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gen_837i.inc.php
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<?php
/**
* library/gen_837I.inc.php Genetating a UB04 Electronic transmission file.
*
* Program for Generating an Electronic transmission
* file of the UB-04 (CMS 1450)
*
* Copyright (C) 2014-2017 Terry Hill <[email protected]>
*
* LICENSE: This Source Code is subject to the terms of the Mozilla Public License, v. 2.0.
* See the Mozilla Public License for more details.
* If a copy of the MPL was not distributed with this file, You can obtain one at https://mozilla.org/MPL/2.0/.
*
* This program is distributed in the hope that it will be useful,
* but WITHOUT ANY WARRANTY; without even the implied warranty of
* MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
*
* @package LibreHealth EHR
* @author Terry Hill <[email protected]>
* @link http://librehealth.io
*
* Please help the overall project by sending changes you make to the authors and to the LibreHealth EHR community.
*
*/
$fake_register_globals=false;
$sanitize_all_escapes=true;
require_once("Claim.class.php");
function gen_837I($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() .
// date of transmission "*030911" .
"*" . date('Ymd', $today) .
//Time of transmission "*1630" .
"*" . date('Hi', $today) .
"*" . ($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" .
// "*" . $claim->x12gsversionstring() .
"*" . "005010X223A2".
"~\n";
++$edicount;
$out .= "ST" .
"*837" .
"*0021" .
//($CMS_5010 ? ("*" . $claim->x12gsversionstring()) : "") .
"*" . "005010X223A2".
"~\n";
++$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;
//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 1000A Submitter stays in the 837I
"*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 stays in the 837I
"*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 = $HLcount++;
// Situational PRV segment (for provider taxonomy code) omitted here.
// Situational CUR segment (foreign currency information) omitted here.
++$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 2010AA Billing Provider stays in the 837I
"*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()) {
$log .= "*** Payer-specific provider insurance number is present but has no type assigned.\n";
}
// Situational PER*1C segment.
++$edicount;
$out .= "PER" .
"*IC" .
"*" . $claim->billingContactName() .
"*TE" .
"*" . $claim->billingContactPhone();
if (!$CMS_5010 && $claim->x12gsper06()) {
$out .= "*ED*" . $claim->x12gsper06();
}
$out .= "~\n";
// Pay-To Address defaults to billing provider and is no longer required in 5010.
if (!$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";
}
}
// This is also excluded in the 837I
// Loop 2010AC Pay-To Plan Name omitted. Includes:
// NM1*PE, N3, N4, REF*2U, REF*EI
$PatientHL = $claim->isSelfOfInsured() ? 0 : 1;
$HLSubscriber = $HLcount++;
++$edicount;
// loop 2000B
$out .= "HL" . // Loop 2000B Subscriber HL Loop
"*$HLSubscriber" .
"*$HLBillingPayToProvider" .
"*22" .
"*$PatientHL" .
"~\n";
if (!$claim->payerSequence()) {
$log .= "*** Error: Insurance information is missing!\n";
}
++$edicount;
//SBR01 is either a P or S SBR02 for care is always 18 "patient" SBR09 is always MA
$out .= "SBR" . // Subscriber Information
"*" . $claim->payerSequence() .
"*" . ($claim->isSelfOfInsured() ? '18' : '') .
"*" . $claim->groupNumber() .
"*" . (($CMS_5010 && $claim->groupNumber()) ? '' : $claim->groupName()) .
"*" . $claim->insuredTypeCode() . // applies for secondary medicare
"*" .
"*" .
"*" .
"*" . $claim->claimType() . // Zirmed replaces this
"~\n";
// 2000C Segment PAT omitted.
++$edicount;
$out .= "NM1" . // Loop 2010BA Subscriber same in 837I
"*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 may need this elsed in to the loop 2000C
"*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
"*" .
"*" ;
//Service location this need to be bill type from ub form type_of_bill
//IF (substr($claim->ub04_options[type_of_bill],0,1) == '0'AND strlen($claim->ub04_options[type_of_bill]) == 4){
IF (strlen($claim->ub04_options[type_of_bill]) >= 3){
$out .= "*" . substr($claim->ub04_options['type_of_bill'],1,1) . ":" .
substr($claim->ub04_options['type_of_bill'],2,1) . ":" .
substr($claim->ub04_options['type_of_bill'],3,1) ;
}
//"*" . sprintf('%02d', $claim->facilityPOS()) . ":" .
// ($CMS_5010 ? "B" : "") . ":" .
// $claim->frequencyTypeCode() .
$out .= "*" .
"*A" .
"*" . ($claim->billingFacilityAssignment() ? 'Y' : 'N') .
"*Y" .
($CMS_5010 ? "" : "*C") .
"~\n";
// discharge hour
// DTP 096 TM (Discharge hour from form)
if ($claim->ub04_options['discharge_hour']) {
++$edicount;
$out .= "DTP" . // Loop 2300
"*096" .
"*TM" .
"*" . $claim->ub04_options['discharge_hour'] .
"~\n";
}
// Statment Dates
// DTP 434 RD8 (Statment from OR to date)
if ($claim->ub04_options['hospitalization_date_from']) {
++$edicount;
$tmp = substr($claim->ub04_options['hospitalization_date_from'],0 ,4) . substr($claim->ub04_options['hospitalization_date_from'],5,2). substr($claim->ub04_options['hospitalization_date_from'],8,2);
$tmp1 = substr($claim->ub04_options['hospitalization_date_to'],0 ,4) . substr($claim->ub04_options['hospitalization_date_to'],5,2). substr($claim->ub04_options['hospitalization_date_to'],8,2);
$out .= "DTP" . // Loop 2300
"*434" .
"*RD8" .
"*" . $tmp .'-'. $tmp1.
"~\n";
}
// if ($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" .
// "*" . $claim->dateInitialTreatment() .
// "~\n";
//}
// Admission Date / Hour
// DTP 435 DT (Admission Date and Hour from form)
if ($claim->ub04_options['hospitalization_date_from']) {
++$edicount;
$tmp = substr($claim->ub04_options['hospitalization_date_from'],0 ,4) . substr($claim->ub04_options['hospitalization_date_from'],5,2). substr($claim->ub04_options['hospitalization_date_from'],8,2);
$out .= "DTP" . // Loop 2300
"*435" .
"*DT" .
"*" . $tmp . $claim->ub04_options['admission_hour'] .
"~\n";
}
if (strlen(trim($claim->ub04_options['admission_hour'])) == 0) {
$log .= "*** Error: No Admission Time Entered!\n";
}
// Repricer Received Date
// DTP 050 D8 (Admission Date and Hour from form)
// Institutional Claim Code
// CL1 (Admission Type Code) (Admission Source Code) (Patient Status Code)
// This may not be needed for any thing except a hospital thats why it ic commited out
if ($claim->ub04_options['is_hospitalized']) {
++$edicount;
$out .= "CL1" . // Loop 2300
"*" . $claim->ub04_options['admit_type'] .
"*" . $claim->ub04_options['admit_source'] .
"*" . $claim->ub04_options['discharge_status'] .
"~\n";
}
// Segment PWK (Claim Supplemental Information) omitted.
// Segment CN1 (Contract Information) omitted.
// Patient Estimated Amount Due
// Check logic
// $patientpaid = $claim->patientPaidAmount();
// if ($patientpaid != 0) {
// ++$edicount;
// $out .= "AMT" . // Patient paid amount. Page 190/220.
// "*F5" .
// "*" . $patientpaid .
// "~\n";
// }
// Segment REF*4N (Service Authorization Exception Code) omitted.
// Segment REF*9F (Referral Number) omitted.
// Prior Authorization
//
if ($claim->priorAuth()) {
++$edicount;
$out .= "REF" . // Prior Authorization Number
"*G1" .
"*" . $claim->priorAuth() .
"~\n";
}
// Segment REF*F8 (Payer Claim Control Number) omitted.
// This may be needed for the UB04 Claim if so change the 'MB' to 'MA'
//if ($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" .
// "*" . $claim->cliaCode() .
// "~\n";
// }
// Segment REF*9A (Repriced Claim Number) omitted.
// Segment REF*9C (Adjusted Repriced Claim Number) omitted.
// Segment REF*LX (Investigational Device Exemption Number) omitted.
// Segment REF*S9 (Claim Identifier for Transmission Intermediaries) omitted.
// Segment REF*LU (Auto Accident State) omitted.
// Segment REF*EA (Medical Record Number) omitted.
// Segment REF*P4 (Demonstration Project Identifier) omitted.
// Segment REF*G4 (Peer Review Organization PRO Approval Number) omitted.
// Segment K3 (File Information) omitted.
if ($claim->additionalNotes()) {
// Claim Note
// Has a list of valaid codes. Required when PROVIDER deems necessary
// Billing note.
// Check to verify I am getting this information on the ub04 form
++$edicount;
$out .= "NTE" . // comments box 19
"*" . ($CMS_5010 ? "ADD" : "") .
"*" . $claim->additionalNotes() .
"~\n";
}
// Segment CRC (EPSDT Referral) omitted.
// Diagnoses, up to $max_per_seg per HI segment. Check this
$max_per_seg = 18 ;
$da = $claim->diagArray();
if ($claim->diagtype == "ICD9") {
$diag_type_code = 'BK';
}
ELSE
{
$diag_type_code = 'ABK';
}
$tmp = 0;
foreach ($da as $diag) {
if ($tmp == 1) continue;
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) $out .= "~\n";
// Segment HI*BI (Occurrence Span Information).
// HI BI (Occurrence Span Code 1) RD8 (Occurrence Span Code Associated Date)
if ($claim->ub04_options['occurrence_span_code_1']) {
$max_per_seg = 4 ;
$diag_type_code = 'BI';
$tmp = 0;
for ($i=0; $i<=3;) {
if ($tmp % $max_per_seg == 0) {
if ($tmp) $out .= "~\n";
++$edicount;
$out .= "HI"; // Health Diagnosis Codes
}
if ($claim->ub04_options['occurrence_span_code_1']) {
//if ($i=1) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_span_code_1'] .
":" . $claim->ub04_options['occurrence_span_date_from_1'] .
":" . $claim->ub04_options['occurrence_span_date_to_1'] ;
$diag_type_code = 'BI';
//}
}
if ($i=2) {
if ($claim->ub04_options['occurrence_span_code_2']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_span_code_2'] .
":" . $claim->ub04_options['occurrence_span_date_from_2'] .
":" . $claim->ub04_options['occurrence_span_date_to_2'] ;
$diag_type_code = 'BI';
}
}
if ($i=3) {
if ($claim->ub04_options['occurrence_span_code_1A']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_span_code_1A'] .
":" . $claim->ub04_options['occurrence_span_date_from_1A'] .
":" . $claim->ub04_options['occurrence_span_date_to_1A'] ;
$diag_type_code = 'BI';
}
}
if ($i=4) {
if ($claim->ub04_options['occurrence_span_code_2A']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_span_code_2A'] .
":" . $claim->ub04_options['occurrence_span_date_from_2A'] .
":" . $claim->ub04_options['occurrence_span_date_to_2A'] ;
$diag_type_code = 'BI';
}
}
++$tmp;
++$i ;
}
if ($tmp) $out .= "~\n";
}
// Segment HI*BH (Occurrence Information).
// HI BH (Occurrence Code 1) D8 (Occurrence Code Associated Date)
if ($claim->ub04_options['occurrence_code_1']) {
$max_per_seg = 8 ;
$diag_type_code = 'BH';
$tmp = 0;
for ($i=0; $i<=7;) {
if ($tmp % $max_per_seg == 0) {
if ($tmp) $out .= "~\n";
++$edicount;
$out .= "HI"; // Health Diagnosis Codes
}
if ($claim->ub04_options['occurrence_code_1']) {
//if ($i=1) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_1'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_1'] ;
$diag_type_code = 'BH';
//}
}
if ($i=2) {
if ($claim->ub04_options['occurrence_code_2']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_2'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_2'] ;
$diag_type_code = 'BH';
}
}
if ($i=3) {
if ($claim->ub04_options['occurrence_code_3']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_3'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_3'] ;
$diag_type_code = 'BH';
}
}
if ($i=4) {
if ($claim->ub04_options['occurrence_code_4']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_4'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_4'] ;
$diag_type_code = 'BH';
}
}
if ($claim->ub04_options['occurrence_code_1A']) {
if ($i=5) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_1A'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_1A'] ;
$diag_type_code = 'BH';
}
}
if ($i=6) {
if ($claim->ub04_options['occurrence_code_2A']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_2A'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_2A'] ;
$diag_type_code = 'BH';
}
}
if ($i=7) {
if ($claim->ub04_options['occurrence_code_3A']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_3A'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_3A'] ;
$diag_type_code = 'BH';
}
}
if ($i=8) {
if ($claim->ub04_options['occurrence_code_4A']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['occurrence_code_4A'] .
":D8" .
":" . $claim->ub04_options['occurrence_date_4A'] ;
$diag_type_code = 'BH';
}
}
++$tmp;
++$i ;
}
if ($tmp) $out .= "~\n";
}
// Segment HI*BE (Value Information).
// HI BE (Value Code 1) *.* (Value Code Amount)
if ($claim->ub04_options['value_code_1a']) {
$max_per_seg = 12 ;
$diag_type_code = 'BE';
$tmp = 0;
for ($i=0; $i<=11;) {
if ($tmp % $max_per_seg == 0) {
if ($tmp) $out .= "~\n";
++$edicount;
$out .= "HI"; // Health Diagnosis Codes
}
if ($claim->ub04_options['value_code_1a']) {
//if ($i=1) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_1a'] .
":" .
":" . $claim->ub04_options['value_code_amount_1a'] ;
$diag_type_code = 'BE';
//}
}
if ($i=2) {
if ($claim->ub04_options['value_code_2a']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_2a'] .
":" .
":" . $claim->ub04_options['value_code_amount_2a'] ;
$diag_type_code = 'BE';
}
}
if ($i=3) {
if ($claim->ub04_options['value_code_3a']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_3a'] .
":" .
":" . $claim->ub04_options['value_code_amount_3a'] ;
$diag_type_code = 'BE';
}
}
if ($i=4) {
if ($claim->ub04_options['value_code_1b']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_1b'] .
":" .
":" . $claim->ub04_options['value_code_amount_1b'] ;
$diag_type_code = 'BE';
}
}
if ($i=5) {
if ($claim->ub04_options['value_code_2b']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_2b'] .
":" .
":" . $claim->ub04_options['value_code_amount_2b'] ;
$diag_type_code = 'BE';
}
}
if ($i=6) {
if ($claim->ub04_options['value_code_3b']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_3b'] .
":" .
":" . $claim->ub04_options['value_code_amount_3b'] ;
$diag_type_code = 'BE';
}
}
if ($i=7) {
if ($claim->ub04_options['value_code_1c']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_1c'] .
"*" .
":" . $claim->ub04_options['value_code_amount_1c'] ;
$diag_type_code = 'BE';
}
}
if ($i=8) {
if ($claim->ub04_options['value_code_2c']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_2c'] .
"*" .
":" . $claim->ub04_options['value_code_amount_2c'] ;
$diag_type_code = 'BE';
}
}
if ($i=9) {
if ($claim->ub04_options['value_code_3c']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_3c'] .
"*" .
":" . $claim->ub04_options['value_code_amount_3c'] ;
$diag_type_code = 'BE';
}
}
if ($i=10) {
if ($claim->ub04_options['value_code_1d']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_1d'] .
"*" .
":" . $claim->ub04_options['value_code_amount_1d'] ;
$diag_type_code = 'BE';
}
}
if ($i=11) {
if ($claim->ub04_options['value_code_2d']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_2d'] .
"*" .
":" . $claim->ub04_options['value_code_amount_2d'] ;
$diag_type_code = 'BE';
}
}
if ($i=12) {
if ($claim->ub04_options['value_code_3d']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['value_code_3d'] .
"*" .
":" . $claim->ub04_options['value_code_amount_3d'] ;
$diag_type_code = 'BE';
}
}
++$tmp;
++$i ;
}
if ($tmp) $out .= "~\n";
}
// Segment HI*BG (Condition Information).
// HI BG (Condition Code 1)
if ($claim->ub04_options['condition_code_1']) {
$max_per_seg = 11 ;
$diag_type_code = 'BG';
$tmp = 0;
for ($i=0; $i<=10;) {
if ($tmp % $max_per_seg == 0) {
if ($tmp) $out .= "~\n";
++$edicount;
$out .= "HI"; // Health Diagnosis Codes
}
if ($claim->ub04_options['condition_code_1']) {
//if ($i=1) {
$out .= "*$diag_type_code:" . $claim->ub04_options['condition_code_1'] ;
$diag_type_code = 'BG';
//}
}
if ($i=2) {
if ($claim->ub04_options['condition_code_2']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['condition_code_2'];
$diag_type_code = 'BG';
}
}
if ($i=3) {
if ($claim->ub04_options['condition_code_3']) {
$out .= "*$diag_type_code:" . $claim->ub04_options['condition_code_3'] ;
$diag_type_code = 'BG';