| 1 | BPSNCPDP ;BHAM ISC/LJE - API to submit a claim to ECME ;8/01/03
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| 2 | ;;1.0;E CLAIMS MGMT ENGINE;**1,3,4,2,5**;JUN 2004;Build 45
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| 3 | ;;Per VHA Directive 2004-038, this routine should not be modified.
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| 4 | ;
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| 5 | ; For comments regarding this API, see routine BPSNCPD1.
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| 6 | ; They were moved to BPSNCPD1 due to size constraints
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| 7 | ;
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| 8 | EN(BRXIEN,BFILL,BFILLDAT,BWHERE,BILLNDC,REVREAS,DURREC,BPOVRIEN,BPSCLARF,BPSAUTH) ;
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| 9 | EN1 N DFN,PNAME,BRX,BPSARRY,MOREDATA,SITE,WFLG,OLDRESP,IEN59
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| 10 | N %,%I,%H,X,TODAY
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| 11 | N QUIT,CERTIEN
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| 12 | N REBILL,REVONLY,CLMSTAT,RESPONSE,BPSTART,IB,RESP
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| 13 | ;
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| 14 | ; Default variables
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| 15 | S RESPONSE="",CLMSTAT=""
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| 16 | ;
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| 17 | ; Check for valid RX and fill
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| 18 | I '$G(BRXIEN) S CLMSTAT="Prescription IEN parameter missing",RESPONSE=5 G END
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| 19 | I '$G(BFILL) S BFILL=0
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| 20 | ;
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| 21 | ; Setup IEN59, and initialize log
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| 22 | S IEN59=$$IEN59^BPSOSRX(BRXIEN,BFILL)
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| 23 | I IEN59="" S CLMSTAT="BPS Transaction IEN could not be calculated",RESPONSE=1 G END
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| 24 | D LOG^BPSOSL(IEN59,$T(+0)_"-Start of claim","DT")
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| 25 | ;
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| 26 | ; Check for BWHERE parameter
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| 27 | I $G(BWHERE)="" S CLMSTAT="RX Action parameter missing",RESPONSE=5 G END
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| 28 | ;
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| 29 | ; Get prescription number
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| 30 | S BRX=$$RXAPI1^BPSUTIL1(BRXIEN,.01,"I")
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| 31 | ;
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| 32 | ; Check that the prescription exists
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| 33 | I BRX="" S CLMSTAT="Prescription does not exist",RESPONSE=5 G END
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| 34 | ;
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| 35 | ; Get the NDC if it was not passed in
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| 36 | I $G(BILLNDC)="" S BILLNDC=$$GETNDC^PSONDCUT(BRXIEN,BFILL)
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| 37 | ;
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| 38 | ; Patient Info
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| 39 | S DFN=$$RXAPI1^BPSUTIL1(BRXIEN,2,"I"),PNAME=$$GET1^DIQ(2,DFN,.01)
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| 40 | ;
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| 41 | ; Set write flag
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| 42 | S WFLG=1
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| 43 | I ",ARES,AREV,CRLB,CRLR,CRLX,DDED,DE,EREV,HLD,PC,PE,PL,RS,"[(","_BWHERE_",") S WFLG=0
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| 44 | ;
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| 45 | ; Get status of previously submitted claim and set rebill/revonly flags
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| 46 | S (REBILL,REVONLY)=0
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| 47 | S OLDRESP=$P($$STATUS^BPSOSRX(BRXIEN,BFILL,1),U,1)
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| 48 | I ",AREV,CRLR,CRLX,DC,DDED,DE,EREV,HLD,RS,"[(","_BWHERE_",") S REVONLY=1
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| 49 | E I OLDRESP="E PAYABLE"!(OLDRESP="E DUPLICATE") S REBILL=1
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| 50 | ;
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| 51 | ; Get Site info and check if the site has ECME turned on. Note that
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| 52 | ; ECMEON will also return false if there is no NPI after the drop
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| 53 | ; dead date. Do not do this check for reversals/rebill as these
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| 54 | ; need to be processed for the old site
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| 55 | I 'BFILL S SITE=$$RXAPI1^BPSUTIL1(BRXIEN,20,"I")
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| 56 | I BFILL S SITE=$$RXSUBF1^BPSUTIL1(BRXIEN,52,52.1,+BFILL,8,"I")
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| 57 | I 'REVONLY,'REBILL D I RESPONSE=1 G END
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| 58 | . I '$G(SITE) S CLMSTAT="No Site Information",RESPONSE=1 Q
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| 59 | . I '$$ECMEON^BPSUTIL(SITE) S CLMSTAT="ECME switch is not on for the site",RESPONSE=1
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| 60 | ;
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| 61 | ; In Progress/Stranded claims check
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| 62 | I OLDRESP["IN PROGRESS" D G END
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| 63 | . S CLMSTAT="Previous request is IN PROGRESS. It may need to be unstranded.",RESPONSE=4
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| 64 | . I WFLG W !,CLMSTAT,! H 2
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| 65 | . ; If not OP, then send an email to the OPECC
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| 66 | . I ",AREV,BB,ERES,EREV,"'[(","_BWHERE_",") D BULL^BPSNCPD1(BRXIEN,BFILL,$G(SITE),$G(DFN),$G(PNAME))
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| 67 | ;
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| 68 | ; Backbilling check
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| 69 | I BWHERE="BB",OLDRESP'="" D G END
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| 70 | . S CLMSTAT="Previously billed through ECME: "_OLDRESP,RESPONSE=1
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| 71 | . I WFLG W !,CLMSTAT,! H 2
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| 72 | ;
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| 73 | ; Do not reverse if the prescription was not previously billed through ECME
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| 74 | I OLDRESP="",(",AREV,CRLR,CRLX,DC,DDED,DE,EREV,HLD,RS,"[(","_BWHERE_",")) D G END
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| 75 | . S CLMSTAT="Prescription not previously billed through ECME. Cannot Reverse claim.",RESPONSE=1
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| 76 | . I WFLG W !,CLMSTAT,! H 2
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| 77 | ;
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| 78 | ; If returning to stock or deleting and the previous claim was not paid, then no reversal is needed
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| 79 | ; so close the prescription and quit
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| 80 | I OLDRESP'["E PAYABLE",OLDRESP'["E REVERSAL REJECTED",(",RS,DE,"[(","_BWHERE_",")) D G END
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| 81 | . D CLOSE2^BPSBUTL(BRXIEN,BFILL,BWHERE)
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| 82 | . S CLMSTAT="Claim was not payable so it has been closed. No ECME claim created.",RESPONSE=3
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| 83 | . I WFLG W !,CLMSTAT,! H 2
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| 84 | ;
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| 85 | ; Do not reverse if the claim is not E PAYABLE
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| 86 | I OLDRESP'["E PAYABLE",OLDRESP'["E DUPLICATE",(",AREV,CRLR,CRLX,DC,DDED,HLD,"[(","_BWHERE_",")) D G END
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| 87 | . S CLMSTAT="Claim has status "_OLDRESP_". Not reversed.",RESPONSE=1
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| 88 | . I WFLG W !,CLMSTAT,! H 2
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| 89 | ;
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| 90 | ; EREV can be re-reversed if the previous submission is Payable or Rejected Revesal
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| 91 | I BWHERE="EREV",",E PAYABLE,E DUPLICATE,E REVERSAL REJECTED,E REVERSAL STRANDED,"'[(","_OLDRESP_",") D G END
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| 92 | . S CLMSTAT="Claim has status "_OLDRESP_". Not reversed.",RESPONSE=1
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| 93 | . I WFLG W !,CLMSTAT,! H 2
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| 94 | ;
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| 95 | ; Make sure fill date is not in the future or empty
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| 96 | D NOW^%DTC
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| 97 | S TODAY=$P(%,".",1)
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| 98 | I '$G(BFILLDAT)!($G(BFILLDAT)>TODAY) S BFILLDAT=TODAY
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| 99 | ;
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| 100 | ; Store needed parameters into MOREDATA
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| 101 | ; In instances where duz is null set it equal to .5 (postmaster)
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| 102 | S MOREDATA("USER")=$S('DUZ:.5,1:DUZ)
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| 103 | S MOREDATA("RX ACTION")=$G(BWHERE)
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| 104 | S MOREDATA("DATE OF SERVICE")=$P($G(BFILLDAT),".",1)
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| 105 | S MOREDATA("REVERSAL REASON")=$S($G(REVREAS)="":"UNKNOWN",1:$E($G(REVREAS),1,40))
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| 106 | I $G(DURREC)]"" S MOREDATA("DUR",1,0)=DURREC
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| 107 | I $G(BPOVRIEN)]"" S MOREDATA("BPOVRIEN")=BPOVRIEN
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| 108 | I $G(BPSCLARF)]"" S MOREDATA("BPSCLARF")=BPSCLARF
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| 109 | I $TR($G(BPSAUTH),"^")]"" S MOREDATA("BPSAUTH")=BPSAUTH
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| 110 | ;
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| 111 | ; Do a reversal for the appropriate actions
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| 112 | I ",AREV,CRLR,CRLX,DC,DDED,DE,EREV,HLD,RS,"[(","_BWHERE_",") D G STATUS:RESPONSE=0,END:RESPONSE=4
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| 113 | . ; If override flag is set, prompt for override values - MUST be commented out for any release.
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| 114 | . ;I $L($T(CHECK^ZZGIZOV1))>0,$$CHECK^ZZGIZOV1 D GETOVER^ZZGIZOV1(BRXIEN,BFILL,OLDRESP,BWHERE,"R")
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| 115 | . ;
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| 116 | . ; Needed for Turn-Around Stats - Do NOT delete/alter!!
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| 117 | . D LOG(IEN59,"Before Submit of Reversal")
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| 118 | . S BPSTART=$$STTM()
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| 119 | . S RESP=$$UNCLAIM^BPSOSRX(BRXIEN,BFILL,.MOREDATA)
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| 120 | . D LOG(IEN59,"After Submit of Reversal. Return Value: "_RESP)
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| 121 | . I RESP=1 D
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| 122 | .. S RESPONSE=0,CLMSTAT="Reversing prescription "_BRX_"."
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| 123 | .. I WFLG W !,CLMSTAT H 2
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| 124 | . I RESP=0 D
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| 125 | .. S RESPONSE=4,CLMSTAT="No claim submission made. Unable to queue reversal."
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| 126 | .. D LOG(IEN59,CLMSTAT)
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| 127 | .. I WFLG W !,CLMSTAT,! H 2
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| 128 | .. L -^BPST
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| 129 | ;
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| 130 | ; Can not resubmit reversed claims unless they are accepted
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| 131 | I OLDRESP]"",OLDRESP["E REVERSAL",OLDRESP'="E REVERSAL ACCEPTED" D G END
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| 132 | . S CLMSTAT="Can not resubmit a rejected or stranded reversal",RESPONSE=1
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| 133 | . I WFLG W !,CLMSTAT,! H 2
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| 134 | ;
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| 135 | ; Some actions require a paid claim (they will not do a reversal/resubmit)
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| 136 | I OLDRESP]"",OLDRESP'="E REVERSAL ACCEPTED",OLDRESP'="E REJECTED",(",CRLB,ED,ERES,RL,RRL,"'[(","_BWHERE_",")) D G END
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| 137 | . S CLMSTAT="Previously billed through ECME: "_OLDRESP,RESPONSE=1
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| 138 | . I WFLG W !,CLMSTAT,! H 2
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| 139 | ;
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| 140 | ; Certification Testing
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| 141 | S QUIT=0,CERTIEN=""
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| 142 | I ^BPS(9002313.99,1,"CERTIFIER")=DUZ D I QUIT S CLMSTAT="User exited from certification questions",RESPONSE=1 G END
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| 143 | C1 . R !,"ENTER NDC: ",BILLNDC:120 S:BILLNDC="^" QUIT=1 Q:QUIT I BILLNDC="" G C1
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| 144 | C3 . R !,"CERTIFICATION ENTRY: ",CERTIEN:120 I '$D(^BPS(9002313.31,CERTIEN)) S:CERTIEN="^" QUIT=1 Q:QUIT W !,"INVALID IEN" G C3
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| 145 | I WFLG W !!
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| 146 | ;
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| 147 | ; Build array BPSARRY with prescription data
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| 148 | D STARRAY^BPSNCPD1(BRXIEN,BFILL,BWHERE,.BPSARRY,$G(SITE))
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| 149 | ;
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| 150 | ; Do IB billing determination and check response
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| 151 | ; If IB=2, then not billable, so write messages
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| 152 | S IB=0
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| 153 | D EN^BPSNCPD2(DFN,BWHERE,.MOREDATA,.BPSARRY,.IB)
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| 154 | I IB=2,(OLDRESP="E PAYABLE")!(OLDRESP="E DUPLICATE"),(",CRLB,ED,ERES,RL,RRL,"[(","_BWHERE_",")) D
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| 155 | .S MOREDATA("REVERSE THEN RESUBMIT")=2
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| 156 | .S CLMSTAT=$P(MOREDATA("BILL"),"^",2)
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| 157 | .D LOG(IEN59,CLMSTAT_" - Claim Will Be Reversed But Will Not Be Resubmitted")
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| 158 | .I WFLG W !,CLMSTAT_" - Claim Will Be Reversed But Will Not Be Resubmitted" H 2
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| 159 | I IB=2,$G(MOREDATA("REVERSE THEN RESUBMIT"))'=2 D G END
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| 160 | . S RESPONSE=2
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| 161 | . S CLMSTAT=$P(MOREDATA("BILL"),"^",2)
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| 162 | . I OLDRESP]"" D LOG(IEN59,CLMSTAT)
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| 163 | ;
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| 164 | ; Check for missing data (Will IB billing determination catch this?)
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| 165 | I $D(MOREDATA("IBDATA",1,1)),$P(MOREDATA("IBDATA",1,1),"^",1)="",$G(MOREDATA("REVERSE THEN RESUBMIT"))'=2 D G END
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| 166 | . S RESPONSE=2,CLMSTAT="Information missing from IB data."
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| 167 | . I WFLG W !,CLMSTAT,! H 2
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| 168 | ;
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| 169 | ; Check for missing/invalid payer sheets (I think IB billing determination will catch this)
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| 170 | I $P($G(MOREDATA("IBDATA",1,1)),"^",4)="",$G(MOREDATA("REVERSE THEN RESUBMIT"))'=2 D G END
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| 171 | . S RESPONSE=2,CLMSTAT="Invalid/missing payer sheet from IB data."
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| 172 | . I WFLG W !,CLMSTAT,! H 2
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| 173 | ;
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| 174 | ; Check if IB says to bill
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| 175 | I '$G(MOREDATA("BILL")),$G(MOREDATA("REVERSE THEN RESUBMIT"))'=2 D G END
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| 176 | . S RESPONSE=2
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| 177 | . S CLMSTAT="Flagged by IB to not 3rd Party Insurance bill through ECME."
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| 178 | . I WFLG W !,CLMSTAT,! H 2
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| 179 | ;
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| 180 | ; Log message to ECME log
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| 181 | ; Needed for Turn-Around Stats - Do NOT delete/alter!!
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| 182 | D LOG(IEN59,"Before submit of claim")
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| 183 | ;
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| 184 | ; If override flag is set, prompt for override values - MUST be commented out for any release.
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| 185 | ;I $L($T(CHECK^ZZGIZOV1))>0,$$CHECK^ZZGIZOV1 D GETOVER^ZZGIZOV1(BRXIEN,BFILL,OLDRESP,BWHERE,"S")
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| 186 | ;
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| 187 | ; Get require data
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| 188 | S BPSTART=$$STTM()
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| 189 | ;
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| 190 | ; Submit claim and check result
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| 191 | S RESP=$$CLAIM^BPSOSRX(BRXIEN,BFILL,.MOREDATA)
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| 192 | D LOG(IEN59,"After Submit of Claim. Return Value: "_RESP)
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| 193 | I RESP=1 D
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| 194 | . S RESPONSE=0
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| 195 | . I $G(MOREDATA("REVERSE THEN RESUBMIT"))=2 S CLMSTAT="Prescription "_BRX_" successfully submitted to ECME for claim reversal."
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| 196 | . E S CLMSTAT="Prescription "_BRX_" successfully submitted to ECME for claim generation."
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| 197 | . I WFLG W !!,CLMSTAT
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| 198 | I RESP=0 D G END
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| 199 | . S RESPONSE=4
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| 200 | . S CLMSTAT="No claim submission made. Unable to queue claim submission."
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| 201 | . I WFLG W !!,CLMSTAT,!
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| 202 | . D LOG(IEN59,CLMSTAT)
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| 203 | ;
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| 204 | ; Display status
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| 205 | STATUS I 'WFLG H 1
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| 206 | E D STATUS^BPSNCPD1(BRXIEN,BFILL,REBILL,REVONLY,BPSTART,BWHERE)
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| 207 | ;
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| 208 | ;Update Response for Reversal but no Resubmit
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| 209 | I $G(MOREDATA("REVERSE THEN RESUBMIT"))=2 S RESPONSE=10,CLMSTAT=$P($G(MOREDATA("BILL")),U,2)
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| 210 | ;
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| 211 | ; Clean up and quit
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| 212 | END K BRXIEN,BFILL,BFILLDAT,BWHERE,MOREDATA
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| 213 | S:'$D(RESPONSE) RESPONSE=1
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| 214 | I $G(IEN59) D
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| 215 | . N MSG
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| 216 | . S MSG="Foreground Process Complete-RESPONSE="_$G(RESPONSE)
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| 217 | . I $G(RESPONSE)'=0 S MSG=MSG_", CLMSTAT="_$G(CLMSTAT)
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| 218 | . D LOG(IEN59,MSG)
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| 219 | Q RESPONSE_"^"_$G(CLMSTAT)
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| 220 | ;
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| 221 | LOG(IEN59,MSG) ;
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| 222 | D LOG^BPSOSL(IEN59,$T(+0)_"-"_MSG)
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| 223 | Q
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| 224 | STTM() ;
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| 225 | N %,%H,%I
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| 226 | D NOW^%DTC
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| 227 | Q %
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