public virtual List<FormPage> TransformHcfa1500ToFormPages(HCFA1500Claim hcfa)
{
List<FormPage> pages = new List<FormPage>();
FormPage page = null;
for (int i = 0; i < hcfa.Field24_ServiceLines.Count; i++)
{
if (i % 6 == 0)
{
page = new FormPage();
pages.Add(page);
page.MasterReference = "hcfa1500";
page.ImagePath = _formImagePath;
// Render header
// LINE 1
AddBlock(page, 4, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsMedicare));
AddBlock(page, 11, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsMedicaid));
AddBlock(page, 18, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsTricareChampus));
AddBlock(page, 27, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsChampVa));
AddBlock(page, 34, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsGroupHealthPlan));
AddBlock(page, 42, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsFECABlkLung));
AddBlock(page, 48, 7, 2, ConditionalMarker(hcfa.Field01_TypeOfCoverageIsOther));
AddBlock(page, 53, 7, 30, hcfa.Field01a_InsuredsIDNumber);
// LINE 2
AddBlock(page, 4, 9, 28.5m, hcfa.Field02_PatientsName);
AddBlock(page, 34, 9, 3, hcfa.Field03_PatientsDateOfBirth.MM);
AddBlock(page, 37, 9, 3, hcfa.Field03_PatientsDateOfBirth.DD);
AddBlock(page, 40, 9, 3, hcfa.Field03_PatientsDateOfBirth.YY);
AddBlock(page, 44.5m, 9, 2.5m, ConditionalMarker(hcfa.Field03_PatientsSexMale), TextAlignEnum.center);
AddBlock(page, 49.5m, 9, 2.5m, ConditionalMarker(hcfa.Field03_PatientsSexFemale), TextAlignEnum.center);
AddBlock(page, 53, 9, 30, hcfa.Field04_InsuredsName);
// LINE 3
AddBlock(page, 4, 11, 28.5m, hcfa.Field05_PatientsAddress_Street);
AddBlock(page, 36, 11, 2, ConditionalMarker(hcfa.Field06_PatientRelationshipToInsuredIsSelf)); //self
AddBlock(page, 41, 11, 2, ConditionalMarker(hcfa.Field06_PatientRelationshipToInsuredIsSpouseOf)); //spouse
AddBlock(page, 45, 11, 2, ConditionalMarker(hcfa.Field06_PatientRelationshipToInsuredIsChildOf)); //child
AddBlock(page, 50, 11, 2, ConditionalMarker(hcfa.Field06_PatientRelationshipToInsuredIsOther)); // other
AddBlock(page, 53, 11, 30, hcfa.Field07_InsuredsAddress_Street);
// LINE 4
AddBlock(page, 4, 13, 25, hcfa.Field05_PatientsAddress_City);
AddBlock(page, 29, 13, 3.5m, hcfa.Field05_PatientsAddress_State);
// Field 8 unused in CMS-1500
AddBlock(page, 38, 13, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsSingle));
AddBlock(page, 44, 13, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsMarried));
AddBlock(page, 50, 13, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsOther));
AddBlock(page, 53, 13, 23, hcfa.Field07_InsuredsAddress_City);
AddBlock(page, 77, 13, 6, hcfa.Field07_InsuredsAddress_State);
// LINE 5
AddBlock(page, 4, 15, 13, hcfa.Field05_PatientsAddress_Zip);
AddBlock(page, 18, 15, 14.5m, hcfa.Field05_PatientsTelephone);
// Field 8 unused in CMS-1500
AddBlock(page, 38, 15, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsEmployed));
AddBlock(page, 44, 15, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsFullTimeStudent));
AddBlock(page, 50, 15, 2, ConditionalMarker(hcfa.Field08_PatientStatusIsPartTimeStudent));
AddBlock(page, 53, 15, 12, hcfa.Field07_InsuredsAddress_Zip);
AddBlock(page, 68.5m, 15, 14.5m, hcfa.Field07_InsuredsPhoneNumber);
// LINE 6
AddBlock(page, 4, 17, 28.5m, hcfa.Field09_OtherInsuredsName);
AddBlock(page, 53, 17, 30, hcfa.Field09a_OtherInsuredsPolicyOrGroup);
// LINE 7
AddBlock(page, 4, 19, 28.5m, hcfa.Field09a_OtherInsuredsPolicyOrGroup);
AddBlock(page, 38, 19, 2, ConditionalMarker(hcfa.Field10a_PatientConditionRelatedToEmployment));
AddBlock(page, 44, 19, 2, ConditionalMarker(!hcfa.Field10a_PatientConditionRelatedToEmployment));
AddBlock(page, 56, 19, 3, hcfa.Field11a_InsuredsDateOfBirth.MM);
AddBlock(page, 59, 19, 3, hcfa.Field11a_InsuredsDateOfBirth.DD);
AddBlock(page, 62, 19, 3, hcfa.Field11a_InsuredsDateOfBirth.YY);
AddBlock(page, 71.25m, 19, 2, ConditionalMarker(hcfa.Field11a_InsuredsSexIsMale), TextAlignEnum.center);
AddBlock(page, 78.5m, 19, 2, ConditionalMarker(hcfa.Field11a_InsuredsSexIsFemale), TextAlignEnum.center);
// LINE 8
// Field 9b is not supplied by 837P data.
AddBlock(page, 5, 21, 3, hcfa.Field09b_OtherInsuredsDateOfBirth.MM);
AddBlock(page, 8, 21, 3, hcfa.Field09b_OtherInsuredsDateOfBirth.DD);
AddBlock(page, 11, 21, 3, hcfa.Field09b_OtherInsuredsDateOfBirth.YY);
AddBlock(page, 21, 21, 2, ConditionalMarker(hcfa.Field09b_OtherInsuredIsMale));
AddBlock(page, 27, 21, 2, ConditionalMarker(hcfa.Field09b_OtherInsuredIsFemale));
AddBlock(page, 38, 21, 2, ConditionalMarker(hcfa.Field10b_PatientConditionRelatedToAutoAccident));
AddBlock(page, 44, 21, 2, ConditionalMarker(!hcfa.Field10b_PatientConditionRelatedToAutoAccident));
AddBlock(page, 48, 21, 2.5m, hcfa.Field10b_PatientConditionRelToAutoAccidentState);
AddBlock(page, 53, 21, 30, hcfa.Field09c_OtherInsuredsEmployerNameOrSchoolName);
// LINE 9
AddBlock(page, 4, 23, 28.5m, hcfa.Field09c_OtherInsuredsEmployerNameOrSchoolName);
AddBlock(page, 38, 23, 2, ConditionalMarker(hcfa.Field10c_PatientConditionRelatedToOtherAccident));
AddBlock(page, 44, 23, 2, ConditionalMarker(!hcfa.Field10c_PatientConditionRelatedToOtherAccident));
AddBlock(page, 53, 23, 30, hcfa.Field09d_OtherInsuredsInsurancePlanNameOrProgramName);
// LINE 10
AddBlock(page, 4, 25, 28.5m, hcfa.Field09d_OtherInsuredsInsurancePlanNameOrProgramName);
AddBlock(page, 33, 25, 20, hcfa.Field10d_ReservedForLocalUse);
AddBlock(page, 55, 25, 2, ConditionalMarker(hcfa.Field11d_IsThereOtherHealthBenefitPlan));
AddBlock(page, 60, 25, 2, ConditionalMarker(!hcfa.Field11d_IsThereOtherHealthBenefitPlan));
// LINE 11
AddBlock(page, 9, 29, 25, hcfa.Field12_PatientsOrAuthorizedSignature, TextAlignEnum.center);
AddBlock(page, 39, 29, 14, hcfa.Field12_PatientsOrAuthorizedSignatureDate.ToString(), TextAlignEnum.center);
AddBlock(page, 59, 29, 24, hcfa.Field13_InsuredsOrAuthorizedSignature, TextAlignEnum.center);
// LINE 12
if (hcfa.Field14_DateOfCurrentIllnessInjuryOrPregnancy != null)
{
AddBlock(page, 5, 31, 3, hcfa.Field14_DateOfCurrentIllnessInjuryOrPregnancy.MM);
AddBlock(page, 8, 31, 3, hcfa.Field14_DateOfCurrentIllnessInjuryOrPregnancy.DD);
AddBlock(page, 11, 31, 3, hcfa.Field14_DateOfCurrentIllnessInjuryOrPregnancy.YY);
}
// Field 15
AddBlock(page, 40, 31, 3, hcfa.Field15_DatePatientHadSameOrSimilarIllness.MM);
AddBlock(page, 43, 31, 3, hcfa.Field15_DatePatientHadSameOrSimilarIllness.DD);
AddBlock(page, 46, 31, 3, hcfa.Field15_DatePatientHadSameOrSimilarIllness.YY);
if (hcfa.Field16_DatePatientUnableToWork_Start != null)
{
AddBlock(page, 57, 31, 3, hcfa.Field16_DatePatientUnableToWork_Start.MM);
AddBlock(page, 60, 31, 3, hcfa.Field16_DatePatientUnableToWork_Start.DD);
AddBlock(page, 63, 31, 3, hcfa.Field16_DatePatientUnableToWork_Start.YY);
}
if (hcfa.Field16_DatePatientUnableToWork_End != null)
{
AddBlock(page, 71, 31, 3, hcfa.Field16_DatePatientUnableToWork_End.MM);
AddBlock(page, 74, 31, 3, hcfa.Field16_DatePatientUnableToWork_End.DD);
AddBlock(page, 77, 31, 3, hcfa.Field16_DatePatientUnableToWork_End.YY);
}
// LINE 13
AddBlock(page, 4, 33, 26, hcfa.Field17_ReferringProviderOrOtherSource_Name);
AddBlock(page, 33, 32, 3, hcfa.Field17a_OtherID_Qualifier);
AddBlock(page, 36, 32, 16, hcfa.Field17a_OtherID_Number);
AddBlock(page, 36, 33, 16, hcfa.Field17b_NationalProviderIdentifier);
// Field 18
AddBlock(page, 57, 33, 3, hcfa.Field18_HospitalizationDateFrom.MM);
AddBlock(page, 60, 33, 3, hcfa.Field18_HospitalizationDateFrom.DD);
AddBlock(page, 63, 33, 3, hcfa.Field18_HospitalizationDateFrom.YY);
AddBlock(page, 71, 33, 3, hcfa.Field18_HospitalizationDateTo.MM);
AddBlock(page, 74, 33, 3, hcfa.Field18_HospitalizationDateTo.DD);
AddBlock(page, 77, 33, 3, hcfa.Field18_HospitalizationDateTo.YY);
// LINE 14
AddBlock(page, 4, 35, 49, hcfa.Field19_ReservedForLocalUse);
AddBlock(page, 55, 35, 2, ConditionalMarker(hcfa.Field20_OutsideLab));
AddBlock(page, 60, 35, 2, ConditionalMarker(!hcfa.Field20_OutsideLab));
AddBlock(page, 65, 35, 9, hcfa.Field20_OutsideLab ? Convert.ToString(hcfa.Field20_OutsideLabCharges) : "", TextAlignEnum.right);
AddBlock(page, 74, 35, 9, "", TextAlignEnum.right); // Note, we do not use second charge box at all here.
// Line 15
AddBlock(page, 6.5m, 37, 8, hcfa.Field21_Diagnosis1);
AddBlock(page, 33.5m, 37, 8, hcfa.Field21_Diagnosis3);
AddBlock(page, 53, 37, 11, hcfa.Field22_MedicaidSubmissionCode);
AddBlock(page, 65, 37, 18, hcfa.Field22_OriginalReferenceNumber);
// Line 16
AddBlock(page, 6.5m, 39, 8, hcfa.Field21_Diagnosis2);
AddBlock(page, 33.5m, 39, 8, hcfa.Field21_Diagnosis4);
AddBlock(page, 53, 39, 30, hcfa.Field23_PriorAuthorizationNumber);
}
// Render service lines
decimal y = 42 + 2 * (i % 6);
var line = hcfa.Field24_ServiceLines[i];
AddBlock(page, 4, y, 60, line.CommentLine);
AddBlock(page, 68, y, 3, line.RenderingProviderIdQualifier);
AddBlock(page, 71, y, 12, line.RenderingProviderId);
AddBlock(page, 4, y + 1, 3, line.DateFrom.MM);
AddBlock(page, 7, y + 1, 3, line.DateFrom.DD);
AddBlock(page, 10, y + 1, 3, line.DateFrom.YY);
AddBlock(page, 13, y + 1, 3, line.DateTo.MM);
AddBlock(page, 16, y + 1, 3, line.DateTo.DD);
AddBlock(page, 19, y + 1, 3, line.DateTo.YY);
AddBlock(page, 22, y + 1, 3, line.PlaceOfService);
AddBlock(page, 25, y + 1, 2, line.EmergencyIndicator);
AddBlock(page, 29, y + 1, 6, line.ProcedureCode);
AddBlock(page, 36, y + 1, 3, line.Mod1);
AddBlock(page, 39, y + 1, 3, line.Mod2);
AddBlock(page, 42, y + 1, 3, line.Mod3);
AddBlock(page, 45, y + 1, 3, line.Mod4);
AddBlock(page, 48, y + 1, 2, line.DiagnosisPointer1);
AddBlock(page, 49, y + 1, 2, line.DiagnosisPointer2);
AddBlock(page, 50, y + 1, 2, line.DiagnosisPointer3);
AddBlock(page, 51, y + 1, 2, line.DiagnosisPointer4);
AddBlock(page, 53, y + 1, 9, String.Format("{0:0.00}", line.Charges).Replace(".", " "), TextAlignEnum.right);
AddBlock(page, 62, y + 1, 4, String.Format("{0}", line.DaysOrUnits), TextAlignEnum.right);
AddBlock(page, 66, y + 1, 2, line.EarlyPeriodicScreeningDiagnosisAndTreatment);
AddBlock(page, 71, y + 1, 12, line.RenderingProviderNpi);
if (i % 6 == 5 || i == hcfa.Field24_ServiceLines.Count - 1) // Footer
{
// Render footer
AddBlock(page, 4, 55, 15, hcfa.Field25_FederalTaxIDNumber);
if (hcfa.Field25_IsSSN)
AddBlock(page, 20, 55, 2, "X");
if (hcfa.Field25_IsEIN)
AddBlock(page, 22, 55, 2, "X");
AddBlock(page, 26, 55, 14, hcfa.Field26_PatientAccountNumber);
if (hcfa.Field27_AcceptAssignment.HasValue)
{
if (hcfa.Field27_AcceptAssignment.Value == true)
AddBlock(page, 41, 55, 2, "X");
else
AddBlock(page, 46, 55, 2, "X");
}
AddBlock(page, 55, 55, 9, String.Format("{0:0.00}", hcfa.Field28_TotalCharge).Replace(".", " "), TextAlignEnum.right);
AddBlock(page, 65, 55, 9, String.Format("{0:0.00}", hcfa.Field29_AmountPaid).Replace(".", " "), TextAlignEnum.right);
AddBlock(page, 74, 55, 9, String.Format("{0:0.00}", hcfa.Field30_BalanceDue).Replace(".", " "), TextAlignEnum.right);
// Box 31
if (hcfa.Field31_PhysicianOrSupplierSignatureIsOnFile.HasValue)
{
AddBlock(page, 4, 58, 21, "PROVIDER SIGNATURE", TextAlignEnum.center);
if (hcfa.Field31_PhysicianOrSupplierSignatureIsOnFile.Value == true)
AddBlock(page, 4, 59, 21, "IS ON FILE", TextAlignEnum.center);
else
AddBlock(page, 4, 59, 21, "NOT ON FILE", TextAlignEnum.center);
}
// Box 32
AddBlock(page, 26, 57, 27, hcfa.Field32_ServiceFacilityLocation_Name);
AddBlock(page, 26, 58, 27, hcfa.Field32_ServiceFacilityLocation_Street);
AddBlock(page, 26, 59, 27, String.Format("{0}, {1} {2}", hcfa.Field32_ServiceFacilityLocation_City, hcfa.Field32_ServiceFacilityLocation_State, hcfa.Field32_ServiceFacilityLocation_Zip));
AddBlock(page, 27, 60, 10, hcfa.Field32a_ServiceFacilityLocation_Npi);
AddBlock(page, 38, 60, 15, hcfa.Field32b_ServiceFacilityLocation_OtherID);
// Box 33
AddBlock(page, 69, 56, 27, hcfa.Field33_BillingProvider_TelephoneNumber);
AddBlock(page, 53, 57, 27, hcfa.Field33_BillingProvider_Name);
AddBlock(page, 53, 58, 27, hcfa.Field33_BillingProvider_Street);
AddBlock(page, 53, 59, 27, String.Format("{0}, {1} {2}", hcfa.Field33_BillingProvider_City, hcfa.Field33_BillingProvider_State, hcfa.Field33_BillingProvider_Zip));
AddBlock(page, 54, 60, 10, hcfa.Field33a_BillingProvider_Npi);
AddBlock(page, 65, 60, 15, hcfa.Field33b_BillingProvider_OtherID);
}
}
return pages;
}
/// <summary>
/// Takes a generic claim object stream parameter and maps properties to
/// corresponding properties in the HCFA 1500 claim. Returns a HCFA1500 claim.
/// Follows crosswalk published at http://www.nucc.org/images/stories/PDF/1500_form_map_to_837p_4010a1_v1-0_112008.pdf
/// </summary>
/// <param name="claim"></param>
/// <returns></returns>
public virtual HCFA1500Claim TransformClaimToHcfa1500(Claim claim)
{
var hcfa = new HCFA1500Claim();
String indicatorCode = null;
if (claim != null &&
claim.SubscriberInformation != null &&
claim.SubscriberInformation.ClaimFilingIndicatorCode != null)
{
indicatorCode = claim.SubscriberInformation.ClaimFilingIndicatorCode;
}
switch (indicatorCode)
{
case "CH":
hcfa.Field01_TypeOfCoverageIsTricareChampus = true;
break;
case "MB":
hcfa.Field01_TypeOfCoverageIsMedicare = true;
break;
case "MC":
hcfa.Field01_TypeOfCoverageIsMedicaid = true;
break;
case "VA":
hcfa.Field01_TypeOfCoverageIsChampVa = true;
break;
default:
if (claim.SubscriberInformation != null && claim.SubscriberInformation.ClaimFilingIndicatorCode != null)
hcfa.Field01_TypeOfCoverageIsOther = true;
break;
}
// XXX: I don't see any code corresponding to FECA Black Lung in the 837P standard
hcfa.Field01_TypeOfCoverageIsFECABlkLung = false;
hcfa.Field01_TypeOfCoverageIsGroupHealthPlan = false;
ClaimMember patient = claim.Patient ?? claim.Subscriber;
ClaimMember subscriber = claim.Subscriber;
if (!string.IsNullOrEmpty(patient.MemberId))
{
hcfa.Field01a_InsuredsIDNumber = patient.MemberId;
}
else if (patient != null &&
patient.Name != null &&
patient.Name.Identification != null &&
patient.Name.Identification.Id != null)
{
hcfa.Field01a_InsuredsIDNumber = patient.Name.Identification.Id;
}
else if (!string.IsNullOrEmpty(subscriber.MemberId))
{
hcfa.Field01a_InsuredsIDNumber = subscriber.MemberId;
}
else if (subscriber != null &&
subscriber.Name != null &&
subscriber.Name.Identification != null &&
subscriber.Name.Identification.Id != null)
{
hcfa.Field01a_InsuredsIDNumber = subscriber.Name.Identification.Id;
}
// Patient Name
if (patient.Name != null)
hcfa.Field02_PatientsName = patient.Name.Formatted();
// patient birthdate
if (patient.DateOfBirth != null)
hcfa.Field03_PatientsDateOfBirth = formatFormDate(patient.DateOfBirth);
hcfa.Field03_PatientsSexFemale = patient.Gender == GenderEnum.Female;
hcfa.Field03_PatientsSexMale = patient.Gender == GenderEnum.Male;
if (subscriber.Name != null)
hcfa.Field04_InsuredsName = subscriber.Name.Formatted();
// Patient Address
if (patient.Address != null)
{
hcfa.Field05_PatientsAddress_Street = String.Format("{0} {1}", patient.Address.Line1, patient.Address.Line2).TrimEnd();
hcfa.Field05_PatientsAddress_City = patient.Address.City;
hcfa.Field05_PatientsAddress_State = patient.Address.StateCode;
hcfa.Field05_PatientsAddress_Zip = patient.Address.PostalCode;
}
// Relationship information from https://www.cahabagba.com/part_b/msp/Providers_Electronic_Billing_Instructions.htm
String patientRelationship = "";
if (claim.SubscriberInformation != null)
{
patientRelationship = claim.SubscriberInformation.IndividualRelationshipCode;
}
switch (patientRelationship)
{
case "01":
hcfa.Field06_PatientRelationshipToInsuredIsSpouseOf = true;
break;
case "19":
hcfa.Field06_PatientRelationshipToInsuredIsChildOf = true;
break;
case "18":
hcfa.Field06_PatientRelationshipToInsuredIsSelf = true;
break;
default:
if (claim.SubscriberInformation != null && claim.SubscriberInformation.ClaimFilingIndicatorCode != null)
hcfa.Field01_TypeOfCoverageIsOther = true;
break;
}
if (subscriber.Address != null)
{
hcfa.Field07_InsuredsAddress_City = subscriber.Address.City;
hcfa.Field07_InsuredsAddress_State = subscriber.Address.StateCode;
hcfa.Field07_InsuredsAddress_Street = subscriber.Address.Line1;
hcfa.Field07_InsuredsAddress_Zip = subscriber.Address.PostalCode;
}
// Not present on 837P
hcfa.Field07_InsuredsAreaCode = String.Empty;
hcfa.Field07_InsuredsPhoneNumber = string.Empty;
// Not present on 837P
hcfa.Field08_PatientStatusIsEmployed = false;
hcfa.Field08_PatientStatusIsFullTimeStudent = false;
hcfa.Field08_PatientStatusIsMarried = false;
hcfa.Field08_PatientStatusIsOther = false;
hcfa.Field08_PatientStatusIsPartTimeStudent = false;
hcfa.Field08_PatientStatusIsSingle = false;
var otherSubscriber = claim.OtherSubscriberInformations.FirstOrDefault();
// No way to get below three fields using 837P
hcfa.Field09b_OtherInsuredIsFemale = false;
hcfa.Field09b_OtherInsuredIsMale = false;
hcfa.Field09b_OtherInsuredsDateOfBirth = new FormDate();
if (otherSubscriber != null)
{
hcfa.Field09_OtherInsuredsName = otherSubscriber.Name.Formatted();
hcfa.Field09a_OtherInsuredsPolicyOrGroup = otherSubscriber.SubscriberInformation.ReferenceIdentification;
hcfa.Field09b_OtherInsuredsDateOfBirth = formatFormDate(otherSubscriber.DateOfBirth);
hcfa.Field09b_OtherInsuredIsFemale = otherSubscriber.Gender == GenderEnum.Female;
hcfa.Field09b_OtherInsuredIsMale = otherSubscriber.Gender == GenderEnum.Male;
hcfa.Field09c_OtherInsuredsEmployerNameOrSchoolName = otherSubscriber.OtherPayer.LastName; // XXX: OK to assume org in last name?
hcfa.Field09d_OtherInsuredsInsurancePlanNameOrProgramName = otherSubscriber.OtherPayer.Identification.Id;
}
hcfa.Field10a_PatientConditionRelatedToEmployment = claim.RelatedCauseCode1 == "AA" || claim.RelatedCauseCode2 == "AA" || claim.RelatedCauseCode3 == "AA";
hcfa.Field10b_PatientConditionRelatedToAutoAccident = claim.RelatedCauseCode1 == "EM" || claim.RelatedCauseCode2 == "EM" || claim.RelatedCauseCode3 == "EM";
hcfa.Field10c_PatientConditionRelatedToOtherAccident = claim.RelatedCauseCode1 == "AB" || claim.RelatedCauseCode1 == "AP" || claim.RelatedCauseCode1 == "OA" ||
claim.RelatedCauseCode2 == "AB" || claim.RelatedCauseCode2 == "AP" || claim.RelatedCauseCode2 == "OA" ||
claim.RelatedCauseCode3 == "AB" || claim.RelatedCauseCode3 == "AP" || claim.RelatedCauseCode3 == "OA";
hcfa.Field10b_PatientConditionRelToAutoAccidentState = claim.AutoAccidentState;
hcfa.Field10d_ReservedForLocalUse = string.Empty;
hcfa.Field11_InsuredsPolicyGroupOfFECANumber = string.Empty;
hcfa.Field11a_InsuredsDateOfBirth = formatFormDate(subscriber.DateOfBirth);
hcfa.Field11a_InsuredsSexIsFemale = subscriber.Gender == GenderEnum.Female;
hcfa.Field11a_InsuredsSexIsMale = subscriber.Gender == GenderEnum.Male;
hcfa.Field11b_InsuredsEmployerOrSchool = string.Empty;
hcfa.Field11c_InsuredsPlanOrProgramName = string.Empty;
hcfa.Field11d_IsThereOtherHealthBenefitPlan = otherSubscriber != null;
hcfa.Field12_PatientsOrAuthorizedSignature = string.Empty;
switch (claim.PatientSignatureSourceCode)
{
case "B":
case "C":
case "M":
case "S":
hcfa.Field12_PatientsOrAuthorizedSignature = "Signature on file";
break;
case "P":
hcfa.Field12_PatientsOrAuthorizedSignature = "Signature generated by provider";
break;
}
hcfa.Field12_PatientsOrAuthorizedSignatureDate = new FormDate();
hcfa.Field13_InsuredsOrAuthorizedSignature = string.Empty;
var onsetDate = claim.Dates.FirstOrDefault(dr => dr.Qualifier == "431");
if (onsetDate != null)
{
hcfa.Field14_DateOfCurrentIllnessInjuryOrPregnancy = formatFormDate(onsetDate.Date);
}
var similarIllnessDate = claim.Dates.FirstOrDefault(dr => dr.Qualifier == "438"); // only supported in 4010 837P
if (similarIllnessDate != null)
{
hcfa.Field15_DatePatientHadSameOrSimilarIllness = formatFormDate(similarIllnessDate.Date);
}
var disabilityStart = claim.Dates.FirstOrDefault(dr => dr.Qualifier == "360");
var disabilityEnd = claim.Dates.FirstOrDefault(dr => dr.Qualifier == "361");
if (disabilityStart != null)
{
hcfa.Field16_DatePatientUnableToWork_Start = formatFormDate(disabilityStart.Date);
}
if (disabilityEnd != null)
{
hcfa.Field16_DatePatientUnableToWork_End = formatFormDate(disabilityEnd.Date);
}
var referringProvider = claim.Providers.FirstOrDefault(pr => pr.Name.Type.Identifier == "DN" && pr.Name.Identification.Qualifier == "XX");
if (referringProvider != null)
{
hcfa.Field17_ReferringProviderOrOtherSource_Name = referringProvider.Name.Formatted();
var id = referringProvider.Identifications.FirstOrDefault();
if (id != null)
{
hcfa.Field17a_OtherID_Number = id.Id;
hcfa.Field17a_OtherID_Qualifier = id.Qualifier;
}
hcfa.Field17b_NationalProviderIdentifier = referringProvider.Npi;
}
// Admission date and hour
hcfa.Field18_HospitalizationDateFrom = new FormDate();
hcfa.Field18_HospitalizationDateTo = new FormDate();
if (claim.AdmissionDate.HasValue)
{
hcfa.Field18_HospitalizationDateFrom = formatFormDate(claim.AdmissionDate);
}
if (claim.DischargeTime.HasValue)
{
hcfa.Field18_HospitalizationDateTo = formatFormDate(claim.DischargeTime);
}
hcfa.Field19_ReservedForLocalUse = string.Empty;
// Outside services are stored in claim service lines
double totalAmountSpent = 0.0;
foreach (var line in claim.ServiceLines)
{
if (line.PurchasedServiceIdentifier != null)
{
hcfa.Field20_OutsideLab = true;
if (line.PurchasedServiceAmount != null)
{
totalAmountSpent += Convert.ToDouble(line.PurchasedServiceAmount);
}
}
}
hcfa.Field20_OutsideLabCharges = (Decimal)totalAmountSpent;
var principalDiagnosis = claim.Diagnoses.FirstOrDefault(d => d.DiagnosisType == DiagnosisTypeEnum.Principal);
var otherDiagnoses = claim.Diagnoses.Where(d => d.DiagnosisType == DiagnosisTypeEnum.Other).ToList();
// Diagnosis codes
if (principalDiagnosis != null)
hcfa.Field21_Diagnosis1 = principalDiagnosis.FormattedCode();
if (otherDiagnoses.Count >= 1)
hcfa.Field21_Diagnosis2 = otherDiagnoses[0].FormattedCode();
if (otherDiagnoses.Count >= 2)
hcfa.Field21_Diagnosis3 = otherDiagnoses[1].FormattedCode();
if (otherDiagnoses.Count >= 3)
hcfa.Field21_Diagnosis4 = otherDiagnoses[2].FormattedCode();
var frequencyType = "";
if (claim.BillTypeCode.Length == 3)
{
frequencyType = claim.BillTypeCode.Substring(2, 1);
}
if (frequencyType == "7" || frequencyType == "8")
hcfa.Field22_MedicaidSubmissionCode = frequencyType;
else
hcfa.Field22_MedicaidSubmissionCode = string.Empty;
var originalRef = claim.Identifications.FirstOrDefault(id => id.Qualifier == "F8");
if (originalRef != null)
hcfa.Field22_OriginalReferenceNumber = originalRef.Id;
else
hcfa.Field22_OriginalReferenceNumber = string.Empty;
hcfa.Field23_PriorAuthorizationNumber = claim.PriorAuthorizationNumber;
var hcfaServiceLines = new List<HCFA1500ServiceLine>();
// Service Lines
foreach (var line in claim.ServiceLines)
{
var hcfaLine = new HCFA1500ServiceLine();
hcfaLine.DateFrom = new FormDate
{
MM = String.Format("{0:MM}", line.ServiceDateFrom),
DD = String.Format("{0:dd}", line.ServiceDateFrom),
YY = String.Format("{0:yy}", line.ServiceDateFrom)
};
hcfaLine.DateTo = new FormDate
{
MM = String.Format("{0:MM}", line.ServiceDateTo),
DD = String.Format("{0:dd}", line.ServiceDateTo),
YY = String.Format("{0:yy}", line.ServiceDateTo)
};
if (line.PlaceOfService != null && !string.IsNullOrWhiteSpace(line.PlaceOfService.Code))
hcfaLine.PlaceOfService = line.PlaceOfService.Code;
else
hcfaLine.PlaceOfService = claim.ServiceLocationInfo.FacilityCode;
hcfaLine.EmergencyIndicator = line.EmergencyIndicator;
hcfaLine.ProcedureCode = line.Procedure.ProcedureCode;
hcfaLine.ProcedureCode = line.Procedure.ProcedureCode;
hcfaLine.Mod1 = line.Procedure.Modifier1;
hcfaLine.Mod2 = line.Procedure.Modifier2;
hcfaLine.Mod3 = line.Procedure.Modifier3;
hcfaLine.Mod4 = line.Procedure.Modifier4;
hcfaLine.DiagnosisPointer1 = line.DiagnosisCodePointer1;
hcfaLine.DiagnosisPointer2 = line.DiagnosisCodePointer2;
hcfaLine.DiagnosisPointer3 = line.DiagnosisCodePointer3;
hcfaLine.DiagnosisPointer4 = line.DiagnosisCodePointer4;
hcfaLine.Charges = line.ChargeAmount;
hcfaLine.DaysOrUnits = line.Quantity;
hcfaLine.EarlyPeriodicScreeningDiagnosisAndTreatment = line.EpsdtIndicator;
if (line.RenderingProvider != null && !string.IsNullOrWhiteSpace(line.RenderingProvider.Npi))
hcfaLine.RenderingProviderNpi = line.RenderingProvider.Npi;
else if (claim.RenderingProvider != null && !string.IsNullOrWhiteSpace(claim.RenderingProvider.Npi))
hcfaLine.RenderingProviderNpi = claim.RenderingProvider.Npi;
if (line.RenderingProvider != null && line.RenderingProvider.Identifications.Count > 0)
{
hcfaLine.RenderingProviderIdQualifier = line.RenderingProvider.Identifications[0].Qualifier;
hcfaLine.RenderingProviderId = line.RenderingProvider.Identifications[0].Id;
}
else if (line.RenderingProvider != null && line.RenderingProvider.ProviderInfo != null)
{
hcfaLine.RenderingProviderIdQualifier = line.RenderingProvider.ProviderInfo.Qualifier;
hcfaLine.RenderingProviderId = line.RenderingProvider.ProviderInfo.Id;
}
else if (claim.RenderingProvider != null && claim.RenderingProvider.Identifications.Count > 0)
{
hcfaLine.RenderingProviderIdQualifier = claim.RenderingProvider.Identifications[0].Qualifier;
hcfaLine.RenderingProviderId = claim.RenderingProvider.Identifications[0].Id;
}
else if (claim.RenderingProvider != null && claim.RenderingProvider.ProviderInfo != null)
{
hcfaLine.RenderingProviderIdQualifier = claim.RenderingProvider.ProviderInfo.Qualifier;
hcfaLine.RenderingProviderId = claim.RenderingProvider.ProviderInfo.Id;
}
hcfaServiceLines.Add(hcfaLine);
}
hcfa.Field24_ServiceLines = hcfaServiceLines;
// Federal Tax Number
if (!string.IsNullOrWhiteSpace(claim.PayToProvider.TaxId))
{
hcfa.Field25_FederalTaxIDNumber = claim.PayToProvider.TaxId;
if (claim.PayToProvider.Identifications.Exists(id=>id.Qualifier == "EI"))
hcfa.Field25_IsEIN = true;
if (claim.PayToProvider.Identifications.Exists(id => id.Qualifier == "SY"))
hcfa.Field25_IsSSN = true;
}
else
{
hcfa.Field25_FederalTaxIDNumber = claim.BillingProvider.TaxId;
if (claim.BillingProvider.Identifications.Exists(id => id.Qualifier == "EI"))
hcfa.Field25_IsEIN = true;
if (claim.BillingProvider.Identifications.Exists(id => id.Qualifier == "SY"))
hcfa.Field25_IsSSN = true;
}
// shouldnt we represent hcfa.Field25_IsSSN and Field25_IsEIN to know which type TaxID?
hcfa.Field26_PatientAccountNumber = claim.PatientControlNumber;
if (claim.ProviderAcceptAssignmentCode == "A" || claim.ProviderAcceptAssignmentCode == "B")
hcfa.Field27_AcceptAssignment = true;
else if (claim.ProviderAcceptAssignmentCode == "C")
hcfa.Field27_AcceptAssignment = false;
hcfa.Field28_TotalCharge = claim.TotalClaimChargeAmount;
hcfa.Field29_AmountPaid = claim.PatientAmountPaid;
hcfa.Field30_BalanceDue = null; // does not exist on 837P
if (claim.ProviderSignatureOnFile == "Y")
hcfa.Field31_PhysicianOrSupplierSignatureIsOnFile = true;
else if (claim.ProviderSignatureOnFile == "N")
hcfa.Field31_PhysicianOrSupplierSignatureIsOnFile = false;
// Service Location
var serviceLocation = claim.ServiceLocation;
hcfa.Field32_ServiceFacilityLocation_Name = serviceLocation.Name.LastName;
hcfa.Field32_ServiceFacilityLocation_Street = serviceLocation.Address.Line1;
hcfa.Field32_ServiceFacilityLocation_City = serviceLocation.Address.City;
hcfa.Field32_ServiceFacilityLocation_State = serviceLocation.Address.StateCode;
hcfa.Field32_ServiceFacilityLocation_Zip = serviceLocation.Address.PostalCode;
hcfa.Field32a_ServiceFacilityLocation_Npi = serviceLocation.Npi;
if (serviceLocation.Identifications.Count > 0)
hcfa.Field32b_ServiceFacilityLocation_OtherID = serviceLocation.Identifications.First().Id;
// Pay To Provider
hcfa.Field33_BillingProvider_Name = claim.BillingProvider.Name.LastName;
hcfa.Field33_BillingProvider_Street = claim.BillingProvider.Address.Line1;
hcfa.Field33_BillingProvider_City = claim.BillingProvider.Address.City;
hcfa.Field33_BillingProvider_State = claim.BillingProvider.Address.StateCode;
hcfa.Field33_BillingProvider_Zip = claim.BillingProvider.Address.PostalCode;
hcfa.Field33a_BillingProvider_Npi = claim.BillingProvider.Npi;
return hcfa;
}
