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gen_x12_837.inc.php
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gen_x12_837.inc.php
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<?php
/*
* This program creates a 5010 837P file
*
* @package OpenEMR
* @author Rod Roark <[email protected]>
* @author Stephen Waite <[email protected]>
* @copyright Copyright (c) 2009 Rod Roark <[email protected]>
* @copyright Copyright (c) 2018 Stephen Waite <[email protected]>
* @link https://github.com/openemr/openemr/tree/master
* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
*/
require_once(dirname(__FILE__) . "/invoice_summary.inc.php");
use OpenEMR\Billing\Claim;
function stripZipCode($zip)
{
$temp = preg_replace('/[-\s]*/', '', $zip);
if (strlen($temp) == 5) {
return $temp . "9999";
} else {
return $temp;
}
}
function gen_x12_837($pid, $encounter, &$log, $encounter_claim = false)
{
$today = time();
$out = '';
$claim = new Claim($pid, $encounter);
$edicount = 0;
$HLcount = 0;
$log .= "Generating claim $pid" . "-" . $encounter . " for " .
$claim->patientFirstName() . ' ' .
$claim->patientMiddleName() . ' ' .
$claim->patientLastName() . ' on ' .
date('Y-m-d H:i', $today) . ".\n";
$out .= "ISA" .
"*" . $claim->x12gsisa01() .
"*" . $claim->x12gsisa02() .
"*" . $claim->x12gsisa03() .
"*" . $claim->x12gsisa04() .
"*" . $claim->x12gsisa05() .
"*" . $claim->x12gssenderid() .
"*" . $claim->x12gsisa07() .
"*" . $claim->x12gsreceiverid() .
"*" . "030911" . // dummy data replace by billing_process.php
"*" . "1630" . // ditto
"*" . "^" .
"*" . "00501" .
"*" . "000000001" .
"*" . $claim->x12gsisa14() .
"*" . $claim->x12gsisa15() .
"*:" .
"~\n";
$out .= "GS" .
"*" . "HC" .
"*" . $claim->x12gsgs02() .
"*" . trim($claim->x12gs03()) .
"*" . date('Ymd', $today) .
"*" . date('Hi', $today) .
"*" . "1" .
"*" . "X" .
"*" . $claim->x12gsversionstring() .
"~\n";
++$edicount;
$out .= "ST" .
"*" . "837" .
"*" . "0021" .
"*" . $claim->x12gsversionstring() .
"~\n";
++$edicount;
$out .= "BHT" .
"*" . "0019" . // 0019 is required here
"*" . "00" . // 00 = original transmission
"*" . "0123" . // reference identification
"*" . date('Ymd', $today) . // transaction creation date
"*" . date('Hi', $today) . // transaction creation time
"*" . ($encounter_claim ? "RP" : "CH") . // RP = reporting, CH = chargeable
"~\n";
++$edicount;
if ($claim->federalIdType() == "SY") { // check entity type for NM*102 1 == person, 2 == non-person entity
$firstName = $claim->providerFirstName();
$lastName = $claim->providerLastName();
$middleName = $claim->providerMiddleName();
$suffixName = $claim->providerSuffixName();
$out .= "NM1" . // Loop 1000A Submitter
"*" . "41" .
"*" . "1" .
"*" . $lastName .
"*" . $firstName .
"*" . $middleName .
"*" . // Name Prefix not used
"*" . $suffixName .
"*" . "46";
} else {
$billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
if ($billingFacilityName == '') {
$log .= "*** billing facility name in 1000A loop is empty\n";
}
$out .= "NM1" .
"*" . "41" .
"*" . "2" .
"*" . $billingFacilityName .
"*" .
"*" .
"*" .
"*" .
"*" . "46";
}
$out .= "*" . $claim->billingFacilityETIN();
$out .= "~\n";
++$edicount;
$out .= "PER" . // Loop 1000A, Submitter EDI contact information
"*" . "IC" .
"*" . $claim->billingContactName() .
"*" . "TE" .
"*" . $claim->billingContactPhone() .
"*" . "EM" .
"*" . $claim->billingContactEmail();
$out .= "~\n";
++$edicount;
$out .= "NM1" . // Loop 1000B Receiver
"*" . "40" .
"*" . "2" .
"*" . $claim->clearingHouseName() .
"*" .
"*" .
"*" .
"*" .
"*" . "46" .
"*" . $claim->clearingHouseETIN() .
"~\n";
++$HLcount;
++$edicount;
$out .= "HL" . // Loop 2000A Billing/Pay-To Provider HL Loop
"*" . $HLcount .
"*" .
"*" . "20" .
"*" . "1" . // 1 indicates there are child segments
"~\n";
$HLBillingPayToProvider = $HLcount++;
// Situational PRV segment for provider taxonomy.
if ($claim->facilityTaxonomy()) {
++$edicount;
$out .= "PRV" .
"*" . "BI" .
"*" . "PXC" .
"*" . $claim->facilityTaxonomy() .
"~\n";
}
// Situational CUR segment (foreign currency information) omitted here.
++$edicount;
if ($claim->federalIdType() == "SY") { // check for entity type like in 1000A
$firstName = $claim->providerFirstName();
$lastName = $claim->providerLastName();
$middleName = $claim->providerMiddleName();
$out .= "NM1" .
"*" . "85" .
"*" . "1" .
"*" . $lastName .
"*" . $firstName .
"*" . $middleName .
"*" . // Name Prefix not used
"*";
} else {
$billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
if ($billingFacilityName == '') {
$log .= "*** billing facility name in 2010A loop is empty\n";
}
$out .= "NM1" . // Loop 2010AA Billing Provider
"*" . "85" .
"*" . "2" .
"*" . $billingFacilityName .
"*" .
"*" .
"*" .
"*";
}
if ($claim->billingFacilityNPI()) {
$out .= "*XX*" . $claim->billingFacilityNPI();
} else {
$log .= "*** Billing facility has no NPI.\n";
}
$out .= "~\n";
++$edicount;
$out .= "N3" .
"*" . $claim->billingFacilityStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->billingFacilityCity() .
"*" . $claim->billingFacilityState() .
"*" . stripZipCode($claim->billingFacilityZip()) .
"~\n";
if ($claim->billingFacilityNPI() && $claim->billingFacilityETIN()) {
++$edicount;
$out .= "REF";
if ($claim->federalIdType()) {
$out .= "*" . $claim->federalIdType();
} else {
$out .= "*EI"; // For dealing with the situation before adding TaxId type In facility.
}
$out .= "*" . $claim->billingFacilityETIN() . "~\n";
} else {
$log .= "*** No billing facility NPI and/or ETIN.\n";
}
if ($claim->providerNumberType() && $claim->providerNumber() && !$claim->billingFacilityNPI()) {
++$edicount;
$out .= "REF" .
"*" . $claim->providerNumberType() .
"*" . $claim->providerNumber() .
"~\n";
} else if ($claim->providerNumber() && !$claim->providerNumberType()) {
$log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
}
// Situational PER*1C segment omitted.
// Pay-To Address defaults to billing provider and is no longer required in 5010 but may be useful
if ($claim->facilityStreet() != $claim->billingFacilityStreet()) {
++$edicount;
$billingFacilityName = substr($claim->billingFacilityName(), 0, 60);
$out .= "NM1" . // Loop 2010AB Pay-To Provider
"*" . "87" .
"*" . "2" .
"*" . $billingFacilityName .
"*" .
"*" .
"*" .
"*";
if ($claim->billingFacilityNPI()) {
$out .= "*XX*" . $claim->billingFacilityNPI();
}
$out .= "~\n";
++$edicount;
$out .= "N3" .
"*" . $claim->billingFacilityStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->billingFacilityCity() .
"*" . $claim->billingFacilityState() .
"*" . stripZipCode($claim->billingFacilityZip()) .
"~\n";
}
// Loop 2010AC Pay-To Plan Name omitted. Includes:
// NM1*PE, N3, N4, REF*2U, REF*EI
$PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
$HLSubscriber = $HLcount++;
++$edicount;
$out .= "HL" . // Loop 2000B Subscriber HL Loop
"*" . $HLSubscriber .
"*" . $HLBillingPayToProvider .
"*" . "22" .
"*" . $PatientHL .
"~\n";
if (!$claim->payerSequence()) {
$log .= "*** Error: Insurance information is missing!\n";
}
++$edicount;
$out .= "SBR" . // Subscriber Information
"*" . $claim->payerSequence() .
"*" . ($claim->isSelfOfInsured() ? '18' : '') .
"*" . $claim->groupNumber() .
"*" . ($claim->groupNumber() ? '' : $claim->groupName()) . // if groupNumber no groupName
"*" . $claim->insuredTypeCode() . // applies for secondary medicare
"*" .
"*" .
"*" .
"*" . $claim->claimType() .
"~\n";
// Segment PAT omitted.
++$edicount;
$out .= "NM1" . // Loop 2010BA Subscriber
"*" . "IL" .
"*" . "1" . // 1 = person, 2 = non-person
"*" . $claim->insuredLastName() .
"*" . $claim->insuredFirstName() .
"*" . $claim->insuredMiddleName() .
"*" .
"*" . // Name Suffix not used
"*" . "MI" .
// "MI" = Member Identification Number
// "II" = Standard Unique Health Identifier, "Required if the
// HIPAA Individual Patient Identifier is mandated use."
// Here we presume that is not true yet.
"*" . $claim->policyNumber() .
"~\n";
// For 5010, further subscriber info is sent only if they are the patient.
if ($claim->isSelfOfInsured()) {
++$edicount;
$out .= "N3" .
"*" . $claim->insuredStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->insuredCity() .
"*" . $claim->insuredState() .
"*" . stripZipCode($claim->insuredZip()) .
"~\n";
++$edicount;
$out .= "DMG" .
"*" . "D8" .
"*" . $claim->insuredDOB() .
"*" . $claim->insuredSex() .
"~\n";
}
// Segment REF*SY (Subscriber Secondary Identification) omitted.
// Segment REF*Y4 (Property and Casualty Claim Number) omitted.
// Segment PER*IC (Property and Casualty Subscriber Contact Information) omitted.
++$edicount;
$payerName = substr($claim->payerName(), 0, 60);
$out .= "NM1" . // Loop 2010BB Payer
"*" . "PR" .
"*" . "2" .
"*" . $payerName .
"*" .
"*" .
"*" .
"*" .
"*" . "PI" .
"*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
"~\n";
if (!$claim->payerID()) {
$log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
}
++$edicount;
$out .= "N3" .
"*" . $claim->payerStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->payerCity() .
"*" . $claim->payerState() .
"*" . stripZipCode($claim->payerZip()) .
"~\n";
// Segment REF (Payer Secondary Identification) omitted.
// Segment REF (Billing Provider Secondary Identification) omitted.
if (!$claim->isSelfOfInsured()) {
++$edicount;
$out .= "HL" . // Loop 2000C Patient Information
"*" . $HLcount .
"*" . $HLSubscriber .
"*" . "23" .
"*" . "0" .
"~\n";
$HLcount++;
++$edicount;
$out .= "PAT" .
"*" . $claim->insuredRelationship() .
"~\n";
++$edicount;
$out .= "NM1" . // Loop 2010CA Patient
"*" . "QC" .
"*" . "1" .
"*" . $claim->patientLastName() .
"*" . $claim->patientFirstName();
if ($claim->patientMiddleName() !== '') {
$out .= "*" . $claim->patientMiddleName();
}
$out .= "~\n";
++$edicount;
$out .= "N3" .
"*" . $claim->patientStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->patientCity() .
"*" . $claim->patientState() .
"*" . stripZipCode($claim->patientZip()) .
"~\n";
++$edicount;
$out .= "DMG" .
"*" . "D8" .
"*" . $claim->patientDOB() .
"*" . $claim->patientSex() .
"~\n";
// Segment REF*Y4 (Property and Casualty Claim Number) omitted.
// Segment REF (Property and Casualty Patient Identifier) omitted.
// Segment PER (Property and Casualty Patient Contact Information) omitted.
} // end of patient different from insured
$proccount = $claim->procCount();
$clm_total_charges = 0;
for ($prockey = 0; $prockey < $proccount; ++$prockey) {
$clm_total_charges += $claim->cptCharges($prockey);
}
if (!$clm_total_charges) {
$log .= "*** This claim has no charges!\n";
}
++$edicount;
$out .= "CLM" . // Loop 2300 Claim
"*" . $pid . "-" . $encounter .
"*" . sprintf("%.2f", $clm_total_charges) .
"*" .
"*" .
"*" . sprintf('%02d', $claim->facilityPOS()) . ":" . "B" . ":" . $claim->frequencyTypeCode() .
"*" . "Y" .
"*" . "A" .
"*" . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
"*" . "Y" .
"~\n";
// above is for historical use of encounter onset date, now in misc_billing_options
// Segment DTP*431 (Onset of Current Symptoms or Illness)
// Segment DTP*484 (Last Menstrual Period Date)
if ($claim->onsetDate() && ($claim->onsetDate() !== $claim->serviceDate()) && ($claim->onsetDateValid())) {
++$edicount;
$out .= "DTP" . // Date of Onset
"*" . "431" .
"*" . "D8" .
"*" . $claim->onsetDate() .
"~\n";
} else if ($claim->miscOnsetDate() && ($claim->miscOnsetDate() !== $claim->serviceDate())
&& ($claim->box14Qualifier()) && ($claim->miscOnsetDateValid())) {
++$edicount;
$out .= "DTP" .
"*" . $claim->box14Qualifier() .
"*" . "D8" .
"*" . $claim->miscOnsetDate() .
"~\n";
}
// Segment DTP*304 (Last Seen Date)
// Segment DTP*453 (Acute Manifestation Date)
// Segment DTP*439 (Accident Date)
// Segment DTP*455 (Last X-Ray Date)
// Segment DTP*471 (Hearing and Vision Prescription Date)
// Segment DTP*314 (Disability) omitted.
// Segment DTP*360 (Initial Disability Period Start) omitted.
// Segment DTP*361 (Initial Disability Period End) omitted.
// Segment DTP*297 (Last Worked Date)
// Segment DTP*296 (Authorized Return to Work Date)
// Segment DTP*454 (Initial Treatment Date)
if ($claim->dateInitialTreatment() && ($claim->box15Qualifier()) && ($claim->dateInitialTreatmentValid())) {
++$edicount;
$out .= "DTP" . // Date Last Seen
"*" . $claim->box15Qualifier() .
"*" . "D8" .
"*" . $claim->dateInitialTreatment() .
"~\n";
}
if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->onsetDateValid()) {
++$edicount;
$out .= "DTP" . // Date of Hospitalization
"*" . "435" .
"*" . "D8" .
"*" . $claim->onsetDate() .
"~\n";
}
// above is for historical use of encounter onset date, now in misc_billing_options
if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->hospitalizedFromDateValid()) {
++$edicount;
$out .= "DTP" . // Date of Admission
"*" . "435" .
"*" . "D8" .
"*" . $claim->hospitalizedFrom() .
"~\n";
}
// Segment DTP*096 (Discharge Date)
if (strcmp($claim->facilityPOS(), '21') == 0 && $claim->hospitalizedToDateValid()) {
++$edicount;
$out .= "DTP" . // Date of Discharge
"*" . "96" .
"*" . "D8" .
"*" . $claim->hospitalizedTo() .
"~\n";
}
// Segments DTP (Assumed and Relinquished Care Dates) omitted.
// Segment DTP*444 (Property and Casualty Date of First Contact) omitted.
// Segment DTP*050 (Repricer Received Date) omitted.
// Segment PWK (Claim Supplemental Information) omitted.
// Segment CN1 (Contract Information) omitted.
$patientpaid = $claim->patientPaidAmount();
if ($patientpaid != 0) {
++$edicount;
$out .= "AMT" . // Patient paid amount. Page 190/220.
"*" . "F5" .
"*" . $patientpaid .
"~\n";
}
// Segment REF*4N (Service Authorization Exception Code) omitted.
// Segment REF*F5 (Mandatory Medicare Crossover Indicator) omitted.
// Segment REF*EW (Mammography Certification Number) omitted.
// Segment REF*9F (Referral Number) omitted.
if ($claim->priorAuth()) {
++$edicount;
$out .= "REF" . // Prior Authorization Number
"*" . "G1" .
"*" . $claim->priorAuth() .
"~\n";
}
// Segment REF*F8 Payer Claim Control Number for claim re-submission.icn_resubmission_number
if (trim($claim->billing_options['icn_resubmission_number']) > 3) {
++$edicount;
error_log("Method 1: " . $claim->billing_options['icn_resubmission_number'], 0);
$out .= "REF" .
"*" . "F8" .
"*" . $claim->icnResubmissionNumber() .
"~\n";
}
if ($claim->cliaCode() && ($claim->claimType() === 'MB')) {
// Required by Medicare when in-house labs are done.
++$edicount;
$out .= "REF" . // Clinical Laboratory Improvement Amendment Number
"*" . "X4" .
"*" . $claim->cliaCode() .
"~\n";
}
// Segment REF*9A (Repriced Claim Number) omitted.
// Segment REF*9C (Adjusted Repriced Claim Number) omitted.
// Segment REF*LX (Investigational Device Exemption Number) omitted.
// Segment REF*D9 (Claim Identifier for Transmission Intermediaries) omitted.
// Segment REF*EA (Medical Record Number) omitted.
// Segment REF*P4 (Demonstration Project Identifier) omitted.
// Segment REF*1J (Care Plan Oversight) omitted.
// Segment K3 (File Information) omitted.
if ($claim->additionalNotes()) {
// Claim note.
++$edicount;
$out .= "NTE" . // comments box 19
"*" . "ADD" .
"*" . $claim->additionalNotes() .
"~\n";
}
// Segment CR1 (Ambulance Transport Information) omitted.
// Segment CR2 (Spinal Manipulation Service Information) omitted.
// Segment CRC (Ambulance Certification) omitted.
// Segment CRC (Patient Condition Information: Vision) omitted.
// Segment CRC (Homebound Indicator) omitted.
// Segment CRC (EPSDT Referral).
if ($claim->epsdtFlag()) {
++$edicount;
$out .= "CRC" .
"*" . "ZZ" .
"*" . "Y" .
"*" . $claim->medicaidReferralCode() .
"~\n";
}
// Diagnoses, up to $max_per_seg per HI segment.
$max_per_seg = 12;
$da = $claim->diagArray();
if ($claim->diagtype == "ICD9") {
$diag_type_code = 'BK';
} else {
$diag_type_code = 'ABK';
}
$tmp = 0;
foreach ($da as $diag) {
if ($tmp % $max_per_seg == 0) {
if ($tmp) {
$out .= "~\n";
}
++$edicount;
$out .= "HI"; // Health Diagnosis Codes
}
$out .= "*" . $diag_type_code . ":" . $diag;
if ($claim->diagtype == "ICD9") {
$diag_type_code = 'BF';
} else {
$diag_type_code = 'ABF';
}
++$tmp;
}
if ($tmp) {
$out .= "~\n";
}
// Segment HI*BP (Anesthesia Related Procedure) omitted.
// Segment HI*BG (Condition Information) omitted.
// Segment HCP (Claim Pricing/Repricing Information) omitted.
if ($claim->referrerLastName()) {
// Medicare requires referring provider's name and UPIN.
++$edicount;
$out .= "NM1" . // Loop 2310A Referring Provider
"*" . "DN" .
"*" . "1" .
"*" . $claim->referrerLastName() .
"*" . $claim->referrerFirstName() .
"*" . $claim->referrerMiddleName() .
"*" .
"*";
if ($claim->referrerNPI()) {
$out .=
"*" . "XX" .
"*" . $claim->referrerNPI();
} else {
$log .= "*** Referring provider has no NPI.\n";
}
$out .= "~\n";
}
// Per the implementation guide lines, only include this information if it is different
// than the Loop 2010AA information
if ($claim->providerNPIValid() && ($claim->billingFacilityNPI() !== $claim->providerNPI())) {
++$edicount;
$out .= "NM1" . // Loop 2310B Rendering Provider
"*" . "82" .
"*" . "1" .
"*" . $claim->providerLastName() .
"*" . $claim->providerFirstName() .
"*" . $claim->providerMiddleName() .
"*" .
"*";
if ($claim->providerNPI()) {
$out .=
"*" . "XX" .
"*" . $claim->providerNPI();
} else {
$log .= "*** Rendering provider has no NPI.\n";
}
$out .= "~\n";
if ($claim->providerTaxonomy()) {
++$edicount;
$out .= "PRV" .
"*" . "PE" . // Performing provider
"*" . "PXC" .
"*" . $claim->providerTaxonomy() .
"~\n";
} else {
$log .= "*** Performing provider has no taxonomy code.\n";
}
} else {
$log .= "*** Rendering provider is billing under a group.\n";
}
if (!$claim->providerNPIValid()) {
// If the loop was skipped because the provider NPI was invalid, generate a warning for the log.
$log .= "*** Skipping 2310B because " . $claim->providerLastName() . "," . $claim->providerFirstName() . " has invalid NPI.\n";
}
if (!$claim->providerNPI() && in_array($claim->providerNumberType(), array('0B', '1G', 'G2', 'LU'))) {
if ($claim->providerNumber()) {
++$edicount;
$out .= "REF" .
"*" . $claim->providerNumberType() .
"*" . $claim->providerNumber() .
"~\n";
}
}
// End of Loop 2310B
// Loop 2310C is omitted in the case of home visits (POS=12).
if ($claim->facilityPOS() != 12 && ($claim->facilityNPI() != $claim->billingFacilityNPI())) {
++$edicount;
$out .= "NM1" . // Loop 2310C Service Location
"*" . "77" .
"*" . "2";
$facilityName = substr($claim->facilityName(), 0, 60);
if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) {
$out .=
"*" . $facilityName;
} else {
$log .= "*** Check for invalid facility name, NPI, and/or tax id.\n";
}
if ($claim->facilityNPI() || $claim->facilityETIN()) {
$out .=
"*" .
"*" .
"*" .
"*";
if ($claim->facilityNPI()) {
$out .=
"*" . "XX" . "*" . $claim->facilityNPI();
} else {
$out .=
"*" . "24" . "*" . $claim->facilityETIN();
}
if (!$claim->facilityNPI()) {
$log .= "*** Service location has no NPI.\n";
}
}
$out .= "~\n";
if ($claim->facilityStreet()) {
++$edicount;
$out .= "N3" .
"*" . $claim->facilityStreet() .
"~\n";
}
if ($claim->facilityState()) {
++$edicount;
$out .= "N4" .
"*" . $claim->facilityCity() .
"*" . $claim->facilityState() .
"*" . stripZipCode($claim->facilityZip()) .
"~\n";
}
}
// Segment REF (Service Facility Location Secondary Identification) omitted.
// Segment PER (Service Facility Contact Information) omitted.
// Loop 2310D, Supervising Provider
if (! empty($claim->supervisorLastName())) {
++$edicount;
$out .= "NM1" .
"*" . "DQ" . // Supervising Physician
"*" . "1" . // Person
"*" . $claim->supervisorLastName() .
"*" . $claim->supervisorFirstName() .
"*" . $claim->supervisorMiddleName() .
"*" . // NM106 not used
"*"; // Name Suffix not used
if ($claim->supervisorNPI()) {
$out .=
"*" . "XX" .
"*" . $claim->supervisorNPI();
} else {
$log .= "*** Supervising Provider has no NPI.\n";
}
$out .= "~\n";
if ($claim->supervisorNumber()) {
++$edicount;
$out .= "REF" .
"*" . $claim->supervisorNumberType() .
"*" . $claim->supervisorNumber() .
"~\n";
}
}
// Segments NM1*PW, N3, N4 (Ambulance Pick-Up Location) omitted.
// Segments NM1*45, N3, N4 (Ambulance Drop-Off Location) omitted.
// Loops 2320 and 2330, other subscriber/payer information.
// Remember that insurance index 0 is always for the payer being billed
// by this claim, and 1 and above are always for the "other" payers.
for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
$tmp1 = $claim->claimType($ins);
$tmp2 = 'C1'; // Here a kludge. See page 321.
if ($tmp1 === 'CI') {
$tmp2 = 'C1';
}
if ($tmp1 === 'AM') {
$tmp2 = 'AP';
}
if ($tmp1 === 'HM') {
$tmp2 = 'HM';
}
if ($tmp1 === 'MB') {
$tmp2 = 'MB';
}
if ($tmp1 === 'MC') {
$tmp2 = 'MC';
}
if ($tmp1 === '09') {
$tmp2 = 'PP';
}
++$edicount;
$out .= "SBR" . // Loop 2320, Subscriber Information - page 297/318
"*" . $claim->payerSequence($ins) .
"*" . $claim->insuredRelationship($ins) .
"*" . $claim->groupNumber($ins) .
"*" . ($claim->groupNumber() ? '' : $claim->groupName()) .
"*" . $claim->insuredTypeCode($ins) .
"*" .
"*" .
"*" .
"*" . $claim->claimType($ins) .
"~\n";
// Things that apply only to previous payers, not future payers.
if ($claim->payerSequence($ins) < $claim->payerSequence()) {
// Generate claim-level adjustments.
$aarr = $claim->payerAdjustments($ins);
foreach ($aarr as $a) {
++$edicount;
$out .= "CAS" . // Previous payer's claim-level adjustments. Page 301/323.
"*" . $a[1] .
"*" . $a[2] .
"*" . $a[3] .
"~\n";
}
$payerpaid = $claim->payerTotals($ins);
++$edicount;
$out .= "AMT" . // Previous payer's paid amount. Page 307/332.
"*" . "D" .
"*" . $payerpaid[1] .
"~\n";
// Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
// Segment AMT*EAF (Remaining Patient Liability) omitted.
} // End of things that apply only to previous payers.
++$edicount;
$out .= "OI" . // Other Insurance Coverage Information. Page 310/344.
"*" .
"*" .
"*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
// For this next item, the 5010 example in the spec does not match its
// description. So this might be wrong.
"*" .
"*" .
"*" .
"Y" .
"~\n";
// Segment MOA (Medicare Outpatient Adjudication) omitted.
++$edicount;
$out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
"*" . "IL" .
"*" . "1" .
"*" . $claim->insuredLastName($ins) .
"*" . $claim->insuredFirstName($ins) .
"*" . $claim->insuredMiddleName($ins) .
"*" .
"*" .
"*" . "MI" .
"*" . $claim->policyNumber($ins) .
"~\n";
++$edicount;
$out .= "N3" .
"*" . $claim->insuredStreet($ins) .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->insuredCity($ins) .
"*" . $claim->insuredState($ins) .
"*" . stripZipCode($claim->insuredZip($ins)) .
"~\n";
// Segment REF (Other Subscriber Secondary Identification) omitted.
++$edicount;
$payerName = substr($claim->payerName($ins), 0, 60);
$out .= "NM1" . // Loop 2330B Payer info for other insco. Page 322/359.
"*" . "PR" .
"*" . "2" .
"*" . $payerName .
"*" .
"*" .
"*" .
"*" .
"*" . "PI" .
"*" . $claim->payerID($ins) .
"~\n";
if (!$claim->payerID($ins)) {
$log .= "*** CMS ID is missing for payer '" . $claim->payerName($ins) . "'.\n";
}
++$edicount;
$out .= "N3" .
"*" . $claim->payerStreet($ins) .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->payerCity($ins) .
"*" . $claim->payerState($ins) .
"*" . stripZipCode($claim->payerZip($ins)) .
"~\n";
// Segment DTP*573 (Claim Check or Remittance Date) omitted.
// Segment REF (Other Payer Secondary Identifier) omitted.
// Segment REF*G1 (Other Payer Prior Authorization Number) omitted.
// Segment REF*9F (Other Payer Referral Number) omitted.
// Segment REF*T4 (Other Payer Claim Adjustment Indicator) omitted.
// Segment REF*F8 (Other Payer Claim Control Number) omitted.
// Segment NM1 (Other Payer Referring Provider) omitted.
// Segment REF (Other Payer Referring Provider Secondary Identification) omitted.
// Segment NM1 (Other Payer Rendering Provider) omitted.
// Segment REF (Other Payer Rendering Provider Secondary Identification) omitted.
// Segment NM1 (Other Payer Service Facility Location) omitted.
// Segment REF (Other Payer Service Facility Location Secondary Identification) omitted.
// Segment NM1 (Other Payer Supervising Provider) omitted.
// Segment REF (Other Payer Supervising Provider Secondary Identification) omitted.
// Segment NM1 (Other Payer Billing Provider) omitted.
// Segment REF (Other Payer Billing Provider Secondary Identification) omitted.
} // End loops 2320/2330*.
$loopcount = 0;
// Loop 2400 Procedure Loop.
//
for ($prockey = 0; $prockey < $proccount; ++$prockey) {
++$loopcount;
++$edicount;
$out .= "LX" . // Segment LX, Service Line. Page 398.
"*" . $loopcount .
"~\n";
++$edicount;
$out .= "SV1" . // Segment SV1, Professional Service. Page 400.
"*" . "HC:" . $claim->cptKey($prockey) .
"*" . sprintf('%.2f', $claim->cptCharges($prockey)) .
"*" . "UN" .
"*" . $claim->cptUnits($prockey) .
"*" .
"*" .
"*";
$dia = $claim->diagIndexArray($prockey);
$i = 0;
foreach ($dia as $dindex) {
if ($i) {
$out .= ':';
}
$out .= $dindex;
if (++$i >= 4) {
break;
}
}
# needed for epstd
if ($claim->epsdtFlag()) {
$out .= "*" .
"*" .
"*" .
"*" . "Y" .
"~\n";
} else {
$out .= "~\n";
}
if (!$claim->cptCharges($prockey)) {
$log .= "*** Procedure '" . $claim->cptKey($prockey) . "' has no charges!\n";
}
if (empty($dia)) {
$log .= "*** Procedure '" . $claim->cptKey($prockey) . "' is not justified!\n";
}
// Segment SV5 (Durable Medical Equipment Service) omitted.
// Segment PWK01 (Line Supplemental Information) omitted.
// Segment CR1 (Ambulance Transport Information) omitted.
// Segment CR3 (Durable Medical Equipment Certification) omitted.
// Segment CRC (Ambulance Certification) omitted.
// Segment CRC (Hospice Employee Indicator) omitted.
// Segment CRC (Condition Indicator / Durable Medical Equipment) omitted.
++$edicount;
$out .= "DTP" . // Date of Service. Page 435.
"*" . "472" .
"*" . "D8" .