work on payment reversals, but forcing manual handling of them and al…

…so denied claims for now

interface/billing/sl_eob_process.php

@@ -1,5 +1,5 @@
 <?php
- // Copyright (C) 2006 Rod Roark <[email protected]>
+ // Copyright (C) 2006-2007 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
@@ -167,6 +167,17 @@ function era_callback(&$out) {
  // }
  }
 
+ if ($csc == '4') {
+ $inverror = true;
+ writeMessageLine($bgcolor, 'errdetail',
+ "Not posting adjustments for denied claims, please follow up manually!");
+ }
+ else if ($csc == '22') {
+ $inverror = true;
+ writeMessageLine($bgcolor, 'errdetail',
+ "Payment reversals are not automated, please enter manually!");
+ }
+
  if ($out['warnings']) {
  writeMessageLine($bgcolor, 'infdetail', nl2br(rtrim($out['warnings'])));
  }
@@ -189,7 +200,7 @@ function era_callback(&$out) {
  writeOldDetail($prev, $patient_name, $invnumber, $service_date, $svc['code'], $bgcolor);
  // Check for sanity in amount charged.
  $prevchg = sprintf("%.2f", $prev['chg'] + $prev['adj']);
- if ($prevchg != $svc['chg']) {
+ if ($prevchg != abs($svc['chg'])) {
  writeMessageLine($bgcolor, 'errdetail',
  "EOB charge amount " . $svc['chg'] . " for this code does not match our invoice");
  $error = true;
@@ -320,13 +331,21 @@ function era_callback(&$out) {
 
  } // End of service item
 
- // Report any existing service items not mentioned in the ERA.
+ // Report any existing service items not mentioned in the ERA, and
+ // determine if any of them are still missing an insurance response
+ // (if so, then insurance is not yet done with the claim).
+ $insurance_done = true;
  foreach ($codes as $code => $prev) {
  writeOldDetail($prev, $arrow['name'], $invnumber, $service_date, $code, $bgcolor);
+ $got_response = false;
+ foreach ($prev['dtl'] as $ddata) {
+ if ($ddata['pmt'] || $ddata['rsn']) $got_response = true;
+ }
+ if (!$got_response) $insurance_done = false;
  }
 
- // Cleanup: If all is well, mark Ins1 done and check for secondary billing.
- if (!$error && !$debug) {
+ // Cleanup: If all is well, mark Ins<x> done and check for secondary billing.
+ if (!$error && !$debug && $insurance_done) {
  $shipvia = 'Done: Ins1';
  if ($inslabel != 'Ins1') $shipvia .= ',Ins2';
  if ($inslabel == 'Ins3') $shipvia .= ',Ins3';

library/parse_era.inc.php

@@ -9,20 +9,51 @@
 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. Whenever this is an issue it should result from
- // claim-level adjustments, and in this case the first SVC item
- // that we stored was a 'Claim' type.
+ // 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 = $out['amount_approved'];
- foreach ($out['svc'] as $svc) $paytotal -= $svc['paid'];
+ $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);
- if ($paytotal != 0) {
-  $out['svc'][0]['paid'] += $paytotal;
+ $adjtotal = round($adjtotal, 2);
+ if ($paytotal != 0 || $adjtotal != 0) {
  if ($out['svc'][0]['code'] != 'Claim') {
- $out['warnings'] .= "First service item payment amount " .
- "adjusted by $paytotal due to payment imbalance. " .
- "This should not happen!\n";
+ array_unshift($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);
@@ -285,12 +316,13 @@ function parse_era($filename, $cb) {
  if (! $out['loopid']) return 'Unexpected SVC segment';
  $out['loopid'] = '2110';
  if ($seg[6]) {
- // SVC06 if present is our original procedure code that they are bundling.
+ // 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('^', $seg[6]);
  $tmp = explode('^', $seg[1]);
- $out['warnings'] .= "Payer is bundling " . $svc[1] . " into " . $tmp[1] . ".\n";
+ $out['warnings'] .= "Payer is restating our procedure " . $svc[1] .
+ " as " . $tmp[1] . ".\n";
  } else {
  $svc = explode('^', $seg[1]);
  }