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@@ -63,7 +63,7 @@
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</div>
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<div class="form-group">
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<label for="" class="control-label">Manual Determination Strategy</label>
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- <select name="baseManualDeterminationValue.manualDeterminationStrategy" class="form-control input-sm">
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+ <select name="manualDeterminationStrategy" class="form-control input-sm">
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<option value="">--select--</option>
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<option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
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<option value="CALLED_PAYER">Called payer</option>
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@@ -511,6 +511,143 @@
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</div>
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</form>
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</div>
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+
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+ <div moe relative>
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+ <a href="" start show class="">Manual Determination</a>
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+
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+ <form url="/api/clientPrimaryCoverage/manualDeterminationForMedicare" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$cpc->uid}}" class="form-control input-sm" />
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Strategy</label>
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+ <select name="manualDeterminationStrategy" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
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+ <option value="CALLED_PAYER">Called payer</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category</label>
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+ <select name="manualDeterminationCategory" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="COVERED">Covered</option>
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+ <option value="NOT_COVERED">Not Covered</option>
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+ <option value="INVALID">Invalid</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category Memo</label>
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+ <input type="text" name="baseManualDeterminationValue.manualDeterminationCategoryMemo" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Detail Json</label>
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+ <input type="text" name="baseManualDeterminationValuemanualDetailJson" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Part B Primary</label>
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+ <select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Part B Active</label>
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+ <select name="manualMedicareIsPartBActive" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Part C Active</label>
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+ <select name="manualMedicareIsPartCActive" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Inpatient</label>
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+ <select name="manualMedicareIsInpatient" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
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+ <select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Is Msp</label>
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+ <select name="manualMedicareIsMsp" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Msp Memo</label>
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+ <select name="manualMedicareMspMemo" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="YES">Yes</option>
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+ <option value="NO">No</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Start Date</label>
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+ <input type="date" name="manualMedicareMpbStartDate" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb End Date</label>
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+ <input type="date" name="manualMedicareMpbEndDate" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Deductible</label>
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+ <input type="number" name="manualMedicareMpbDeductible" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Remaining</label>
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+ <input type="number" name="manualMedicareMpbRemaining" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Insurance Type</label>
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+ <input type="text" name="manualMedicareMpbInsuranceType" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Insurance Type Label</label>
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+ <input type="text" name="manualMedicareMpbInsuranceTypeLabel" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Coinsurance Percent</label>
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+ <input type="number" name="manualMedicareMpbCoinsurancePercent" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Info Valid Until</label>
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+ <input type="date" name="manualMedicareMpbInfoValidUntil" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Medicare Mpb Info Valid Till</label>
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+ <input type="date" name="manualMedicareMpbInfoValidTill" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <button class="btn btn-sm" submit>Submt</button>
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+ <button class="btn btn-sm" close>Close</button>
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+ </div>
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+ </form>
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+ </div>
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@endif
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@if($cpc->plan_type == 'MEDICAID')
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<div moe relative>
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@@ -527,6 +664,45 @@
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</div>
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</form>
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</div>
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+ <div moe relative>
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+ <a href="" start show class="">Manual Determination</a>
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+
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+ <form url="/api/clientPrimaryCoverage/manualDeterminationForMedicaid" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$cpc->uid}}" class="form-control input-sm" />
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Strategy</label>
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+ <select name="manualDeterminationStrategy" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
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+ <option value="CALLED_PAYER">Called payer</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category</label>
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+ <select name="manualDeterminationCategory" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="COVERED">Covered</option>
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+ <option value="NOT_COVERED">Not Covered</option>
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+ <option value="INVALID">Invalid</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category Memo</label>
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+ <input type="text" name="baseManualDeterminationValue.manualDeterminationCategoryMemo" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Detail Json</label>
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+ <input type="text" name="baseManualDeterminationValuemanualDetailJson" class="form-control input-sm"/>
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+ </div>
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+
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+
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+ <div class="form-group">
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+ <button class="btn btn-sm" submit>Submt</button>
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+ <button class="btn btn-sm" close>Close</button>
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+ </div>
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+ </form>
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+ </div>
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@endif
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@if($cpc->plan_type == 'COMMERCIAL')
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<div moe relative>
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@@ -543,6 +719,45 @@
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</div>
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</form>
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</div>
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+ <div moe relative>
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+ <a href="" start show class="">Manual Determination</a>
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+
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+ <form url="/api/clientPrimaryCoverage/manualDeterminationForCommercial" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$cpc->uid}}" class="form-control input-sm" />
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Strategy</label>
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+ <select name="manualDeterminationStrategy" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
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+ <option value="CALLED_PAYER">Called payer</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category</label>
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+ <select name="manualDeterminationCategory" class="form-control input-sm">
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+ <option value="">--select--</option>
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+ <option value="COVERED">Covered</option>
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+ <option value="NOT_COVERED">Not Covered</option>
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+ <option value="INVALID">Invalid</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Determination Category Memo</label>
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+ <input type="text" name="baseManualDeterminationValue.manualDeterminationCategoryMemo" class="form-control input-sm"/>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Manual Detail Json</label>
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+ <input type="text" name="baseManualDeterminationValuemanualDetailJson" class="form-control input-sm"/>
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+ </div>
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+
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+
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+ <div class="form-group">
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+ <button class="btn btn-sm" submit>Submt</button>
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+ <button class="btn btn-sm" close>Close</button>
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+ </div>
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+ </form>
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+ </div>
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@endif
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</td>
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<td>{{$cpc->creation_strategy}}</td>
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