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parse_era.inc.php
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parse_era.inc.php
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<?php
// Copyright (C) 2006 Rod Roark <[email protected]>
//
// This program is free software; you can redistribute it and/or
// modify it under the terms of the GNU General Public License
// as published by the Free Software Foundation; either version 2
// of the License, or (at your option) any later version.
function parse_era_2100(&$out, $cb) {
if ($out['loopid'] == '2110' || $out['loopid'] == '2100') {
// Production date is posted with adjustments, so make sure it exists.
if (!$out['production_date']) $out['production_date'] = $out['check_date'];
// Force the sum of service payments to equal the claim payment
// amount, and the sum of service adjustments to equal the CLP's
// (charged amount - paid amount - patient responsibility amount).
// This may result from claim-level adjustments, and in this case the
// first SVC item that we stored was a 'Claim' type. It also may result
// from poorly reported payment reversals, in which case we may need to
// create the 'Claim' service type here.
//
$paytotal = $out['amount_approved'];
$adjtotal = $out['amount_charged'] - $out['amount_approved'] - $out['amount_patient'];
foreach ($out['svc'] as $svc) {
$paytotal -= $svc['paid'];
foreach ($svc['adj'] as $adj) {
if ($adj['group_code'] != 'PR') $adjtotal -= $adj['amount'];
}
}
$paytotal = round($paytotal, 2);
$adjtotal = round($adjtotal, 2);
if ($paytotal != 0 || $adjtotal != 0) {
if ($out['svc'][0]['code'] != 'Claim') {
array_unshift($out['svc'], array());
$out['svc'][0]['code'] = 'Claim';
$out['svc'][0]['mod'] = '';
$out['svc'][0]['chg'] = '0';
$out['svc'][0]['paid'] = '0';
$out['svc'][0]['adj'] = array();
$out['warnings'] .= "Procedure 'Claim' is inserted artificially to " .
"force claim balancing.\n";
}
$out['svc'][0]['paid'] += $paytotal;
if ($adjtotal) {
$j = count($out['svc'][0]['adj']);
$out['svc'][0]['adj'][$j] = array();
$out['svc'][0]['adj'][$j]['group_code'] = 'CR'; // presuming a correction or reversal
$out['svc'][0]['adj'][$j]['reason_code'] = 'Balancing';
$out['svc'][0]['adj'][$j]['amount'] = $adjtotal;
}
// if ($out['svc'][0]['code'] != 'Claim') {
// $out['warnings'] .= "First service item payment amount " .
// "adjusted by $paytotal due to payment imbalance. " .
// "This should not happen!\n";
// }
}
$cb($out);
}
}
function parse_era($filename, $cb) {
$delimiter1 = '~';
$delimiter2 = '|';
$delimiter3 = '^';
$infh = fopen($filename, 'r');
if (! $infh) return "ERA input file open failed";
$out = array();
$out['loopid'] = '';
$out['st_segment_count'] = 0;
$buffer = '';
$segid = '';
while (true) {
if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
$tpos = strpos($buffer, $delimiter1);
if ($tpos === false) break;
$inline = substr($buffer, 0, $tpos);
$buffer = substr($buffer, $tpos + 1);
// If this is the ISA segment then figure out what the delimiters are.
if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
$delimiter2 = substr($inline, 3, 1);
$delimiter3 = substr($inline, -1);
}
$seg = explode($delimiter2, $inline);
$segid = $seg[0];
if ($segid == 'ISA') {
if ($out['loopid']) return 'Unexpected ISA segment';
$out['isa_sender_id'] = trim($seg[6]);
$out['isa_receiver_id'] = trim($seg[8]);
$out['isa_control_number'] = trim($seg[13]);
// TBD: clear some stuff if we allow multiple transmission files.
}
else if ($segid == 'GS') {
if ($out['loopid']) return 'Unexpected GS segment';
$out['gs_date'] = trim($seg[4]);
$out['gs_time'] = trim($seg[5]);
$out['gs_control_number'] = trim($seg[6]);
}
else if ($segid == 'ST') {
parse_era_2100($out, $cb);
$out['loopid'] = '';
$out['st_control_number'] = trim($seg[2]);
$out['st_segment_count'] = 0;
}
else if ($segid == 'BPR') {
if ($out['loopid']) return 'Unexpected BPR segment';
$out['check_amount'] = trim($seg[2]);
$out['check_date'] = trim($seg[16]); // yyyymmdd
// TBD: BPR04 is a payment method code.
}
else if ($segid == 'TRN') {
if ($out['loopid']) return 'Unexpected TRN segment';
$out['check_number'] = trim($seg[2]);
$out['payer_tax_id'] = substr($seg[3], 1); // 9 digits
$out['payer_id'] = trim($seg[4]);
// Note: TRN04 further qualifies the paying entity within the
// organization identified by TRN03.
}
else if ($segid == 'REF' && $seg[1] == 'EV') {
if ($out['loopid']) return 'Unexpected REF|EV segment';
}
else if ($segid == 'CUR' && ! $out['loopid']) {
if ($seg[3] && $seg[3] != 1.0) {
return("We cannot handle foreign currencies!");
}
}
else if ($segid == 'REF' && ! $out['loopid']) {
// ignore
}
else if ($segid == 'DTM' && $seg[1] == '405') {
if ($out['loopid']) return 'Unexpected DTM|405 segment';
$out['production_date'] = trim($seg[2]); // yyyymmdd
}
//
// Loop 1000A is Payer Information.
//
else if ($segid == 'N1' && $seg[1] == 'PR') {
if ($out['loopid']) return 'Unexpected N1|PR segment';
$out['loopid'] = '1000A';
$out['payer_name'] = trim($seg[2]);
}
else if ($segid == 'N3' && $out['loopid'] == '1000A') {
$out['payer_street'] = trim($seg[1]);
// TBD: N302 may exist as an additional address line.
}
else if ($segid == 'N4' && $out['loopid'] == '1000A') {
$out['payer_city'] = trim($seg[1]);
$out['payer_state'] = trim($seg[2]);
$out['payer_zip'] = trim($seg[3]);
}
else if ($segid == 'REF' && $out['loopid'] == '1000A') {
// Other types of REFs may be given to identify the payer, but we
// ignore them.
}
else if ($segid == 'PER' && $out['loopid'] == '1000A') {
// TBD: Report payer contact information as a note.
}
//
// Loop 1000B is Payee Identification.
//
else if ($segid == 'N1' && $seg[1] == 'PE') {
if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
$out['loopid'] = '1000B';
$out['payee_name'] = trim($seg[2]);
$out['payee_tax_id'] = trim($seg[4]);
}
else if ($segid == 'N3' && $out['loopid'] == '1000B') {
$out['payee_street'] = trim($seg[1]);
}
else if ($segid == 'N4' && $out['loopid'] == '1000B') {
$out['payee_city'] = trim($seg[1]);
$out['payee_state'] = trim($seg[2]);
$out['payee_zip'] = trim($seg[3]);
}
else if ($segid == 'REF' && $out['loopid'] == '1000B') {
// Used to report additional ID numbers. Ignored.
}
//
// Loop 2000 provides for logical grouping of claim payment information.
// LX is required if any CLPs are present, but so far we do not care
// about loop 2000 content.
//
else if ($segid == 'LX') {
if (! $out['loopid']) return 'Unexpected LX segment';
parse_era_2100($out, $cb);
$out['loopid'] = '2000';
}
else if ($segid == 'TS2' && $out['loopid'] == '2000') {
// ignore
}
else if ($segid == 'TS3' && $out['loopid'] == '2000') {
// ignore
}
//
// Loop 2100 is Claim Payment Information. The good stuff begins here.
//
else if ($segid == 'CLP') {
if (! $out['loopid']) return 'Unexpected CLP segment';
parse_era_2100($out, $cb);
$out['loopid'] = '2100';
$out['warnings'] = '';
// Clear some stuff to start the new claim:
$out['subscriber_lname'] = '';
$out['subscriber_fname'] = '';
$out['subscriber_mname'] = '';
$out['subscriber_member_id'] = '';
$out['crossover']=0;
$out['svc'] = array();
//
// This is the poorly-named "Patient Account Number". For 837p
// it comes from CLM01 which we populated as pid-diagid-procid,
// where diagid and procid are id values from the billing table.
// For HCFA 1500 claims it comes from field 26 which we
// populated with our familiar pid-encounter billing key.
//
// The 835 spec calls this the "provider-assigned claim control
// number" and notes that it is specifically intended for
// identifying the claim in the provider's database.
$out['our_claim_id'] = trim($seg[1]);
//
$out['claim_status_code'] = trim($seg[2]);
$out['amount_charged'] = trim($seg[3]);
$out['amount_approved'] = trim($seg[4]);
$out['amount_patient'] = trim($seg[5]); // pt responsibility, copay + deductible
$out['payer_claim_id'] = trim($seg[7]); // payer's claim number
}
else if ($segid == 'CAS' && $out['loopid'] == '2100') {
// This is a claim-level adjustment and should be unusual.
// Handle it by creating a dummy zero-charge service item and
// then populating the adjustments into it. See also code in
// parse_era_2100() which will later plug in a payment reversal
// amount that offsets these adjustments.
$i = 0; // if present, the dummy service item will be first.
if (!$out['svc'][$i]) {
$out['svc'][$i] = array();
$out['svc'][$i]['code'] = 'Claim';
$out['svc'][$i]['mod'] = '';
$out['svc'][$i]['chg'] = '0';
$out['svc'][$i]['paid'] = '0';
$out['svc'][$i]['adj'] = array();
}
for ($k = 2; $k < 20; $k += 3) {
if (!$seg[$k]) break;
$j = count($out['svc'][$i]['adj']);
$out['svc'][$i]['adj'][$j] = array();
$out['svc'][$i]['adj'][$j]['group_code'] = $seg[1];
$out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
$out['svc'][$i]['adj'][$j]['amount'] = $seg[$k+1];
}
}
// QC = Patient
else if ($segid == 'NM1' && $seg[1] == 'QC' && $out['loopid'] == '2100') {
$out['patient_lname'] = trim($seg[3]);
$out['patient_fname'] = trim($seg[4]);
$out['patient_mname'] = trim($seg[5]);
$out['patient_member_id'] = trim($seg[9]);
}
// IL = Insured or Subscriber
else if ($segid == 'NM1' && $seg[1] == 'IL' && $out['loopid'] == '2100') {
$out['subscriber_lname'] = trim($seg[3]);
$out['subscriber_fname'] = trim($seg[4]);
$out['subscriber_mname'] = trim($seg[5]);
$out['subscriber_member_id'] = trim($seg[9]);
}
// 82 = Rendering Provider
else if ($segid == 'NM1' && $seg[1] == '82' && $out['loopid'] == '2100') {
$out['provider_lname'] = trim($seg[3]);
$out['provider_fname'] = trim($seg[4]);
$out['provider_mname'] = trim($seg[5]);
$out['provider_member_id'] = trim($seg[9]);
}
else if ($segid == 'NM1' && $seg[1] == 'TT' && $out['loopid'] == '2100') {
$out['crossover'] = 1;//Claim automatic forward case.
}
// 74 = Corrected Insured
// TT = Crossover Carrier (Transfer To another payer)
// PR = Corrected Payer
else if ($segid == 'NM1' && $out['loopid'] == '2100') {
// $out['warnings'] .= "NM1 segment at claim level ignored.\n";
}
else if ($segid == 'MOA' && $out['loopid'] == '2100') {
$out['warnings'] .= "MOA segment at claim level ignored.\n";
}
// REF segments may provide various identifying numbers, where REF02
// indicates the type of number.
else if ($segid == 'REF' && $seg[1] == '1W' && $out['loopid'] == '2100') {
$out['claim_comment'] = trim($seg[2]);
}
else if ($segid == 'REF' && $out['loopid'] == '2100') {
// ignore
}
else if ($segid == 'DTM' && $seg[1] == '050' && $out['loopid'] == '2100') {
$out['claim_date'] = trim($seg[2]); // yyyymmdd
}
// 036 = expiration date of coverage
// 050 = date claim received by payer
// 232 = claim statement period start
// 233 = claim statement period end
else if ($segid == 'DTM' && $out['loopid'] == '2100') {
// ignore?
}
else if ($segid == 'PER' && $out['loopid'] == '2100') {
$out['payer_insurance'] = trim($seg[2]);
$out['warnings'] .= 'Claim contact information: ' .
$seg[4] . "\n";
}
// For AMT01 see the Amount Qualifier Codes on pages 135-135 of the
// Implementation Guide. AMT is only good for comments and is not
// part of claim balancing.
else if ($segid == 'AMT' && $out['loopid'] == '2100') {
$out['warnings'] .= "AMT segment at claim level ignored.\n";
}
// For QTY01 see the Quantity Qualifier Codes on pages 137-138 of the
// Implementation Guide. QTY is only good for comments and is not
// part of claim balancing.
else if ($segid == 'QTY' && $out['loopid'] == '2100') {
$out['warnings'] .= "QTY segment at claim level ignored.\n";
}
//
// Loop 2110 is Service Payment Information.
//
else if ($segid == 'SVC') {
if (! $out['loopid']) return 'Unexpected SVC segment';
$out['loopid'] = '2110';
if ($seg[6]) {
// SVC06 if present is our original procedure code that they are changing.
// We will not put their crap in our invoice, but rather log a note and
// treat it as adjustments to our originally submitted coding.
$svc = explode($delimiter3, $seg[6]);
$tmp = explode($delimiter3, $seg[1]);
$out['warnings'] .= "Payer is restating our procedure " . $svc[1] .
" as " . $tmp[1] . ".\n";
} else {
$svc = explode($delimiter3, $seg[1]);
}
if ($svc[0] != 'HC') return 'SVC segment has unexpected qualifier';
// TBD: Other qualifiers are possible; see IG pages 140-141.
$i = count($out['svc']);
$out['svc'][$i] = array();
// It seems some payers append the modifier with no separator!
if (strlen($svc[1]) == 7 && empty($svc[2])) {
$out['svc'][$i]['code'] = substr($svc[1], 0, 5);
$out['svc'][$i]['mod'] = substr($svc[1], 5);
} else {
$out['svc'][$i]['code'] = $svc[1];
$out['svc'][$i]['mod'] = $svc[2] ? $svc[2] . ':' : '';
$out['svc'][$i]['mod'] .= $svc[3] ? $svc[3] . ':' : '';
$out['svc'][$i]['mod'] .= $svc[4] ? $svc[4] . ':' : '';
$out['svc'][$i]['mod'] .= $svc[5] ? $svc[5] . ':' : '';
$out['svc'][$i]['mod'] = preg_replace('/:$/','',$out['svc'][$i]['mod']);
}
$out['svc'][$i]['chg'] = $seg[2];
$out['svc'][$i]['paid'] = $seg[3];
$out['svc'][$i]['adj'] = array();
// Note: SVC05, if present, indicates the paid units of service.
// It defaults to 1.
}
// DTM01 identifies the type of service date:
// 472 = a single date of service
// 150 = service period start
// 151 = service period end
else if ($segid == 'DTM' && $out['loopid'] == '2110') {
$out['dos'] = trim($seg[2]); // yyyymmdd
}
else if ($segid == 'CAS' && $out['loopid'] == '2110') {
$i = count($out['svc']) - 1;
for ($k = 2; $k < 20; $k += 3) {
if (!$seg[$k]) break;
if ($seg[1] == 'CO' && $seg[$k+1] < 0) {
$out['warnings'] .= "Negative Contractual Obligation adjustment " .
"seems wrong. Inverting, but should be checked!\n";
$seg[$k+1] = 0 - $seg[$k+1];
}
$j = count($out['svc'][$i]['adj']);
$out['svc'][$i]['adj'][$j] = array();
$out['svc'][$i]['adj'][$j]['group_code'] = $seg[1];
$out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
$out['svc'][$i]['adj'][$j]['amount'] = $seg[$k+1];
// Note: $seg[$k+2] is "quantity". A value here indicates a change to
// the number of units of service. We're ignoring that for now.
}
}
else if ($segid == 'REF' && $out['loopid'] == '2110') {
// ignore
}
else if ($segid == 'AMT' && $seg[1] == 'B6' && $out['loopid'] == '2110') {
$i = count($out['svc']) - 1;
$out['svc'][$i]['allowed'] = $seg[2]; // report this amount as a note
}
else if ($segid == 'AMT' && $out['loopid'] == '2110') {
$out['warnings'] .= "$inline at service level ignored.\n";
}
else if ($segid == 'LQ' && $seg[1] == 'HE' && $out['loopid'] == '2110') {
$i = count($out['svc']) - 1;
$out['svc'][$i]['remark'] = $seg[2];
}
else if ($segid == 'QTY' && $out['loopid'] == '2110') {
$out['warnings'] .= "QTY segment at service level ignored.\n";
}
else if ($segid == 'PLB') {
// Provider-level adjustments are a General Ledger thing and should not
// alter the A/R for the claim, so we just report them as notes.
for ($k = 3; $k < 15; $k += 2) {
if (!$seg[$k]) break;
$out['warnings'] .= 'PROVIDER LEVEL ADJUSTMENT (not claim-specific): $' .
sprintf('%.2f', $seg[$k+1]) . " with reason code " . $seg[$k] . "\n";
// Note: For PLB adjustment reason codes see IG pages 165-170.
}
}
else if ($segid == 'SE') {
parse_era_2100($out, $cb);
$out['loopid'] = '';
if ($out['st_control_number'] != trim($seg[2])) {
return 'Ending transaction set control number mismatch';
}
if (($out['st_segment_count'] + 1) != trim($seg[1])) {
return 'Ending transaction set segment count mismatch';
}
}
else if ($segid == 'GE') {
if ($out['loopid']) return 'Unexpected GE segment';
if ($out['gs_control_number'] != trim($seg[2])) {
return 'Ending functional group control number mismatch';
}
}
else if ($segid == 'IEA') {
if ($out['loopid']) return 'Unexpected IEA segment';
if ($out['isa_control_number'] != trim($seg[2])) {
return 'Ending interchange control number mismatch';
}
}
else {
return "Unknown or unexpected segment ID $segid";
}
++$out['st_segment_count'];
}
if ($segid != 'IEA') return 'Premature end of ERA file';
return '';
}
//for getting the check details and provider details
function parse_era_for_check($filename) {
$delimiter1 = '~';
$delimiter2 = '|';
$delimiter3 = '^';
$infh = fopen($filename, 'r');
if (! $infh) return "ERA input file open failed";
$out = array();
$out['loopid'] = '';
$out['st_segment_count'] = 0;
$buffer = '';
$segid = '';
$check_count=0;
while (true) {
if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
$tpos = strpos($buffer, $delimiter1);
if ($tpos === false) break;
$inline = substr($buffer, 0, $tpos);
$buffer = substr($buffer, $tpos + 1);
// If this is the ISA segment then figure out what the delimiters are.
if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
$delimiter2 = substr($inline, 3, 1);
$delimiter3 = substr($inline, -1);
}
$seg = explode($delimiter2, $inline);
$segid = $seg[0];
if ($segid == 'ISA') {
}
else if ($segid == 'BPR') {
++$check_count;
//if ($out['loopid']) return 'Unexpected BPR segment';
$out['check_amount'.$check_count] = trim($seg[2]);
$out['check_date'.$check_count] = trim($seg[16]); // yyyymmdd
// TBD: BPR04 is a payment method code.
}
else if ($segid == 'N1' && $seg[1] == 'PE') {
//if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
$out['loopid'] = '1000B';
$out['payee_name'.$check_count] = trim($seg[2]);
$out['payee_tax_id'.$check_count] = trim($seg[4]);
}
else if ($segid == 'TRN') {
//if ($out['loopid']) return 'Unexpected TRN segment';
$out['check_number'.$check_count] = trim($seg[2]);
$out['payer_tax_id'.$check_count] = substr($seg[3], 1); // 9 digits
$out['payer_id'.$check_count] = trim($seg[4]);
// Note: TRN04 further qualifies the paying entity within the
// organization identified by TRN03.
}
++$out['st_segment_count'];
}
$out['check_count']=$check_count;
era_callback_check($out);
if ($segid != 'IEA') return 'Premature end of ERA file';
return '';
}
?>