function gen_hcfa_1500_page($pid, $encounter, &$log, &$claim)
{
global $hcfa_curr_line, $hcfa_curr_col, $hcfa_data, $hcfa_proc_index;
$hcfa_curr_line = 1;
$hcfa_curr_col = 1;
// According to:
// http://www.ngsmedicare.com/NGSMedicare/PartB/EducationandSupport/ToolsandMaterials/CMS_ClaimFormInst.aspx
// Medicare interprets sections 9 and 11 of the claim form in its own
// special way. This flag tells us to do that. However I'm not 100%
// sure that it applies nationwide, and if you find that it is not right
// for you then set it to false. -- Rod 2009-03-26
$new_medicare_logic = $claim->claimType() == 'MB';
// Payer name, attn, street.
put_hcfa(2, 41, 31, $claim->payerName());
put_hcfa(3, 41, 31, $claim->payerAttn());
put_hcfa(4, 41, 31, $claim->payerStreet());
// Payer city, state, zip.
$tmp = $claim->payerCity() ? $claim->payerCity() . ', ' : '';
put_hcfa(5, 41, 31, $tmp . $claim->payerState() . ' ' . $claim->payerZip());
// Box 1. Insurance Type
$ct = $claim->claimType();
$tmpcol = 45;
// Other
if ($ct === 'MB') {
$tmpcol = 1;
} else {
if ($ct === 'MC') {
$tmpcol = 8;
} else {
if ($ct === 'CH') {
$tmpcol = 15;
} else {
if ($ct === 'CH') {
$tmpcol = 24;
} else {
if ($ct === 'BL') {
$tmpcol = 31;
} else {
if ($ct === '16') {
$tmpcol = 39;
}
}
}
}
}
}
// FECA
put_hcfa(8, $tmpcol, 1, 'X');
// Box 1a. Insured's ID Number
put_hcfa(8, 50, 17, $claim->policyNumber());
// Box 2. Patient's Name
$tmp = $claim->patientLastName() . ', ' . $claim->patientFirstName();
if ($claim->patientMiddleName()) {
$tmp .= ', ' . substr($claim->patientMiddleName(), 0, 1);
}
put_hcfa(10, 1, 28, $tmp);
// Box 3. Patient's Birth Date and Sex
$tmp = $claim->patientDOB();
put_hcfa(10, 31, 2, substr($tmp, 4, 2));
put_hcfa(10, 34, 2, substr($tmp, 6, 2));
put_hcfa(10, 37, 4, substr($tmp, 0, 4));
put_hcfa(10, $claim->patientSex() == 'M' ? 42 : 47, 1, 'X');
// Box 4. Insured's Name
$tmp = $claim->insuredLastName() . ', ' . $claim->insuredFirstName();
if ($claim->insuredMiddleName()) {
$tmp .= ', ' . substr($claim->insuredMiddleName(), 0, 1);
}
put_hcfa(10, 50, 28, $tmp);
// Box 5. Patient's Address
put_hcfa(12, 1, 28, $claim->patientStreet());
// Box 6. Patient Relationship to Insured
$tmp = $claim->insuredRelationship();
$tmpcol = 47;
// Other
if ($tmp === '18') {
$tmpcol = 33;
} else {
if ($tmp === '01') {
$tmpcol = 38;
} else {
if ($tmp === '19') {
$tmpcol = 42;
}
}
}
// child
put_hcfa(12, $tmpcol, 1, 'X');
// Box 7. Insured's Address
put_hcfa(12, 50, 28, $claim->insuredStreet());
// Box 5 continued. Patient's City and State
put_hcfa(14, 1, 20, $claim->patientCity());
put_hcfa(14, 26, 2, $claim->patientState());
// Box 8. Patient (Marital) Status
$tmp = $claim->patientStatus();
$tmpcol = 47;
// Other
if ($tmp === 'S') {
$tmpcol = 35;
} else {
if ($tmp === 'M') {
$tmpcol = 41;
}
}
// Married
put_hcfa(14, $tmpcol, 1, 'X');
// Box 7 continued. Insured's City and State
put_hcfa(14, 50, 20, $claim->insuredCity());
put_hcfa(14, 74, 2, $claim->insuredState());
// Box 5 continued. Patient's Zip Code and Telephone
put_hcfa(16, 1, 10, $claim->patientZip());
$tmp = $claim->patientPhone();
put_hcfa(16, 15, 3, substr($tmp, 0, 3));
put_hcfa(16, 19, 7, substr($tmp, 3));
// Box 8 continued. Patient (Employment) Status
$tmp = $claim->patientOccupation();
if ($tmp === 'STUDENT') {
put_hcfa(16, 41, 1, 'X');
} else {
if ($tmp === 'PT STUDENT') {
put_hcfa(16, 47, 1, 'X');
} else {
if ($tmp !== 'UNEMPLOYED') {
put_hcfa(16, 35, 1, 'X');
}
}
}
// Box 7 continued. Insured's Zip Code and Telephone
put_hcfa(16, 50, 10, $claim->insuredZip());
$tmp = $claim->insuredPhone();
put_hcfa(16, 65, 3, substr($tmp, 0, 3));
put_hcfa(16, 69, 7, substr($tmp, 3));
// Box 9. Other Insured's Name
if ($new_medicare_logic) {
// TBD: Medigap stuff? How do we know if this is a Medigap transfer?
} else {
if ($claim->payerCount() > 1) {
$tmp = $claim->insuredLastName(1) . ', ' . $claim->insuredFirstName(1);
if ($claim->insuredMiddleName(1)) {
$tmp .= ', ' . substr($claim->insuredMiddleName(1), 0, 1);
}
put_hcfa(18, 1, 28, $tmp);
}
}
// Box 11. Insured's Group Number
if ($new_medicare_logic) {
// If this is Medicare secondary then we need the primary's policy number
// here, otherwise the word "NONE".
$tmp = $claim->payerSequence() == 'P' ? 'NONE' : $claim->policyNumber(1);
} else {
$tmp = $claim->groupNumber();
}
put_hcfa(18, 50, 30, $tmp);
// Box 9a. Other Insured's Policy or Group Number
if ($new_medicare_logic) {
// TBD: Medigap stuff?
} else {
if ($claim->payerCount() > 1) {
put_hcfa(20, 1, 28, $claim->policyNumber(1));
}
}
// Box 10a. Employment Related
put_hcfa(20, $claim->isRelatedEmployment() ? 35 : 41, 1, 'X');
// Box 11a. Insured's Birth Date and Sex
if ($new_medicare_logic) {
$tmpdob = $tmpsex = '';
if ($claim->payerSequence() != 'P') {
$tmpdob = $claim->insuredDOB(1);
$tmpsex = $claim->insuredSex(1);
}
} else {
$tmpdob = $claim->insuredDOB();
$tmpsex = $claim->insuredSex();
}
if ($tmpdob) {
put_hcfa(20, 53, 2, substr($tmpdob, 4, 2));
put_hcfa(20, 56, 2, substr($tmpdob, 6, 2));
put_hcfa(20, 59, 4, substr($tmpdob, 0, 4));
}
if ($tmpsex) {
put_hcfa(20, $tmpsex == 'M' ? 68 : 75, 1, 'X');
}
// Box 9b. Other Insured's Birth Date and Sex
if ($new_medicare_logic) {
// TBD: Medigap stuff?
} else {
if ($claim->payerCount() > 1) {
$tmp = $claim->insuredDOB(1);
put_hcfa(22, 2, 2, substr($tmp, 4, 2));
put_hcfa(22, 5, 2, substr($tmp, 6, 2));
put_hcfa(22, 8, 4, substr($tmp, 0, 4));
put_hcfa(22, $claim->insuredSex(1) == 'M' ? 18 : 24, 1, 'X');
}
}
// Box 10b. Auto Accident
put_hcfa(22, $claim->isRelatedAuto() ? 35 : 41, 1, 'X');
if ($claim->isRelatedAuto()) {
put_hcfa(22, 45, 2, $claim->autoAccidentState());
}
// Box 11b. Insured's Employer/School Name
if ($new_medicare_logic) {
$tmp = $claim->payerSequence() == 'P' ? '' : $claim->groupName(1);
} else {
$tmp = $claim->groupName();
}
put_hcfa(22, 50, 30, $tmp);
// Box 9c. Other Insured's Employer/School Name
if ($new_medicare_logic) {
// TBD: Medigap stuff?
} else {
if ($claim->payerCount() > 1) {
put_hcfa(24, 1, 28, $claim->groupName(1));
}
}
// Box 10c. Other Accident
put_hcfa(24, $claim->isRelatedOther() ? 35 : 41, 1, 'X');
// Box 11c. Insurance Plan Name or Program Name
if ($new_medicare_logic) {
$tmp = '';
if ($claim->payerSequence() != 'P') {
$tmp = $claim->planName(1);
if (!$tmp) {
$tmp = $claim->payerName(1);
}
}
} else {
$tmp = $claim->planName();
}
put_hcfa(24, 50, 30, $tmp);
// Box 9d. Other Insurance Plan Name or Program Name
if ($new_medicare_logic) {
// TBD: Medigap stuff?
} else {
if ($claim->payerCount() > 1) {
put_hcfa(26, 1, 28, $claim->planName(1));
}
}
// Box 11d. Is There Another Health Benefit Plan
if (!$new_medicare_logic) {
put_hcfa(26, $claim->payerCount() > 1 ? 52 : 57, 1, 'X');
}
// Box 12. Patient's or Authorized Person's Signature
put_hcfa(29, 7, 17, 'Signature on File');
// Note: Date does not apply unless the person physically signs the form.
// Box 13. Insured's or Authorized Person's Signature
put_hcfa(29, 55, 17, 'Signature on File');
// Box 14. Date of Current Illness/Injury/Pregnancy
$tmp = $claim->onsetDate();
put_hcfa(32, 2, 2, substr($tmp, 4, 2));
put_hcfa(32, 5, 2, substr($tmp, 6, 2));
put_hcfa(32, 8, 4, substr($tmp, 0, 4));
// Box 15. First Date of Same or Similar Illness, if applicable
$tmp = $claim->dateInitialTreatment();
put_hcfa(32, 36, 2, substr($tmp, 4, 2));
put_hcfa(32, 39, 2, substr($tmp, 6, 2));
put_hcfa(32, 42, 4, substr($tmp, 0, 4));
// Box 16. Dates Patient Unable to Work in Current Occupation
if ($claim->isUnableToWork()) {
$tmp = $claim->offWorkFrom();
put_hcfa(32, 54, 2, substr($tmp, 4, 2));
put_hcfa(32, 57, 2, substr($tmp, 6, 2));
put_hcfa(32, 60, 4, substr($tmp, 0, 4));
$tmp = $claim->offWorkTo();
put_hcfa(32, 68, 2, substr($tmp, 4, 2));
put_hcfa(32, 71, 2, substr($tmp, 6, 2));
put_hcfa(32, 74, 4, substr($tmp, 0, 4));
}
// Referring provider stuff. Reports are that for primary care doctors,
// Medicare forbids an entry here and other payers require one.
// There is still confusion over this.
//
if ($claim->referrerLastName() && (empty($GLOBALS['MedicareReferrerIsRenderer']) || $claim->claimType() != 'MB')) {
// Box 17a. Referring Provider Alternate Identifier
if ($claim->referrerUPIN() && $claim->claimType() != 'MB') {
put_hcfa(33, 30, 2, '1G');
put_hcfa(33, 33, 15, $claim->referrerUPIN());
}
// Box 17. Name of Referring Provider or Other Source
$tmp = $claim->referrerLastName() . ', ' . $claim->referrerFirstName();
if ($claim->referrerMiddleName()) {
$tmp .= ', ' . substr($claim->referrerMiddleName(), 0, 1);
}
put_hcfa(34, 1, 25, $tmp);
// Box 17b. Referring Provider NPI
if ($claim->referrerNPI()) {
put_hcfa(34, 33, 15, $claim->referrerNPI());
}
}
// Box 18. Hospitalization Dates Related to Current Services
if ($claim->isHospitalized()) {
$tmp = $claim->hospitalizedFrom();
put_hcfa(34, 54, 2, substr($tmp, 4, 2));
put_hcfa(34, 57, 2, substr($tmp, 6, 2));
put_hcfa(34, 60, 4, substr($tmp, 0, 4));
$tmp = $claim->hospitalizedTo();
put_hcfa(34, 68, 2, substr($tmp, 4, 2));
put_hcfa(34, 71, 2, substr($tmp, 6, 2));
put_hcfa(34, 74, 4, substr($tmp, 0, 4));
}
// Box 19. Reserved for Local Use
put_hcfa(36, 1, 48, $claim->additionalNotes());
// Box 20. Outside Lab
put_hcfa(36, $claim->isOutsideLab() ? 52 : 57, 1, 'X');
if ($claim->isOutsideLab()) {
// Note here that put_hcfa strips the decimal point, as required.
// We right-justify this amount (ending in col. 69).
put_hcfa(36, 63, 8, sprintf('%8s', $claim->outsideLabAmount()));
}
// Box 21. Diagnoses
$tmp = $claim->diagArray();
$diags = array();
foreach ($tmp as $diag) {
$diags[] = $diag;
}
if (!empty($diags[0])) {
put_hcfa(38, 3, 3, substr($diags[0], 0, 3));
put_hcfa(38, 7, 2, substr($diags[0], 3));
}
if (!empty($diags[2])) {
put_hcfa(38, 30, 3, substr($diags[2], 0, 3));
put_hcfa(38, 34, 2, substr($diags[2], 3));
}
// Box 22. Medicaid Resubmission Code and Original Ref. No.
put_hcfa(38, 50, 10, $claim->medicaidResubmissionCode());
put_hcfa(38, 62, 10, $claim->medicaidOriginalReference());
// Box 21 continued. Diagnoses
if (!empty($diags[1])) {
put_hcfa(40, 3, 3, substr($diags[1], 0, 3));
put_hcfa(40, 7, 2, substr($diags[1], 3));
}
if (!empty($diags[3])) {
put_hcfa(40, 30, 3, substr($diags[3], 0, 3));
put_hcfa(40, 34, 2, substr($diags[3], 3));
}
// Box 23. Prior Authorization Number
put_hcfa(40, 50, 28, $claim->priorAuth());
$proccount = $claim->procCount();
// number of procedures
// Charges, adjustments and payments are accumulated by line item so that
// each page of a multi-page claim will stand alone. Payments include the
// co-pay for the first page only.
$clm_total_charges = 0;
$clm_amount_adjusted = 0;
$clm_amount_paid = $hcfa_proc_index ? 0 : $claim->patientPaidAmount();
// Procedure loop starts here.
//
for ($svccount = 0; $svccount < 6 && $hcfa_proc_index < $proccount; ++$hcfa_proc_index) {
$dia = $claim->diagIndexArray($hcfa_proc_index);
if (!$claim->cptCharges($hcfa_proc_index)) {
$log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) . "' has no charges!\n";
}
if (empty($dia)) {
$log .= "*** Procedure '" . $claim->cptKey($hcfa_proc_index) . "' is not justified!\n";
}
$clm_total_charges += $claim->cptCharges($hcfa_proc_index);
// Compute prior payments and "hard" adjustments.
for ($ins = 1; $ins < $claim->payerCount(); ++$ins) {
if ($claim->payerSequence($ins) > $claim->payerSequence()) {
continue;
}
// skip future payers
$payerpaid = $claim->payerTotals($ins, $claim->cptKey($hcfa_proc_index));
$clm_amount_paid += $payerpaid[1];
$clm_amount_adjusted += $payerpaid[2];
}
++$svccount;
$lino = $svccount * 2 + 41;
// Drug Information. Medicaid insurers want this with HCPCS codes.
//
$ndc = $claim->cptNDCID($hcfa_proc_index);
if ($ndc) {
if (preg_match('/^(\\d\\d\\d\\d\\d)-(\\d\\d\\d\\d)-(\\d\\d)$/', $ndc, $tmp)) {
$ndc = $tmp[1] . $tmp[2] . $tmp[3];
} else {
if (preg_match('/^\\d{11}$/', $ndc)) {
} else {
$log .= "*** NDC code '{$ndc}' has invalid format!\n";
}
}
put_hcfa($lino, 1, 50, "N4{$ndc} " . $claim->cptNDCUOM($hcfa_proc_index) . $claim->cptNDCQuantity($hcfa_proc_index));
}
//Note Codes.
put_hcfa($lino, 25, 7, $claim->cptNotecodes($hcfa_proc_index));
// 24i and 24j Top. ID Qualifier and Rendering Provider ID
if ($claim->supervisorNumber()) {
// If there is a supervising provider and that person has a
// payer-specific provider number, then we assume that the SP
// must be identified on the claim and this is how we do it
// (but the NPI of the actual rendering provider appears below).
// BCBS of TN indicated they want it this way. YMMV. -- Rod
put_hcfa($lino, 65, 2, $claim->supervisorNumberType());
put_hcfa($lino, 68, 10, $claim->supervisorNumber());
} else {
if ($claim->providerNumber($hcfa_proc_index)) {
put_hcfa($lino, 65, 2, $claim->providerNumberType($hcfa_proc_index));
put_hcfa($lino, 68, 10, $claim->providerNumber($hcfa_proc_index));
}
}
++$lino;
// 24a. Date of Service
$tmp = $claim->serviceDate();
put_hcfa($lino, 1, 2, substr($tmp, 4, 2));
put_hcfa($lino, 4, 2, substr($tmp, 6, 2));
put_hcfa($lino, 7, 2, substr($tmp, 2, 2));
put_hcfa($lino, 10, 2, substr($tmp, 4, 2));
put_hcfa($lino, 13, 2, substr($tmp, 6, 2));
put_hcfa($lino, 16, 2, substr($tmp, 2, 2));
// 24b. Place of Service
put_hcfa($lino, 19, 2, $claim->facilityPOS());
// 24c. EMG
// Not currently supported.
// 24d. Procedures, Services or Supplies
put_hcfa($lino, 25, 7, $claim->cptCode($hcfa_proc_index));
// replace colon with space for printing
put_hcfa($lino, 33, 12, str_replace(':', ' ', $claim->cptModifier($hcfa_proc_index)));
// 24e. Diagnosis Pointer
$tmp = '';
foreach ($claim->diagIndexArray($hcfa_proc_index) as $value) {
$tmp .= $value;
}
put_hcfa($lino, 45, 4, $tmp);
// 24f. Charges
put_hcfa($lino, 50, 8, str_replace('.', ' ', sprintf('%8.2f', $claim->cptCharges($hcfa_proc_index))));
// 24g. Days or Units
put_hcfa($lino, 59, 3, $claim->cptUnits($hcfa_proc_index));
// 24h. EPSDT Family Plan
// Not currently supported.
// 24j. Rendering Provider NPI
put_hcfa($lino, 68, 10, $claim->providerNPI($hcfa_proc_index));
}
// 25. Federal Tax ID Number
// FrreB hard coded EIN. Changed it to included SSN as well.
put_hcfa(56, 1, 15, $claim->billingFacilityETIN());
if ($claim->federalIdType() == 'SY') {
put_hcfa(56, 16, 1, 'X');
// The SSN checkbox
} else {
put_hcfa(56, 19, 1, 'X');
// The EIN checkbox
}
// 26. Patient's Account No.
// Instructions say hyphens are not allowed, but freeb used them.
put_hcfa(56, 23, 15, "{$pid}-{$encounter}");
// 27. Accept Assignment
put_hcfa(56, $claim->billingFacilityAssignment() ? 38 : 43, 1, 'X');
// 28. Total Charge
put_hcfa(56, 52, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_total_charges)));
if (!$clm_total_charges) {
$log .= "*** This claim has no charges!\n";
}
// 29. Amount Paid
put_hcfa(56, 62, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_amount_paid)));
// 30. Balance Due
// For secondary payers this reflects primary "contracted rate" adjustments,
// so in general box 30 will not equal box 28 minus box 29.
put_hcfa(56, 71, 8, str_replace('.', ' ', sprintf('%8.2f', $clm_total_charges - $clm_amount_paid - $clm_amount_adjusted)));
// 33. Billing Provider: Phone Number
$tmp = $claim->billingContactPhone();
put_hcfa(57, 66, 3, substr($tmp, 0, 3));
put_hcfa(57, 70, 7, substr($tmp, 3));
// 32. Service Facility Location Information: Name
put_hcfa(58, 23, 25, $claim->facilityName());
// 33. Billing Provider: Name
put_hcfa(58, 50, 25, $claim->billingFacilityName());
// 32. Service Facility Location Information: Street
put_hcfa(59, 23, 25, $claim->facilityStreet());
// 33. Billing Provider: Name
put_hcfa(59, 50, 25, $claim->billingFacilityStreet());
// 31. Signature of Physician or Supplier
// FreeB printed the rendering provider's name and the current date here,
// but according to my instructions it must be a real signature and date,
// or else "Signature on File" or "SOF".
put_hcfa(60, 1, 20, 'Signature on File');
//
// $tmp = $claim->providerFirstName();
// if ($claim->providerMiddleName()) $tmp .= ' ' . substr($claim->providerMiddleName(),0,1);
// put_hcfa(60, 1, 20, $tmp . ' ' . $claim->providerLastName());
// 32. Service Facility Location Information: City State Zip
$tmp = $claim->facilityCity() ? $claim->facilityCity() . ' ' : '';
put_hcfa(60, 23, 27, $tmp . $claim->facilityState() . ' ' . $claim->facilityZip());
// 33. Billing Provider: City State Zip
$tmp = $claim->billingFacilityCity() ? $claim->billingFacilityCity() . ' ' : '';
put_hcfa(60, 50, 27, $tmp . $claim->billingFacilityState() . ' ' . $claim->billingFacilityZip());
// 32a. Service Facility NPI
put_hcfa(61, 24, 10, $claim->facilityNPI());
// 32b. Service Facility Other ID
// Note that Medicare does NOT want this any more.
if ($claim->providerGroupNumber()) {
put_hcfa(61, 36, 2, $claim->providerNumberType());
put_hcfa(61, 38, 11, $claim->providerGroupNumber());
}
// 33a. Billing Facility NPI
put_hcfa(61, 51, 10, $claim->billingFacilityNPI());
// 33b. Billing Facility Other ID
// Note that Medicare does NOT want this any more.
if ($claim->providerGroupNumber() && $claim->claimType() != 'MB') {
put_hcfa(61, 63, 2, $claim->providerNumberType());
put_hcfa(61, 65, 14, $claim->providerGroupNumber());
}
// Put an extra line here for compatibility with old hcfa text generated form
put_hcfa(62, 1, 1, ' ');
return;
}
/**
* Add the info to the form
*/
public function put()
{
// Override the default value for "strip" with put_hcfa to keep periods
put_hcfa($this->row, $this->column, $this->width, $this->info, '/#/');
}
