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gen_x12_837.inc.php
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gen_x12_837.inc.php
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<?php
// Copyright (C) 2007-2011 Rod Roark <rod@sunsetsystems.com>
//
// 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.
require_once("Claim.class.php");
function stripZipCode($zip)
{
return preg_replace('/[-\s]*/','',$zip);
}
function gen_x12_837($pid, $encounter, &$log, $encounter_claim=false) {
$today = time();
$out = '';
$claim = new Claim($pid, $encounter);
$edicount = 0;
// This is true for the 5010 standard, false for 4010.
// x12gsversionstring() should be "005010X222A1" or "004010X098A1".
$CMS_5010 = strpos($claim->x12gsversionstring(), '5010') !== false;
$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() .
"*" . $claim->x12gsreceiverid() .
"*030911" .
"*1630" .
"*" . ($CMS_5010 ? "^" : "U" ) .
"*" . ($CMS_5010 ? "00501" : "00401") .
"*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;
$out .= "ST" .
"*837" .
"*0021" .
// Spec says the following is optional, so should be able to leave it out.
($CMS_5010 ? ("*" . $claim->x12gsversionstring()) : "") .
"~\n";
++$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";
if (!$CMS_5010) {
// This segment was deleted for 5010.
++$edicount;
$out .= "REF" .
"*87" .
"*" . $claim->x12gsversionstring() .
"~\n";
}
++$edicount;
if ($claim->federalIdType() == "SY") { // check entity type for NM*102 1 == person, 2 == non-person entity
$tempName = $claim->billingFacilityName();
$partsName = explode(' ', $tempName);// Loop 1000A submitter entity == person
$num_parts = count($partsName);
switch ($num_parts) {
case "2":
$firstName = $partsName[0];
$middleName = '';
$lastName = $partsName[1];
$suffixName = '';
break;
case "3":
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = '';
break;
case "4":
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = $partsName[3];
break;
default:
$log .= "*** submitter name in 1000A loop has more than 4 parts, may not be desirable\n";
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = $partsName[3];
}
$out .= "NM1" . // Loop 1000A Submitter
"*41" .
"*1" .
"*" . $lastName .
"*" . $firstName .
"*" . $middleName .
"*" . // Name Prefix not used
"*" . // Name Suffix not used
"*46";
} else { //Field length is limited to 35. See nucc dataset page 63 www.nucc.org
$billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
if ($billingFacilityName == '') $log .= "*** billing facility name in 1000A loop is empty\n";
$out .= "NM1" .
"*41" .
"*2" .
"*" . $billingFacilityName .
"*" .
"*" .
"*" .
"*" .
"*46";
}
if (trim($claim->x12gsreceiverid()) == '470819582') { // if ECLAIMS EDI
$out .= "*" . $claim->clearingHouseETIN();
} else {
$out .= "*" . $claim->billingFacilityETIN();
}
$out .= "~\n";
++$edicount;
$out .= "PER" .
"*IC" .
"*" . $claim->billingContactName() .
"*TE" .
"*" . $claim->billingContactPhone();
if (!$CMS_5010 && $claim->x12gsper06()) {
$out .= "*ED*" . $claim->x12gsper06();
}
$out .= "~\n";
++$edicount;
$out .= "NM1" . // Loop 1000B Receiver
"*40" .
"*2" .
"*" . $claim->clearingHouseName() .
"*" .
"*" .
"*" .
"*" .
"*46" .
"*" . $claim->clearingHouseETIN() .
"~\n";
$HLcount = 1;
++$edicount;
$out .= "HL" . // Loop 2000A Billing/Pay-To Provider HL Loop
"*$HLcount" .
"*" .
"*20" .
"*1" . // 1 indicates there are child segments
"~\n";
$HLBillingPayToProvider = $HLcount++;
// Situational PRV segment for provider taxonomy code for Medicaid.
if ($claim->claimType() == 'MC') {
++$edicount;
$out .= "PRV*BI*ZZ" .
"*" . $claim->providerTaxonomy() .
"~\n";
}
// Situational CUR segment (foreign currency information) omitted here.
++$edicount;
//Field length is limited to 35. See nucc dataset page 63 www.nucc.org
if ($claim->federalIdType() == "SY") { // check for entity type like in 1000A
$tempName = $claim->billingFacilityName();
$partsName = explode(' ', $tempName);// Loop 2010AA Billing Provider entity == person
$num_parts = count($partsName);
switch ($num_parts) {
case "2":
$firstName = $partsName[0];
$middleName = '';
$lastName = $partsName[1];
$suffixName = '';
break;
case "3":
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = '';
break;
case "4":
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = $partsName[3];
break;
default:
$log .= "*** billing provider name in 2010AA loop has more than 4 parts, may not be desirable\n";
$firstName = $partsName[0];
$middleName = $partsName[1];
$lastName = $partsName[2];
$suffixName = $partsName[3];
}
$out .= "NM1" .
"*85" .
"*1" .
"*" . $lastName .
"*" . $firstName .
"*" . $middleName .
"*" . // Name Prefix not used
"*" . $suffixName;
}
else {
$billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
if ($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 {
$log .= "*** Billing facility has no NPI.\n";
if ($CMS_5010) {
$out .= "*XX*";
}
else {
$out .= "*24*" . $claim->billingFacilityETIN();
}
}
$out .= "~\n";
++$edicount;
$out .= "N3" .
"*" . $claim->billingFacilityStreet() .
"~\n";
++$edicount;
$out .= "N4" .
"*" . $claim->billingFacilityCity() .
"*" . $claim->billingFacilityState() .
"*" . stripZipCode($claim->billingFacilityZip()) .
"~\n";
if ($CMS_5010 || ($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 .= "*" . $claim->billingFacilityETIN() .
"~\n";
}
if ($claim->providerNumberType() && $claim->providerNumber() &&
!($CMS_5010 && $claim->billingFacilityNPI()))
{
++$edicount;
$out .= "REF" .
"*" . $claim->providerNumberType() .
"*" . $claim->providerNumber() .
"~\n";
}
else if ($claim->providerNumber() && !$claim->providerNumberType()) {
$log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
}
// Situational PER*1C segment omitted.
// Pay-To Address defaults to billing provider and is no longer required in 5010.
if (!$CMS_5010) {
++$edicount;
// Field length is limited to 35. See nucc dataset page 63 www.nucc.org
$billingFacilityName = substr($claim->billingFacilityName(), 0, $CMS_5010 ? 60 : 35);
$out .= "NM1" . // Loop 2010AB Pay-To Provider
"*87" .
"*2" .
"*" . $billingFacilityName .
"*" .
"*" .
"*" .
"*";
if ($claim->billingFacilityNPI())
$out .= "*XX*" . $claim->billingFacilityNPI();
else
$out .= "*24*" . $claim->billingFacilityETIN();
$out .= "~\n";
++$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" .
"*EI" .
"*" . $claim->billingFacilityETIN() .
"~\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' : '') .
"*" . $claim->groupNumber() .
"*" . (($CMS_5010 && $claim->groupNumber()) ? '' : $claim->groupName()) .
"*" . $claim->insuredTypeCode() . // applies for secondary medicare
"*" .
"*" .
"*" .
"*" . $claim->claimType() . // Zirmed replaces this
"~\n";
// Segment PAT omitted.
++$edicount;
$out .= "NM1" . // Loop 2010BA Subscriber
"*IL" .
"*1" . // 1 = person, 2 = non-person
"*" . $claim->insuredLastName() .
"*" . $claim->insuredFirstName() .
"*" . $claim->insuredMiddleName() .
"*" .
"*" . // Name Suffix
"*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.
"*" . $claim->policyNumber() .
"~\n";
// For 5010, further subscriber info is sent only if they are the patient.
if (!$CMS_5010 || $claim->isSelfOfInsured()) {
++$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;
//Field length is limited to 35. See nucc dataset page 81 www.nucc.org
$payerName = substr($claim->payerName(), 0, $CMS_5010 ? 60 : 35);
$out .= "NM1" . // Loop 2010BB Payer
"*PR" .
"*2" .
"*" . $payerName .
"*" .
"*" .
"*" .
"*" .
// The 5010 spec says:
// "On or after the mandated implementation date for the HIPAA
// National Plan Identifier (National Plan ID), XV must be sent.
// Prior to the mandated implementation date and prior to any phase-
// in period identified by Federal regulation, PI must be sent."
// *************** Anybody know what that date is? ***************
// August 2011 - Publish interim final rule
// October 1, 2012-March 31, 2013 - Enumeration
// April 1, 2013-September 30, 2013 - Testing
// October 1, 2013 - Implementation
"*PI" .
// Zirmed ignores this if using payer name matching:
"*" . ($encounter_claim ? $claim->payerAltID() : $claim->payerID()) .
"~\n";
// if (!$claim->payerID()) {
// $log .= "*** CMS ID is missing for payer '" . $claim->payerName() . "'.\n";
// }
if (true) { // !$CMS_5010
// The 5010 spec says:
// "Required when the payer address is available and the submitter intends
// for the claim to be printed on paper at the next EDI location (for example, a
// clearinghouse). If not required by this implementation guide, do not send."
++$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) . // Zirmed computes and replaces this
"*" .
"*" .
"*" . sprintf('%02d', $claim->facilityPOS()) . ":" .
($CMS_5010 ? "B" : "") . ":" .
$claim->frequencyTypeCode() . // Changed to correct single digit output
"*Y" .
"*A" .
"*" . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
"*Y" .
($CMS_5010 ? "" : "*C") .
"~\n";
if ($claim->onsetDate() &&
($claim->onsetDate()!== $claim->serviceDate()) &&
($claim->onsetDateValid())
) {
++$edicount;
$out .= "DTP" . // Date of Onset
"*431" .
"*D8" .
"*" . $claim->onsetDate() .
"~\n";
}
if ($claim->dateInitialTreatment() && ($claim->onsetDateValid())) {
++$edicount;
$out .= "DTP" . // Date of Initial Treatment
"*454" .
"*D8" .
"*" . $claim->dateInitialTreatment() .
"~\n";
}
// Segment DTP*304 (Last Seen Date) omitted.
// Segment DTP*453 (Acute Manifestation Date) omitted.
// Segment DTP*439 (Accident Date) omitted.
// Segment DTP*484 (Last Menstrual Period Date) omitted.
// Segment DTP*455 (Last X-Ray Date) omitted.
// Segment DTP*471 (Hearing and Vision Prescription Date) omitted.
// Segments DTP (Disability Dates) omitted.
// Segment DTP*297 (Last Worked Date) omitted.
// Segment DTP*296 (Authorized Return to Work Date) omitted.
if (strcmp($claim->facilityPOS(),'21') == 0 && $claim->onsetDateValid() ) {
++$edicount;
$out .= "DTP" . // Date of Hospitalization
"*435" .
"*D8" .
"*" . $claim->onsetDate() .
"~\n";
}
// Segment DTP*096 (Discharge Date) omitted.
// 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" .
"*" . $claim->priorAuth() .
"~\n";
}
// Segment REF*F8 Payer Claim Control Number for claim re-submission.icn_resubmission_number
#if($claim->billing_options['replacement_claim'] == '1'){
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() && ($CMS_5010 || $claim->claimType() === 'MB')) {
// Required by Medicare when in-house labs are done.
++$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;
$out .= "NTE" . // comments box 19
"*" . ($CMS_5010 ? "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 = $CMS_5010 ? 12 : 8;
$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() .
"*" . $claim->referrerMiddleName() .
"*" .
"*";
if ($CMS_5010 || $claim->referrerNPI()) { $out .=
"*XX" .
"*" . $claim->referrerNPI();
} else { $out .=
"*34" . // not allowed for 5010
"*" . $claim->referrerSSN();
}
$out .= "~\n";
if (!$CMS_5010 && $claim->referrerTaxonomy()) {
++$edicount;
$out .= "PRV" .
"*RF" . // ReFerring provider
"*ZZ" .
"*" . $claim->referrerTaxonomy() .
"~\n";
}
if (!CMS_5010 && $claim->referrerUPIN()) {
++$edicount;
$out .= "REF" . // Referring Provider Secondary Identification
"*1G" .
"*" . $claim->referrerUPIN() .
"~\n";
}
}
/* Per the implementation guide lines, only include this information if it is different
* than the Loop 2010AA information
*/
if(!$CMS_5010 ||
($claim->providerNPIValid() &&
$claim->billingFacilityNPI() !== $claim->providerNPI() ))
{
++$edicount;
$out .= "NM1" . // Loop 2310B Rendering Provider
"*82" .
"*1" .
"*" . $claim->providerLastName() .
"*" . $claim->providerFirstName() .
"*" . $claim->providerMiddleName() .
"*" .
"*";
if ($CMS_5010 || $claim->providerNPI()) { $out .=
"*XX" .
"*" . $claim->providerNPI();
} else { $out .=
"*34" . // not allowed for 5010
"*" . $claim->providerSSN();
$log .= "*** Rendering provider has no NPI.\n";
}
$out .= "~\n";
if ($claim->providerTaxonomy()) {
++$edicount;
$out .= "PRV" .
"*PE" . // Performing provider
"*" .($claim->claimType() != 'MC' ? "PXC" : "ZZ") .
"*" . $claim->providerTaxonomy() .
"~\n";
}
// End of Loop 2310B
}
else
{
// This loop can only get skipped if we are generating a 5010 claim
if(!($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() ."," . $claim->providerFirstName() . " has invalid NPI.\n";
}
/* Skipping this segment because the providerNPI and the billingFacilityNPI are identical
* is a normal condition, so no need to warn.
*/
}
// 4010: REF*1C is required here for the Medicare provider number if NPI was
// specified in NM109. Not sure if other payers require anything here.
// --- apparently ECLAIMS, INC wants the data in 2010 but NOT in 2310B - tony@mi-squared.com
//
// 5010 spec says nothing here if NPI was specified.
//
if (($CMS_5010 && !$claim->providerNPI() && in_array($claim->providerNumberType(), array('0B','1G','G2','LU')))
|| (!$CMS_5010 && trim($claim->x12gsreceiverid()) != '470819582')) // if NOT ECLAIMS EDI
{
if ($claim->providerNumber()) {
++$edicount;
$out .= "REF" .
"*" . $claim->providerNumberType() .
"*" . $claim->providerNumber() .
"~\n";
}
}
// Loop 2310D is omitted in the case of home visits (POS=12).
if ($claim->facilityPOS() != 12 && (!$CMS_5010 ||
($claim->facilityNPI() != $claim->billingFacilityNPI() ||
($claim->facilityNPI() == $claim->billingFacilityNPI() &&
$claim->facilityStreet() != $claim->billingFacilityStreet()))))
{
++$edicount;
$out .= "NM1" . // Loop 2310D Service Location
"*77" .
"*2";
//Field length is limited to 35. See nucc dataset page 77 www.nucc.org
$facilityName = substr($claim->facilityName(), 0, $CMS_5010 ? 60 : 35);
if ($claim->facilityName() || $claim->facilityNPI() || $claim->facilityETIN()) { $out .=
"*" . $facilityName;
}
if ($claim->facilityNPI() || $claim->facilityETIN()) { $out .=
"*" .
"*" .
"*" .
"*";
if ($CMS_5010 || $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 2310E, Supervising Provider
//
if ($claim->supervisorLastName()) {
++$edicount;
$out .= "NM1" .
"*DQ" . // Supervising Physician
"*1" . // Person
"*" . $claim->supervisorLastName() .
"*" . $claim->supervisorFirstName() .
"*" . $claim->supervisorMiddleName() .
"*" . // NM106 not used
"*"; // Name Suffix
if ($CMS_5010 || $claim->supervisorNPI()) { $out .=
"*XX" .
"*" . $claim->supervisorNPI();
} else { $out .=
"*34" .
"*" . $claim->supervisorSSN();
}
if (!$claim->supervisorNPI()) {
$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.
$prev_pt_resp = $clm_total_charges; // for computation below
// Loops 2320 and 2330*, other subscriber/payer information.
// Remember that insurance index 0 is always for the payer being billed
// by this claim, and 1 and above are always for the "other" payers.
//
for ($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) .
"*" . (($CMS_5010 && $claim->groupNumber($ins)) ? '' : $claim->groupName($ins)) .
"*" . ($CMS_5010 ? $claim->insuredTypeCode($ins) : $tmp2) .
"*" .
"*" .
"*" .
"*" . $claim->claimType($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" .
"*" . $payerpaid[1] .
"~\n";
// Segment AMT*A8 (COB Total Non-Covered Amount) omitted.
// Segment AMT*EAF (Remaining Patient Liability) omitted.
if (!$CMS_5010) {
// Patient responsibility amount as of this previous payer.
$prev_pt_resp -= $payerpaid[1]; // reduce by payments
$prev_pt_resp -= $payerpaid[2]; // reduce by adjustments
++$edicount;
$out .= "AMT" . // Allowed amount per previous payer. Page 334.
"*B6" .
"*" . sprintf('%.2f', $payerpaid[1] + $prev_pt_resp) .
"~\n";
++$edicount;
$out .= "AMT" . // Patient responsibility amount per previous payer. Page 335.
"*F2" .
"*" . sprintf('%.2f', $prev_pt_resp) .
"~\n";
}
} // End of things that apply only to previous payers.
if (!$CMS_5010) {
++$edicount;
$out .= "DMG" . // Other subscriber demographic information. Page 342.
"*D8" .
"*" . $claim->insuredDOB($ins) .
"*" . $claim->insuredSex($ins) .
"~\n";
}
++$edicount;
$out .= "OI" . // Other Insurance Coverage Information. Page 310/344.
"*" .
"*" .
"*" . ($claim->billingFacilityAssignment($ins) ? 'Y' : 'N') .
// For this next item, the 5010 example in the spec does not match its
// description. So this might be wrong.
"*" . ($CMS_5010 ? '' : 'B') .
"*" .
"*Y" .
"~\n";
// Segment MOA (Medicare Outpatient Adjudication) omitted.
++$edicount;
$out .= "NM1" . // Loop 2330A Subscriber info for other insco. Page 315/350.
"*IL" .
"*1" .