added payments

resources/views/app/patient/note/partials/_payments_received.blade.php

@@ -7,19 +7,84 @@
             <form url="/api/receivedPayment/createForNote">
                 <input type="hidden" name="noteUid" value="{{$note->uid}}">
                 <div class="mb-2">
-                    <label class="mb-1 text-secondary">Source</label>
-                    <input type="text" name="source" placeholder="Source"
+                    <label class="mb-1 text-secondary">Service Code</label>
+                    <input type="text" name="serviceCode" placeholder="Service code"
                               class="form-control form-control-sm"></input>
                 </div>
                 <div class="mb-2">
-                    <label class="mb-1 text-secondary">Source memo</label>
-                    <textarea type="text" name="sourceMemo" placeholder="Source memo"
-                              class="form-control form-control-sm"></textarea>
+                    <label class="mb-1 text-secondary">Modifier</label>
+                    <input type="text" name="modifier" placeholder="Modifier"
+                           class="form-control form-control-sm"></input>
                 </div>
                 <div class="mb-2">
-                    <label class="mb-1 text-secondary">Amount</label>
-                    <input type="number" step=".01" name="amount" placeholder="amount"
-                              class="form-control form-control-sm"></input>
+                    <label class="mb-1 text-secondary">Charged Amount</label>
+                    <input type="number" step=".01" name="chargedAmount" placeholder="Charged Amount"
+                           class="form-control form-control-sm"></input>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Charged Amount Status</label>
+                    <select type="text" name="chargedAmountStatus" placeholder="Charged Amount Status"
+                           class="form-control form-control-sm">
+                        <option value="NEW">New</option>
+                        <option value="PENDING">Pending</option>
+                        <option value="SUBMITTED">Submitted</option>
+                    </select>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Allowed Amount</label>
+                    <input type="number" step=".01" name="allowedAmount" placeholder="Allowed Amount"
+                           class="form-control form-control-sm"></input>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Primary Insurance</label>
+                    <input type="number" step=".01" name="primaryInsuranceAmount" placeholder="Primary Insurance"
+                           class="form-control form-control-sm"></input>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Primary Insurance Payment Status</label>
+                    <select type="text" name="primaryAmountStatus" placeholder="Primary Insurance Payment Status"
+                            class="form-control form-control-sm">
+                        <option value="PAID">Paid</option>
+                        <option value="DENIED">Denied</option>
+                        <option value="APPEALED">Appealed</option>
+                        <option value="REJECTED">Rejected</option>
+                        <option value="PAYMENT_RECEIVED">Payment Received</option>
+                        <option value="WAIVED">Waived</option>
+                    </select>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Secondary Insurance</label>
+                    <input type="number" step=".01" name="secondaryInsuranceAmount" placeholder="Secondary Insurance"
+                           class="form-control form-control-sm"></input>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Secondary Insurance Payment Status</label>
+                    <select type="text" name="secondaryAmountStatus" placeholder="Secondary Insurance Payment Status"
+                            class="form-control form-control-sm">
+                        <option value="PAID">Paid</option>
+                        <option value="DENIED">Denied</option>
+                        <option value="APPEALED">Appealed</option>
+                        <option value="REJECTED">Rejected</option>
+                        <option value="PAYMENT_RECEIVED">Payment Received</option>
+                        <option value="WAIVED">Waived</option>
+                    </select>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Patient Responsibility</label>
+                    <input type="number" step=".01" name="patientResponsibilityAmount" placeholder="Patient Responsibility Amount"
+                           class="form-control form-control-sm"></input>
+                </div>
+                <div class="mb-2">
+                    <label class="mb-1 text-secondary">Patient Responsibility Payment Status</label>
+                    <select type="text" name="patientResponsibilityAmountStatus" placeholder="Patient Responsibility Payment Status"
+                            class="form-control form-control-sm">
+                        <option value="PAID">Paid</option>
+                        <option value="DENIED">Denied</option>
+                        <option value="APPEALED">Appealed</option>
+                        <option value="REJECTED">Rejected</option>
+                        <option value="PAYMENT_RECEIVED">Payment Received</option>
+                        <option value="WAIVED">Waived</option>
+                    </select>
                 </div>
                 <div class="mb-0">
                     <button class="btn btn-primary btn-sm" submit>Submit</button>
@@ -31,9 +96,14 @@
             <table class="mr-2 w-75 flex-grow-1 table-bordered table-condensed table-sm table-striped">
                 <thead>
                     <tr>
-                        <th>Source</th>
-                        <th>Source Memo</th>
-                        <th>Amount</th>
+                        <th>Service Code</th>
+                        <th>Charged Amount</th>
+                        <th>Allowed Amount</th>
+                        <th>Adjustment</th>
+                        <th>Primary Insurance</th>
+                        <th>Secondary Insurance</th>
+                        <th>Patient Responsiblity</th>
+                        <th>Balance</th>
                         <th></th>
                     </tr>
                 </thead>
@@ -41,33 +111,18 @@
                 @foreach($note->receivedPayments as $rp)
                 <tr>
                     <td class="text-secondary">
-                        {{$rp->source}}
-                        <div moe class="ml-1 d-inline-block">
-                            <a class="text-danger" href="" show start><i class="fa fa-edit"></i></a>
-                            <form url="/api/receivedPayment/updateSource">
-                                <input type="hidden" name="uid" value="{{$rp->uid}}">
-                                <div class="mb-2">
-                                    <label class="mb-1 text-secondary">Source</label>
-                                    <input type="text" name="source" placeholder="Source" value="{{$rp->source}}"
-                                              class="form-control form-control-sm"></input>
-                                </div>
-                                <div class="mb-2">
-                                    <label class="mb-1 text-secondary">Source memo</label>
-                                    <textarea type="text" name="sourceMemo" placeholder="Source memo"
-                                              class="form-control form-control-sm">{{$rp->source_memo}}</textarea>
-                                </div>
-                                <div class="mb-0">
-                                    <button class="btn btn-primary btn-sm" submit>Submit</button>
-                                    <button class="btn btn-default border btn-sm" cancel>Cancel</button>
-                                </div>
-                            </form>
-                        </div>
+                        {{$rp->service_code}}({{$rp->modifier}})
                     </td>
-                    <td>{{$rp->source_memo}}</td>
-                    <td>${{friendly_money($rp->amount)}}</td>
+                    <td>{{friendly_money($rp->charged_amount)}} ({{$rp->charged_amount_status}})</td>
+                    <td>${{friendly_money($rp->allowed_amount)}}</td>
+                    <td>${{friendly_money($rp->adjustment)}}</td>
+                    <td>{{friendly_money($rp->primary_insurance_amount)}} ({{$rp->primary_amount_status}})</td>
+                    <td>{{friendly_money($rp->secondary_insurance_amount)}} ({{$rp->secondary_amount_status}})</td>
+                    <td>{{friendly_money($rp->patient_responsibility_amount)}} ({{$rp->patient_responsibility_amount_status}})</td>
+                    <td>{{friendly_money($rp->balance)}}</td>
                     <td>
                         @if($rp->is_active)
-                            <i class="fa fa-check"></i> 
+                            <i class="fa fa-check"></i>
                             <div moe class="ml-1 d-inline-block">
                                 <a class="text-danger" href="" show start> Deactivate</a>
                                 <form url="/api/receivedPayment/deactivate">
@@ -83,8 +138,101 @@
                                     </div>
                                 </form>
                             </div>
-                        @else 
-                            <i class="fa fa-cancel"></i> 
+
+                            <i class="fa fa-check"></i>
+                            <div moe class="ml-1 d-inline-block">
+                                <a class="text-danger" href="" show start> Update</a>
+                                <form url="/api/receivedPayment/deactivate">
+                                    <input type="hidden" name="uid" value="{{$rp->uid}}">
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Service Code</label>
+                                        <input type="text" name="serviceCode" placeholder="Service code"
+                                               class="form-control form-control-sm" value="{{$rp->service_code}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Modifier</label>
+                                        <input type="text" name="modifier" placeholder="Modifier"
+                                               class="form-control form-control-sm" value="{{$rp->modifier}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Charged Amount</label>
+                                        <input type="number" step=".01" name="chargedAmount" placeholder="Charged Amount"
+                                               class="form-control form-control-sm" value="{{$rp->charged_amount}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Charged Amount Status</label>
+                                        <select type="text" name="chargedAmountStatus" placeholder="Charged Amount Status"
+                                                class="form-control form-control-sm">
+                                            <option {{$rp->charged_amount_status == 'NEW'? 'checked':'' }} value="NEW">New</option>
+                                            <option {{$rp->charged_amount_status == 'PENDING'? 'checked':'' }} value="PENDING">Pending</option>
+                                            <option {{$rp->charged_amount_status == 'SUBMITTED'? 'checked':'' }} value="SUBMITTED">Submitted</option>
+                                        </select>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Allowed Amount</label>
+                                        <input type="number" step=".01" name="allowedAmount" placeholder="Allowed Amount"
+                                               class="form-control form-control-sm" value="{{$rp->allowed_amount}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Primary Insurance</label>
+                                        <input type="number" step=".01" name="primaryInsuranceAmount" placeholder="Primary Insurance"
+                                               class="form-control form-control-sm" value="{{$rp->primary_insurance_amount}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Primary Insurance Payment Status</label>
+                                        <select type="text" name="primaryAmountStatus" placeholder="Primary Insurance Payment Status"
+                                                class="form-control form-control-sm">
+                                            <option {{$rp->primary_amount_status == 'PAID'? 'checked' : ''}} value="PAID">Paid</option>
+                                            <option {{$rp->primary_amount_status == 'DENIED'? 'checked' : ''}} value="DENIED">Denied</option>
+                                            <option {{$rp->primary_amount_status == 'APPEALED'? 'checked' : ''}} value="APPEALED">Appealed</option>
+                                            <option {{$rp->primary_amount_status == 'REJECTED'? 'checked' : ''}} value="REJECTED">Rejected</option>
+                                            <option {{$rp->primary_amount_status == 'PAYMENT_RECEIVED'? 'checked' : ''}} value="PAYMENT_RECEIVED">Payment Received</option>
+                                            <option {{$rp->primary_amount_status == 'WAIVED'? 'checked' : ''}} value="WAIVED">Waived</option>
+                                        </select>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Secondary Insurance</label>
+                                        <input type="number" step=".01" name="secondaryInsuranceAmount" placeholder="Secondary Insurance"
+                                               class="form-control form-control-sm" value="{{$rp->secondary_insurance_amount}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Secondary Insurance Payment Status</label>
+                                        <select type="text" name="secondaryAmountStatus" placeholder="Secondary Insurance Payment Status"
+                                                class="form-control form-control-sm">
+                                            <option {{$rp->secondary_amount_status == 'PAID' ? 'checked': ''}} value="PAID">Paid</option>
+                                            <option {{$rp->secondary_amount_status == 'DENIED' ? 'checked': ''}} value="DENIED">Denied</option>
+                                            <option {{$rp->secondary_amount_status == 'APPEALED' ? 'checked': ''}} value="APPEALED">Appealed</option>
+                                            <option {{$rp->secondary_amount_status == 'REJECTED' ? 'checked': ''}} value="REJECTED">Rejected</option>
+                                            <option {{$rp->secondary_amount_status == 'PAYMENT_RECEIVED' ? 'checked': ''}} value="PAYMENT_RECEIVED">Payment Received</option>
+                                            <option {{$rp->secondary_amount_status == 'WAIVED' ? 'checked': ''}} value="WAIVED">Waived</option>
+                                        </select>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Patient Responsibility</label>
+                                        <input type="number" step=".01" name="patientResponsibilityAmount" placeholder="Patient Responsibility Amount"
+                                               class="form-control form-control-sm" value="{{$rp->patient_responsibility_amount}}"></input>
+                                    </div>
+                                    <div class="mb-2">
+                                        <label class="mb-1 text-secondary">Patient Responsibility Payment Status</label>
+                                        <select type="text" name="patientResponsibilityAmountStatus" placeholder="Patient Responsibility Payment Status"
+                                                class="form-control form-control-sm">
+                                            <option {{$rp->patient_responsibility_status == 'PAID' ? 'checked': ''}} value="PAID">Paid</option>
+                                            <option {{$rp->patient_responsibility_status == 'DENIED' ? 'checked': ''}} value="DENIED">Denied</option>
+                                            <option {{$rp->patient_responsibility_status == 'APPEALED' ? 'checked': ''}} value="APPEALED">Appealed</option>
+                                            <option {{$rp->patient_responsibility_status == 'REJECTED' ? 'checked': ''}} value="REJECTED">Rejected</option>
+                                            <option {{$rp->patient_responsibility_status == 'PAYMENT_RECEIVED' ? 'checked': ''}} value="PAYMENT_RECEIVED">Payment Received</option>
+                                            <option {{$rp->patient_responsibility_status == 'WAIVED' ? 'checked': ''}} value="WAIVED">Waived</option>
+                                        </select>
+                                    </div>
+                                    <div class="mb-0">
+                                        <button class="btn btn-primary btn-sm" submit>Submit</button>
+                                        <button class="btn btn-default border btn-sm" cancel>Cancel</button>
+                                    </div>
+                                </form>
+                            </div>
+
+                        @else
+                            <i class="fa fa-cancel"></i>
                             <div moe class="ml-1 d-inline-block">
                                 <a class="text-danger" href="" show start> Reactivate</a>
                                 <form url="/api/receivedPayment/reactivate">
@@ -141,4 +289,4 @@
         </div>
     </div>
 </div>
-@endif
+@endif