 19, 2, $claim->facilityPOS());
 522
 523         // 24c. EMG
 524         // Not currently supported.
 525
 526         // 24d. Procedures, Services or Supplies
 527         put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
 528         // replace colon with space for printing
 529         put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
 530
 531         // 24e. Diagnosis Pointer
 532         $tmp = '';
 533         foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) {
 534             $value=chr($value+64);
 535             $tmp .= $value;
 536         }
 537
 538         put_hcfa($lino, 45, 4, $tmp);
 539
 540         // 24f. Charges
 541         put_hcfa($lino, 50, 8, str_replace(
 542             '.',
 543             ' ',
 544             sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))
 545         ));
 546
 547         // 24g. Days or Units
 548         put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
 549
 550         // 24h. EPSDT Family Plan
 551         //
 552         if ($claim->epsdtFlag()) {
 553               put_hcfa($lino, 63, 2, '03');
 554         }
 555
 556         // 24j. Rendering Provider NPI
 557         put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
 558     }
 559
 560     // 25. Federal Tax ID Number
 561     put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
 562     if ($claim->federalIdType()=='SY') {
 563         put_hcfa(56, 17, 1, 'X'); // The SSN checkbox
 564     } else {
 565         put_hcfa(56, 19, 1, 'X'); // The EIN checkbox
 566     }
 567
 568     // 26. Patient's Account No.
 569     // Instructions say hyphens are not allowed.
 570     put_hcfa(56, 23, 15, "$pid-$encounter");
 571
 572     // 27. Accept Assignment
 573     put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
 574
 575     // 28. Total Charge
 576     put_hcfa(56, 52, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_total_charges)));
 577     if (!$clm_total_charges) {
 578         $log .= "*** This claim has no charges!\n";
 579     }
 580
 581     // 29. Amount Paid
 582     put_hcfa(56, 62, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_amount_paid)));
 583
 584     // 30. Reserved for NUCC use.
 585
 586     // 33. Billing Provider: Phone Number
 587     $tmp = $claim->billingContactPhone();
 588     put_hcfa(57, 66, 3, substr($tmp, 0, 3));
 589     put_hcfa(57, 70, 3, substr($tmp, 3)); // slight adjustment for better look smw 030315
 590     put_hcfa(57, 73, 1, '-');
 591     put_hcfa(57, 74, 4, substr($tmp, 6));
 592
 593     // 32. Service Facility Location Information: Name
 594     put_hcfa(58, 23, 25, $claim->facilityName());
 595
 596     // 33. Billing Provider: Name
 597     if ($claim->federalIdType() == "SY") { // check entity type for NM*102 1 == person, 2 == non-person entity
 598         $firstName = $claim->providerFirstName();
 599         $lastName = $claim->providerLastName();
 600         $middleName = $claim->providerMiddleName();
 601         $suffixName = $claim->providerSuffixName();
 602         $billingProviderName = $lastName . ", " . $firstName. ", " . $middleName. ", " . $suffixName;
 603         put_hcfa(58, 50, 25, $billingProviderName);
 604     } else {
 605         put_hcfa(58, 50, 25, $claim->billingFacilityName());
 606     }
 607
 608     // 32. Service Facility Location Information: Street
 609     put_hcfa(59, 23, 25, $claim->facilityStreet());
 610
 611     // 33. Billing Provider: Name
 612     put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
 613
 614     // 31. Signature of Physician or Supplier
 615
 616     if ($GLOBALS['cms_1500_box_31_format']==0) {
 617         put_hcfa(60, 1, 20, 'Signature on File');
 618     } else if ($GLOBALS['cms_1500_box_31_format']==1) {
 619         put_hcfa(60, 1, 22, $claim->providerFirstName()." ".$claim->providerLastName());
 620     }
 621
 622     // 32. Service Facility Location Information: City State Zip
 623     $tmp = $claim->facilityCity() ? ($claim->facilityCity() . ' ') : '';
 624     put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' .
 625     $claim->facilityZip());
 626
 627     // 33. Billing Provider: City State Zip
 628     $tmp = $claim->billingFacilityCity() ? ($claim->billingFacilityCity() . ' ') : '';
 629     put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' .
 630     $claim->billingFacilityZip());
 631
 632     // 31. Signature of Physician or Supplier: Date
 633     if ($GLOBALS['cms_1500_box_31_date']>0) {
 634         if ($GLOBALS['cms_1500_box_31_date']==1) {
 635             $date_of_service= $claim->serviceDate();
 636             $MDY=substr($date_of_service, 4, 2)." ".substr($date_of_service, 6, 2)." ".substr($date_of_service, 2, 2);
 637         } else if ($GLOBALS['cms_1500_box_31_date']==2) {
 638             $MDY=date("m/d/y");
 639         }
 640
 641         put_hcfa(61, 6, 10, $MDY);
 642     }
 643
 644     // 32a. Service Facility NPI
 645     put_hcfa(61, 23, 10, $claim->facilityNPI());
 646
 647     // 32b. Service Facility Other ID
 648     // Note that Medicare does NOT want this any more.
 649     if ($claim->providerGroupNumber()) {
 650         put_hcfa(61, 36, 2, $claim->providerNumberType());
 651         put_hcfa(61, 38, 11, $claim->providerGroupNumber());
 652     }
 653
 654     // 33a. Billing Facility NPI
 655     put_hcfa(61, 50, 10, $claim->billingFacilityNPI());
 656
 657     // 33b. Billing Facility Other ID
 658     // Note that Medicare does NOT want this any more.
 659     if ($claim->claimType() == 'MC') {
 660         put_hcfa(61, 63, 2, 'ZZ');
 661         put_hcfa(61, 65, 14, $claim->providerTaxonomy());
 662     } elseif ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
 663         put_hcfa(61, 63, 2, $claim->providerNumberType());
 664         put_hcfa(61, 65, 14, $claim->providerGroupNumber());
 665     }
 666
 667     // Put an extra line here for compatibility with old hcfa text generated form
 668     put_hcfa(62, 1, 1, ' ');
 669     // put a couple more in so that multiple claims correctly print through the text file download
 670     put_hcfa(63, 1, 1, ' ');
 671     put_hcfa(64, 1, 1, ' ');
 672     return;
 673 }