|
@@ -0,0 +1,590 @@
|
|
|
+@extends ('layouts.patient')
|
|
|
+
|
|
|
+@section('inner-content')
|
|
|
+<div>
|
|
|
+ <div class="d-flex align-items-center">
|
|
|
+ <h4 class="font-weight-bold m-0 font-size-16">Client Primary Coverages</h4>
|
|
|
+ <div class="ml-3">
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Medicare Without Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicareWithoutManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name First</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" class="form-control input-sm" />
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name Last</label>
|
|
|
+ <input type="text" name="subscriberNameLast" class="form-control input-sm" />
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" class="form-control input-sm" />
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Payer Member Identifier</label>
|
|
|
+ <input type="text" name="payerMemberIdentifier" class="form-control input-sm" />
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Date Of Service</label>
|
|
|
+ <input type="date" name="dateOfService" class="form-control input-sm" />
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Medicare With Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicareWithManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Name First</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Name Last</label>
|
|
|
+ <input type="text" name="subscriberNameLast" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Payer Member Identifier</label>
|
|
|
+ <input type="text" name="payerMemberIdentifier" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Date Of Service</label>
|
|
|
+ <input type="date" name="dateOfService" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Strategy</label>
|
|
|
+ <select name="baseManualDeterminationValue.manualDeterminationStrategy" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
|
|
|
+ <option value="CALLED_PAYER">Called payer</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Category</label>
|
|
|
+ <select name="manualDeterminationCategory" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="COVERED">Covered</option>
|
|
|
+ <option value="NOT_COVERED">Not Covered</option>
|
|
|
+ <option value="INVALID">Invalid</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Category Memo</label>
|
|
|
+ <input type="text" name="baseManualDeterminationValue.manualDeterminationCategoryMemo" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Detail Json</label>
|
|
|
+ <input type="text" name="baseManualDeterminationValuemanualDetailJson" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Part B Primary</label>
|
|
|
+ <select name="manualMedicareIsPartBPrimary" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Part B Active</label>
|
|
|
+ <select name="manualMedicareIsPartBActive" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Part C Active</label>
|
|
|
+ <select name="manualMedicareIsPartCActive" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Inpatient</label>
|
|
|
+ <select name="manualMedicareIsInpatient" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Hospice Or Home Health</label>
|
|
|
+ <select name="manualMedicareIsHospiceOrHomeHealth" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Is Msp</label>
|
|
|
+ <select name="manualMedicareIsMsp" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Msp Memo</label>
|
|
|
+ <select name="manualMedicareMspMemo" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="YES">Yes</option>
|
|
|
+ <option value="NO">No</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Start Date</label>
|
|
|
+ <input type="date" name="manualMedicareMpbStartDate" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb End Date</label>
|
|
|
+ <input type="date" name="manualMedicareMpbEndDate" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Deductible</label>
|
|
|
+ <input type="number" name="manualMedicareMpbDeductible" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Remaining</label>
|
|
|
+ <input type="number" name="manualMedicareMpbRemaining" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Insurance Type</label>
|
|
|
+ <input type="text" name="manualMedicareMpbInsuranceType" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Insurance Type Label</label>
|
|
|
+ <input type="text" name="manualMedicareMpbInsuranceTypeLabel" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Coinsurance Percent</label>
|
|
|
+ <input type="number" name="manualMedicareMpbCoinsurancePercent" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Info Valid Until</label>
|
|
|
+ <input type="date" name="manualMedicareMpbInfoValidUntil" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Medicare Mpb Info Valid Till</label>
|
|
|
+ <input type="date" name="manualMedicareMpbInfoValidTill" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Medicaid Without Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicaidWithoutManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Name First</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Name Last</label>
|
|
|
+ <input type="text" name="subscriberNameLast" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Payer Member Identifier</label>
|
|
|
+ <input type="String" name="payerMemberIdentifier" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Date Of Service</label>
|
|
|
+ <input type="date" name="dateOfService" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Sex</label>
|
|
|
+ <select name="subscriberSex" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="M">M</option>
|
|
|
+ <option value="F">F</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Plan Name</label>
|
|
|
+ <input type="text" name="planName" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Plan Identifier</label>
|
|
|
+ <input type="text" name="planIdentifier" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Medicaid With Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForMedicaidWithManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Strategy</label>
|
|
|
+ <select name="manualDeterminationStrategy" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
|
|
|
+ <option value="CALLED_PAYER">Called payer</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Category</label>
|
|
|
+ <select name="manualDeterminationCategory" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="COVERED">Covered</option>
|
|
|
+ <option value="NOT_COVERED">Not Covered</option>
|
|
|
+ <option value="INVALID">Invalid</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="form-control-labelManual Determination Category Memo</label>
|
|
|
+ <input type="text" name="manualDeterminationCategoryMemo" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Detail Json</label>
|
|
|
+ <input type="text" name="manualDetailJson" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Commercial Without Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForCommercialWithoutManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name First</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name Last</label>
|
|
|
+ <input type="text" name="subscriberNameLast" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Payer Member Identifier</label>
|
|
|
+ <input type="text" name="payerMemberIdentifier" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Date Of Service</label>
|
|
|
+ <input type="date" name="dateOfService" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Sex</label>
|
|
|
+ <select name="subscriberSex" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="M">M</option>
|
|
|
+ <option value="F">F</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Plan Name</label>
|
|
|
+ <input type="text" name="planName" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Plan Identifier</label>
|
|
|
+ <input type="text" name="planIdentifier" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+ <div moe relative>
|
|
|
+ <a href="" start show class="btn btn-sm btn-primary text-white font-weight-bold small">Create New Coverage For Commercial With Manual Determination</a>
|
|
|
+
|
|
|
+ <form url="/api/clientPrimaryCoverage/createNewCoverageForCommercialWithManualDetermination" class="mcp-theme-1">
|
|
|
+ <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name First</label>
|
|
|
+ <input type="text" name="subscriberNameFirst" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Name Last</label>
|
|
|
+ <input type="text" name="subscriberNameLast" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Subscriber Dob</label>
|
|
|
+ <input type="date" name="subscriberDob" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Payer Member Identifier</label>
|
|
|
+ <input type="text" name="payerMemberIdentifier" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label class="control-label">Date Of Service</label>
|
|
|
+ <input type="date" name="dateOfService" class="form-control input-sm">
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Subscriber Sex</label>
|
|
|
+ <select name="subscriberSex" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="M">M</option>
|
|
|
+ <option value="F">F</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Plan Name</label>
|
|
|
+ <input type="text" name="planName" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Plan Identifier</label>
|
|
|
+ <input type="text" name="planIdentifier" class="form-control input-sm"/>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Strategy</label>
|
|
|
+ <select name="manualDeterminationStrategy" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="REVIEWED_ELECTRONIC">Reviewed electronic</option>
|
|
|
+ <option value="CALLED_PAYER">Called payer</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Category</label>
|
|
|
+ <select name="manualDeterminationCategory" class="form-control input-sm">
|
|
|
+ <option value="">--select--</option>
|
|
|
+ <option value="COVERED">Covered</option>
|
|
|
+ <option value="NOT_COVERED">Not Covered</option>
|
|
|
+ <option value="INVALID">Invalid</option>
|
|
|
+ <option value="UNKNOWN">Unknown</option>
|
|
|
+ </select>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Determination Category Memo</label>
|
|
|
+ <textarea name="manualDeterminationCategoryMemo" class="form-control input-sm"></textarea>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <label for="" class="control-label">Manual Detail Json</label>
|
|
|
+ <textarea name="manualDetailJson" class="form-control input-sm"></textarea>
|
|
|
+ </div>
|
|
|
+ <div class="form-group">
|
|
|
+ <button class="btn btn-sm" submit>Submt</button>
|
|
|
+ <button class="btn btn-sm" close>Close</button>
|
|
|
+ </div>
|
|
|
+ </form>
|
|
|
+ </div>
|
|
|
+
|
|
|
+ </div>
|
|
|
+ </div>
|
|
|
+
|
|
|
+ <table class="table table-sm table-bordered mt-3 mb-0">
|
|
|
+ <thead>
|
|
|
+ <tr>
|
|
|
+ <th>Id</th>
|
|
|
+ <th>Creation Strategy</th>
|
|
|
+ <th>Auto Refresh Of Client Primary Coverage Id</th>
|
|
|
+ <th>Manual Determination Of Client Primary Coverage Id</th>
|
|
|
+ <th>Plan Type</th>
|
|
|
+ <th>Is Partbprimary</th>
|
|
|
+ <th>Is Manually Determined</th>
|
|
|
+ <th>Is Entry Error</th>
|
|
|
+ <th>Subscriber Name First</th>
|
|
|
+ <th>Subscriber Name Last</th>
|
|
|
+ <th>Subscriber Sex</th>
|
|
|
+ <th>Subscriber Dob</th>
|
|
|
+ <th>Payer Member Identifier</th>
|
|
|
+ <th>Plan Name</th>
|
|
|
+ <th>Plan Identifier</th>
|
|
|
+ <th>Date Of Service</th>
|
|
|
+ <th>Auto Is Payer Member Identifier Valid</th>
|
|
|
+ <th>Auto Detail Json</th>
|
|
|
+ <th>Auto Medicare Is Partbprimary</th>
|
|
|
+ <th>Auto Medicare Is Partbactive</th>
|
|
|
+ <th>Auto Medicare Is Partcactive</th>
|
|
|
+ <th>Auto Medicare Is Inpatient</th>
|
|
|
+ <th>Auto Medicare Is Hospice Or Home Health</th>
|
|
|
+ <th>Auto Medicare Is Msp</th>
|
|
|
+ <th>Auto Medicare Msp Memo</th>
|
|
|
+ <th>Auto Medicare Mpb Start Date</th>
|
|
|
+ <th>Auto Medicare Mpb End Date</th>
|
|
|
+ <th>Auto Medicare Mpb Deductible</th>
|
|
|
+ <th>Auto Medicare Mpb Remaining</th>
|
|
|
+ <th>Auto Medicare Mpb Insurance Type</th>
|
|
|
+ <th>Auto Medicare Mpb Insurance Type Label</th>
|
|
|
+ <th>Auto Medicare Mpb Coinsurance Percent</th>
|
|
|
+ <th>Auto Medicare Mpb Info Valid Until</th>
|
|
|
+ <th>Auto Medicare Mpb Info Valid Till</th>
|
|
|
+ <th>Auto Medicare Mpb Last Refreshed At</th>
|
|
|
+ <th>Was Successful</th>
|
|
|
+ <th>Reject Reason Code</th>
|
|
|
+ <th>Reject Reason Description</th>
|
|
|
+ <th>Follow Up Action Code</th>
|
|
|
+ <th>Follow Up Action Description</th>
|
|
|
+ <th>Details</th>
|
|
|
+ <th>Is Mcn Valid Number</th>
|
|
|
+ <th>Address Street Line1</th>
|
|
|
+ <th>Address Street Line2</th>
|
|
|
+ <th>Address City</th>
|
|
|
+ <th>Address State</th>
|
|
|
+ <th>Address Zip</th>
|
|
|
+ <th>Is Hospice</th>
|
|
|
+ <th>Mcn Response Detail</th>
|
|
|
+ <th>Billing Address</th>
|
|
|
+ <th>Reason Not Partb</th>
|
|
|
+ <th>Reason Not Partbmemo</th>
|
|
|
+ <th>Is Medicare Advantage</th>
|
|
|
+ <th>Medicare Advantage Plan</th>
|
|
|
+ <th>Mpb Active</th>
|
|
|
+ <th>Mpb Start Date</th>
|
|
|
+ <th>Mpb End Date</th>
|
|
|
+ <th>Mpb Deductible</th>
|
|
|
+ <th>Mpb Remaining</th>
|
|
|
+ <th>Mpb Insurance Type</th>
|
|
|
+ <th>Mpb Insurance Type Label</th>
|
|
|
+ <th>Mpb Coinsurance Percent</th>
|
|
|
+ <th>Mpb Info Valid Until</th>
|
|
|
+ <th>Mpb Info Valid Till</th>
|
|
|
+ <th>Mpb Last Refreshed At</th>
|
|
|
+ <th>Manual Determination Strategy</th>
|
|
|
+ <th>Manual Determination Category</th>
|
|
|
+ <th>Manual Determination Category Memo</th>
|
|
|
+ <th>Manual Detail Json</th>
|
|
|
+ <th>Manual Medicare Is Partbprimary</th>
|
|
|
+ <th>Manual Medicare Is Partbactive</th>
|
|
|
+ <th>Manual Medicare Is Partcactive</th>
|
|
|
+ <th>Manual Medicare Is Inpatient</th>
|
|
|
+ <th>Manual Medicare Is Hospice Or Home Health</th>
|
|
|
+ <th>Manual Medicare Is Msp</th>
|
|
|
+ <th>Manual Medicare Msp Memo</th>
|
|
|
+ <th>Manual Medicare Mpb Start Date</th>
|
|
|
+ <th>Manual Medicare Mpb End Date</th>
|
|
|
+ <th>Manual Medicare Mpb Deductible</th>
|
|
|
+ <th>Manual Medicare Mpb Remaining</th>
|
|
|
+ <th>Manual Medicare Mpb Insurance Type</th>
|
|
|
+ <th>Manual Medicare Mpb Insurance Type Label</th>
|
|
|
+ <th>Manual Medicare Mpb Coinsurance Percent</th>
|
|
|
+ <th>Manual Medicare Mpb Info Valid Until</th>
|
|
|
+ <th>Manual Medicare Mpb Info Valid Till</th>
|
|
|
+ <th>Manual Medicare Mpb Last Refreshed At</th>
|
|
|
+ <th>Auto Medicare Result Id</th>
|
|
|
+ </tr>
|
|
|
+ </thead>
|
|
|
+ <tbody>
|
|
|
+ @foreach($patient->primaryCoverages as $cpc)
|
|
|
+ <tr>
|
|
|
+ <td>{{$cpc->id}}</td>
|
|
|
+ <td>{{$cpc->creation_strategy}}</td>
|
|
|
+ <td>{{$cpc->auto_refresh_of_client_primary_coverage_id}}</td>
|
|
|
+ <td>{{$cpc->manual_determination_of_client_primary_coverage_id}}</td>
|
|
|
+ <td>{{$cpc->plan_type}}</td>
|
|
|
+ <td>{{$cpc->is_partbprimary}}</td>
|
|
|
+ <td>{{$cpc->is_manually_determined}}</td>
|
|
|
+ <td>{{$cpc->is_entry_error}}</td>
|
|
|
+ <td>{{$cpc->subscriber_name_first}}</td>
|
|
|
+ <td>{{$cpc->subscriber_name_last}}</td>
|
|
|
+ <td>{{$cpc->subscriber_sex}}</td>
|
|
|
+ <td>{{$cpc->subscriber_dob}}</td>
|
|
|
+ <td>{{$cpc->payer_member_identifier}}</td>
|
|
|
+ <td>{{$cpc->plan_name}}</td>
|
|
|
+ <td>{{$cpc->plan_identifier}}</td>
|
|
|
+ <td>{{$cpc->date_of_service}}</td>
|
|
|
+ <td>{{$cpc->auto_is_payer_member_identifier_valid}}</td>
|
|
|
+ <td>{{$cpc->auto_detail_json}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_partbprimary}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_partbactive}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_partcactive}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_inpatient}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_hospice_or_home_health}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_is_msp}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_msp_memo}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_start_date}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_end_date}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_deductible}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_remaining}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_insurance_type}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_insurance_type_label}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_coinsurance_percent}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_info_valid_until}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_info_valid_till}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_mpb_last_refreshed_at}}</td>
|
|
|
+ <td>{{$cpc->was_successful}}</td>
|
|
|
+ <td>{{$cpc->reject_reason_code}}</td>
|
|
|
+ <td>{{$cpc->reject_reason_description}}</td>
|
|
|
+ <td>{{$cpc->follow_up_action_code}}</td>
|
|
|
+ <td>{{$cpc->follow_up_action_description}}</td>
|
|
|
+ <td>{{$cpc->details}}</td>
|
|
|
+ <td>{{$cpc->is_mcn_valid_number}}</td>
|
|
|
+ <td>{{$cpc->address_street_line1}}</td>
|
|
|
+ <td>{{$cpc->address_street_line2}}</td>
|
|
|
+ <td>{{$cpc->address_city}}</td>
|
|
|
+ <td>{{$cpc->address_state}}</td>
|
|
|
+ <td>{{$cpc->address_zip}}</td>
|
|
|
+ <td>{{$cpc->is_hospice}}</td>
|
|
|
+ <td>{{$cpc->mcn_response_detail}}</td>
|
|
|
+ <td>{{$cpc->billing_address}}</td>
|
|
|
+ <td>{{$cpc->reason_not_partb}}</td>
|
|
|
+ <td>{{$cpc->reason_not_partbmemo}}</td>
|
|
|
+ <td>{{$cpc->is_medicare_advantage}}</td>
|
|
|
+ <td>{{$cpc->medicare_advantage_plan}}</td>
|
|
|
+ <td>{{$cpc->mpb_active}}</td>
|
|
|
+ <td>{{$cpc->mpb_start_date}}</td>
|
|
|
+ <td>{{$cpc->mpb_end_date}}</td>
|
|
|
+ <td>{{$cpc->mpb_deductible}}</td>
|
|
|
+ <td>{{$cpc->mpb_remaining}}</td>
|
|
|
+ <td>{{$cpc->mpb_insurance_type}}</td>
|
|
|
+ <td>{{$cpc->mpb_insurance_type_label}}</td>
|
|
|
+ <td>{{$cpc->mpb_coinsurance_percent}}</td>
|
|
|
+ <td>{{$cpc->mpb_info_valid_until}}</td>
|
|
|
+ <td>{{$cpc->mpb_info_valid_till}}</td>
|
|
|
+ <td>{{$cpc->mpb_last_refreshed_at}}</td>
|
|
|
+ <td>{{$cpc->manual_determination_strategy}}</td>
|
|
|
+ <td>{{$cpc->manual_determination_category}}</td>
|
|
|
+ <td>{{$cpc->manual_determination_category_memo}}</td>
|
|
|
+ <td>{{$cpc->manual_detail_json}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_partbprimary}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_partbactive}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_partcactive}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_inpatient}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_hospice_or_home_health}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_is_msp}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_msp_memo}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_start_date}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_end_date}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_deductible}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_remaining}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_insurance_type}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_insurance_type_label}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_coinsurance_percent}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_info_valid_until}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_info_valid_till}}</td>
|
|
|
+ <td>{{$cpc->manual_medicare_mpb_last_refreshed_at}}</td>
|
|
|
+ <td>{{$cpc->auto_medicare_result_id}}</td>
|
|
|
+ </tr>
|
|
|
+ @endforeach
|
|
|
+ </tbody>
|
|
|
+ </table>
|
|
|
+</div>
|
|
|
+@endsection
|