|
@@ -1,217 +1,214 @@
|
|
|
|
|
+@php
|
|
|
|
|
+ $medicaidStates = Config::get('constants.medicaid_states');
|
|
|
|
|
+@endphp
|
|
|
<div moe>
|
|
<div moe>
|
|
|
<a class="text-nowrap" href="" show start>Put Card Info</a>
|
|
<a class="text-nowrap" href="" show start>Put Card Info</a>
|
|
|
- <form url="/api/insuranceCard/putCardInfo" style="min-width: 600px;">
|
|
|
|
|
|
|
+ <form url="/api/insuranceCard/putCardInfo" style="min-width: 600px;" id="editInsuranceCardForm">
|
|
|
<input type="hidden" name="uid" value="{{ $card->uid }}">
|
|
<input type="hidden" name="uid" value="{{ $card->uid }}">
|
|
|
- <div class="bg-light">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Coverage Order</label>
|
|
|
|
|
- <select name="coverageOrder" class="form-control">
|
|
|
|
|
- <option value="PRIMARY" {{ $card->coverage_order === 'PRIMARY' ? 'selected':'' }}>PRIMARY</option>
|
|
|
|
|
- <option value="SECONDARY" {{ $card->coverage_order === 'SECONDARY' ? 'selected':'' }}>SECONDARY</option>
|
|
|
|
|
- <option value="TERTIARY" {{ $card->coverage_order === 'TERTIARY' ? 'selected':'' }}>TERTIARY</option>
|
|
|
|
|
- </select>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Payer Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Carrier Category</label>
|
|
|
|
|
- <select name="carrierCategory" class="form-control">
|
|
|
|
|
- <option value="MEDICARE" {{ $card->carrier_category === 'MEDICARE' ? 'selected':'' }}>MEDICARE</option>
|
|
|
|
|
- <option value="MEDICAID" {{ $card->carrier_category === 'MEDICAID' ? 'selected':'' }}>MEDICAID</option>
|
|
|
|
|
- <option value="COMMERCIAL" {{ $card->carrier_category === 'COMMERCIAL' ? 'selected':'' }}>COMMERCIAL</option>
|
|
|
|
|
- </select>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Carrier Name</label>
|
|
|
|
|
- <input name="carrierName" value="{{ $card->carrier_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Carrier Memo</label>
|
|
|
|
|
- <input name="carrierMemo" value="{{ $card->carrier_memo }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Contact Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Phone Number For Provider</label>
|
|
|
|
|
- <input name="phoneNumberForProvider" value="{{ $card->phone_number_for_provider }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Phone Number For Members</label>
|
|
|
|
|
- <input name="phoneNumberForMembers" value="{{ $card->phone_number_for_members }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Patient Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient First Name</label>
|
|
|
|
|
- <input name="patientFirstName" value="{{ $card->patient_first_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient Middle Name</label>
|
|
|
|
|
- <input name="patientMiddleName" value="{{ $card->patient_middle_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient Last Name</label>
|
|
|
|
|
- <input name="patientLastName" value="{{ $card->patient_last_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient Suffix</label>
|
|
|
|
|
- <input name="patientSuffix" value="{{ $card->patient_suffix }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient Sex</label>
|
|
|
|
|
- <select name="patientSex" class="form-control">
|
|
|
|
|
- <option value="MALE" {{ $card->patient_sex === 'MALE' ? 'selected':'' }}>MALE</option>
|
|
|
|
|
- <option value="FEMALE" {{ $card->patient_sex === 'FEMALE' ? 'selected':'' }}>FEMALE</option>
|
|
|
|
|
- </select>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Patient Birth Date</label>
|
|
|
|
|
- <input type="date" name="patientBirthDate" value="{{ $card->patient_birth_date }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <div class="">
|
|
|
|
|
- <label><input type="checkbox" name="isPatientSubscriber" class="" {{ $card->is_patient_subscriber ? 'checked':'' }} /> Is Patient
|
|
|
|
|
- Subscriber?</label>
|
|
|
|
|
|
|
+ <div id="editInsuranceCardContainer" class="row mx-0 my-2">
|
|
|
|
|
+ <div class="col-md-12 px-2">
|
|
|
|
|
+ <div>
|
|
|
|
|
+ <div class="px-0">
|
|
|
|
|
|
|
|
|
|
+ <div class="row">
|
|
|
|
|
+ <div class="form-group col-md-12">
|
|
|
|
|
+ <p class="mb-1 font-weight-bold">Type of Insurance Card:</p>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" v-on:change="setCarrierCategory(event, 'MEDICARE')" v-model="carrierCategoryInternal" value="MEDICARE">Medicare Part B</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" v-on:change="setCarrierCategory(event, 'MEDICAID')" v-model="carrierCategoryInternal" value="MEDICAID">Medicaid</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" v-on:change="setCarrierCategory(event, 'COMMERCIAL')" v-model="carrierCategoryInternal" value="COMMERCIAL">Commercial</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <input v-if="!!carrierCategory" type="hidden" name="carrierCategory" v-model="carrierCategory">
|
|
|
|
|
+ </div>
|
|
|
</div>
|
|
</div>
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Relationship To Subscriber</label>
|
|
|
|
|
- <input type="text" name="relationshipToSubscriber" value="{{ $card->relationship_to_subscriber }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Subscriber Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber First Name</label>
|
|
|
|
|
- <input name="subscriberFirstName" value="{{ $card->subscriber_first_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber Middle Name</label>
|
|
|
|
|
- <input name="subscriberMiddleName" value="{{ $card->subscriber_middle_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber Last Name</label>
|
|
|
|
|
- <input name="subscriberLastName" value="{{ $card->subscriber_last_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber Suffix</label>
|
|
|
|
|
- <input name="subscriberSuffix" value="{{ $card->subscriber_suffix }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber Sex</label>
|
|
|
|
|
- <select name="subscriberSex" class="form-control">
|
|
|
|
|
- <option value="MALE" {{ $card->subscriber_sex === 'MALE' ? 'selected':'' }}>MALE</option>
|
|
|
|
|
- <option value="FEMALE" {{ $card->subscriber_sex === 'FEMALE' ? 'selected':'' }}>FEMALE</option>
|
|
|
|
|
- </select>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-4">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Subscriber Birth Date</label>
|
|
|
|
|
- <input type="date" name="subscriberBirthDate" value="{{ $card->subscriber_birth_date }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Identifier Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Member ID</label>
|
|
|
|
|
- <input name="memberId" value="{{ $card->member_id }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Group ID</label>
|
|
|
|
|
- <input name="groupId" value="{{ $card->group_id }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="row border rounded pt-3 mb-3 bg-white">
|
|
|
|
|
- <div class="col-md-12">
|
|
|
|
|
- <h6 class="font-weight-bold">Plan Informtion</h6>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Plan Name</label>
|
|
|
|
|
- <input name="planName" value="{{ $card->plan_name }}" class="form-control" />
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Plan Type</label>
|
|
|
|
|
- <select name="planType" class="form-control">
|
|
|
|
|
- <option value="HMO" {{ $card->plan_type === 'HMO' ? 'selected':'' }}>HMO</option>
|
|
|
|
|
- <option value="PPO" {{ $card->plan_type === 'PPO' ? 'selected':'' }}>PPO</option>
|
|
|
|
|
- <option value="EPO" {{ $card->plan_type === 'EPO' ? 'selected':'' }}>EPO</option>
|
|
|
|
|
- <option value="POS" {{ $card->plan_type === 'POS' ? 'selected':'' }}>POS</option>
|
|
|
|
|
- <option value="HDHP" {{ $card->plan_type === 'HDHP' ? 'selected':'' }}>HDHP</option>
|
|
|
|
|
- <option value="MCO" {{ $card->plan_type === 'MCO' ? 'selected':'' }}>MCO</option>
|
|
|
|
|
- <option value="FFS" {{ $card->plan_type === 'FFS' ? 'selected':'' }}>FFS</option>
|
|
|
|
|
- <option value="OTHER" {{ $card->plan_type === 'OTHER' ? 'selected':'' }}>OTHER</option>
|
|
|
|
|
- </select>
|
|
|
|
|
- </div>
|
|
|
|
|
- </div>
|
|
|
|
|
- <div class="col-md-6">
|
|
|
|
|
- <div class="form-group">
|
|
|
|
|
- <label>Plan Effective Date</label>
|
|
|
|
|
- <input type="date" name="planEffectiveDate" value="{{ $card->plan_effective_date }}" class="form-control" />
|
|
|
|
|
|
|
+ <div class="px-0" v-if="!!carrierCategory">
|
|
|
|
|
+
|
|
|
|
|
+ {{-- commercial --}}
|
|
|
|
|
+ <div class="row" v-if="carrierCategory == 'COMMERCIAL'">
|
|
|
|
|
+ <div class="col-md-12">
|
|
|
|
|
+ <div class="px-0 pb-2 mb-2 border-bottom">
|
|
|
|
|
+ <h5 class="m-0 font-weight-bold">Commercial Insurance Information:</h5>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Carrier Name</label>
|
|
|
|
|
+ <input type="text" name="carrierName" class="form-control input-sm" value="{{$card->carrier_name}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Carrier Memo</label>
|
|
|
|
|
+ <input type="text" name="carrierMemo" class="form-control input-sm" value="{{$card->carrier_name}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Member/Subscriber ID</label>
|
|
|
|
|
+ <input type="text" name="memberId" class="form-control input-sm" value="{{$card->member_id}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Group Number</label>
|
|
|
|
|
+ <input type="text" name="groupId" class="form-control input-sm" value="{{$card->group_id}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Phone Number for Providers</label>
|
|
|
|
|
+ <input type="text" name="phoneNumberForProvider" class="form-control input-sm phone" value="{{$card->phone_number_for_provider}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Phone Number for Subscribers</label>
|
|
|
|
|
+ <input type="text" name="phoneNumberForMembers" class="form-control input-sm phone" value="{{$card->phone_number_for_members}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ {{--<div class="row" v-if="carrierCategory">
|
|
|
|
|
+ <div class="col-12">
|
|
|
|
|
+ <hr class="mt-0 mb-2">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <p class="mb-1 font-weight-bold">RPM covered (if medically needed)?</p>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isRpmCoveredIfMedicallyNeeded" value="YES">Yes</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isRpmCoveredIfMedicallyNeeded" value="NO">No</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isRpmCoveredIfMedicallyNeeded" value="UNKNOWN">Unknown</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <p class="mb-1 font-weight-bold">Televisits covered (if medically needed)?</p>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isTelevisitCoveredIfMedicallyNeeded" value="YES">Yes</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isTelevisitCoveredIfMedicallyNeeded" value="NO">No</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label"><input class="form-check-input" type="radio" name="isTelevisitCoveredIfMedicallyNeeded" value="UNKNOWN">Unknown</label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>--}}
|
|
|
|
|
+
|
|
|
|
|
+ {{-- medicaid --}}
|
|
|
|
|
+ <div class="row" v-if="carrierCategory == 'MEDICAID'{{-- || carrierCategory == 'COMMERCIAL'--}}">
|
|
|
|
|
+ <div class="col-md-12">
|
|
|
|
|
+ <div class="px-0 pb-2 mb-2 border-bottom">
|
|
|
|
|
+ <h5 class="m-0 font-weight-bold">Medicaid Information:</h5>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="col-12">
|
|
|
|
|
+ <div class="row">
|
|
|
|
|
+
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label for="" class="control-label">Medicaid State</label>
|
|
|
|
|
+ <input class="form-control input-sm" list="mcdPayerOptions" name="carrierName" id="carrierName" value="{{$card->carrier_name}}">
|
|
|
|
|
+ <datalist id="mcdPayerOptions">
|
|
|
|
|
+ <option value="">--</option>
|
|
|
|
|
+ @foreach($medicaidStates as $state)
|
|
|
|
|
+ <option {{$state == $card->carrier_name ? 'selected' : ''}} >{{ $state }}</option>
|
|
|
|
|
+ @endforeach
|
|
|
|
|
+ </datalist>
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Medicaid Number</label>
|
|
|
|
|
+ <input type="text" name="memberId" class="form-control input-sm" oninput="this.value = this.value.toUpperCase()" value="{{$card->member_id}}">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ {{-- medicare --}}
|
|
|
|
|
+ <div class="row" v-if="carrierCategory == 'MEDICARE'{{-- || carrierCategory == 'COMMERCIAL'--}}">
|
|
|
|
|
+ <div class="col-md-12">
|
|
|
|
|
+ <div class="px-0 pb-2 mb-2 border-bottom">
|
|
|
|
|
+ <h5 class="m-0 font-weight-bold">Medicare Information:</h5>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="col-12">
|
|
|
|
|
+ <div class="row">
|
|
|
|
|
+ <div class="form-group col-md-6">
|
|
|
|
|
+ <label class="control-label">Medicare Number </label>
|
|
|
|
|
+ <input type="text" name="memberId" class="form-control input-sm" oninput="this.value = this.value.toUpperCase()">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ {{-- is subcr == patient? application only for medicaid and commercial --}}
|
|
|
|
|
+ <div class="row" v-if="carrierCategory == 'MEDICAID' || carrierCategory == 'COMMERCIAL'">
|
|
|
|
|
+ <div class="form-group col-md-12">
|
|
|
|
|
+ <div class="form-check form-check-inline">
|
|
|
|
|
+ <label class="form-check-label">
|
|
|
|
|
+ <input type="hidden" name="isPatientSubscriber" :value="isPatientSubscriber ? 1 : 0">
|
|
|
|
|
+ <input class="form-check-input" type="checkbox" v-model="isPatientSubscriber">
|
|
|
|
|
+ Is Patient The Subscriber?
|
|
|
|
|
+ </label>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+
|
|
|
|
|
+ {{-- if subcr != patient. application only for medicaid and commercial --}}
|
|
|
|
|
+ <div v-if="!isPatientSubscriber && (carrierCategory == 'MEDICAID' || carrierCategory == 'COMMERCIAL')" class="row">
|
|
|
|
|
+ <div class="col-md-12 bg-light p-3 mb-2">
|
|
|
|
|
+ <h5 class="m-0 font-weight-bold">Subscriber Details:</h5>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber First Name</label>
|
|
|
|
|
+ <input type="text" name="subscriberFirstName" value="{{ $card->subscriber_first_name }}" class="form-control input-sm">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber Middle Name / MI</label>
|
|
|
|
|
+ <input type="text" name="subscriberMiddleName" value="{{ $card->subscriber_middle_name }}" class="form-control input-sm">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber Last Name</label>
|
|
|
|
|
+ <input type="text" name="subscriberLastName" value="{{ $card->subscriber_last_name }}" class="form-control input-sm">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber Suffix</label>
|
|
|
|
|
+ <input type="text" name="subscriberSuffix" value="{{ $card->subscriber_suffix }}" class="form-control input-sm">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber Sex</label>
|
|
|
|
|
+ <select class="form-control input-sm" name="subscriberSex">
|
|
|
|
|
+ <option value="">--</option>
|
|
|
|
|
+ <option value="M" {{ $card->subscriber_sex === 'MALE' ? 'selected':'' }}>MALE</option>
|
|
|
|
|
+ <option value="F" {{ $card->subscriber_sex === 'FEMALE' ? 'selected':'' }}>FEMALE</option>
|
|
|
|
|
+ <option value="UNKNOWN" {{ $card->subscriber_sex === 'FEMALE' ? 'selected':'' }}>UNKNOWN</option>
|
|
|
|
|
+ </select>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-4">
|
|
|
|
|
+ <label class="control-label">Subscriber Dob</label>
|
|
|
|
|
+ <input type="date" name="subscriberBirthDate" value="{{ $card->subscriber_birth_date }}" class="form-control input-sm">
|
|
|
|
|
+ </div>
|
|
|
|
|
+ <div class="form-group col-md-12">
|
|
|
|
|
+ <label class="control-label">What is the patient's relationship to the subscriber?</label>
|
|
|
|
|
+ <select name="relationshipToSubscriber" class="form-control input-sm">
|
|
|
|
|
+ <option value="">--</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'SPOUSE' ? 'selected' : '' }} value="SPOUSE">Spouse</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'CHILD' ? 'selected' : '' }} value="CHILD">Child</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'EMPLOYEE' ? 'selected' : '' }} value="EMPLOYEE">Employee</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'ORGAN_DONOR' ? 'selected' : '' }} value="ORGAN_DONOR">Organ Donor</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'CADAVER_DONOR' ? 'selected' : '' }} value="CADAVER_DONOR">Cadaver Donor</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'LIFE_PARTNER' ? 'selected' : '' }} value="LIFE_PARTNER">Life Partner</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'OTHER_RELATIONSHIP' ? 'selected' : '' }} value="OTHER_RELATIONSHIP">Other Relationship</option>
|
|
|
|
|
+ <option {{ $card->relationship_to_subscriber == 'UNKNOWN' ? 'selected' : '' }} value="UNKNOWN">Unknown</option>
|
|
|
|
|
+ </select>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ </div>
|
|
|
|
|
+ {{--<div class="mb-1" v-if="carrierCategory == 'COMMERCIAL'">
|
|
|
|
|
+ <h6 class="font-weight-bold">Does the patient also have either a Medicare or Medicaid #? (optional)</h6>
|
|
|
|
|
+ </div>--}}
|
|
|
|
|
+
|
|
|
</div>
|
|
</div>
|
|
|
</div>
|
|
</div>
|
|
|
</div>
|
|
</div>
|
|
|
</div>
|
|
</div>
|
|
|
|
|
+ {{--<button type="button" v-on:click="console.log($('#createInsuranceCardForm').serialize().replaceAll('&', '\n'));">Test Payload</button>--}}
|
|
|
</div>
|
|
</div>
|
|
|
<div class="mb-0">
|
|
<div class="mb-0">
|
|
|
<button class="btn btn-primary btn-sm" submit>Submit</button>
|
|
<button class="btn btn-primary btn-sm" submit>Submit</button>
|
|
@@ -219,3 +216,31 @@
|
|
|
</div>
|
|
</div>
|
|
|
</form>
|
|
</form>
|
|
|
</div>
|
|
</div>
|
|
|
|
|
+<script>
|
|
|
|
|
+ (function() {
|
|
|
|
|
+ function init() {
|
|
|
|
|
+ new Vue({
|
|
|
|
|
+ el: '#editInsuranceCardContainer',
|
|
|
|
|
+ delimiters: ['@{{', '}}'],
|
|
|
|
|
+ data: {
|
|
|
|
|
+ carrierCategory: {!! $card->carrier_category ? "'{$card->carrier_category}'" : 'null' !!},
|
|
|
|
|
+ carrierCategoryInternal: {!! $card->carrier_category ? "'{$card->carrier_category}'" : 'null' !!},
|
|
|
|
|
+ isPatientSubscriber: {!! $card->is_patient_subscriber ? 'true':'false' !!},
|
|
|
|
|
+ },
|
|
|
|
|
+ methods: {
|
|
|
|
|
+ setCarrierCategory: function(_event, _carrierCategory) {
|
|
|
|
|
+ if(!$(_event.target).prop('checked')) return;
|
|
|
|
|
+ this.carrierCategory = _carrierCategory;
|
|
|
|
|
+ },
|
|
|
|
|
+ init: function() {
|
|
|
|
|
+
|
|
|
|
|
+ }
|
|
|
|
|
+ },
|
|
|
|
|
+ mounted: function() {
|
|
|
|
|
+ this.init();
|
|
|
|
|
+ },
|
|
|
|
|
+ });
|
|
|
|
|
+ }
|
|
|
|
|
+ addMCInitializer('editInsuranceCard', init, '#editInsuranceCardContainer');
|
|
|
|
|
+ })();
|
|
|
|
|
+</script>
|
