primary coverage form

app/Http/Controllers/PatientController.php

@@ -536,6 +536,11 @@ class PatientController extends Controller
         return view('app.patient.primary-coverage', compact('patient', 'mbPayers'));
     }
 
+    public function primaryCoverageForm(Request $request, Client $patient) {
+        $mbPayers = MBPayer::all();
+        return view('app.patient.primary-coverage-form', compact('patient', 'mbPayers'));
+    }
+
     public function mbClaim(Request $request, MBClaim $mbClaim) {
         return view('app.patient.mb-claim-single', compact('mbClaim'));
     }

resources/views/app/patient/primary-coverage-form.blade.php

@@ -0,0 +1,233 @@
+	<div id="new-coverage-form-{{$patient->uid}}">
+		<div class="p-3">
+		<form :url="url" class="mcp-theme-1">
+			<input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
+			<div class="row">
+				<div class="form-group col-md-12">
+					<p class="mb-1">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-model="insuranceCardType" name="insuranceCardType" value="medicare">Medicare Part B (Primary)</label>
+					</div>
+					<div class="form-check form-check-inline">
+					  <label class="form-check-label"><input class="form-check-input" type="radio" v-model="insuranceCardType" name="insuranceCardType" value="medicaid">Medicaid (Primary)</label>
+					</div>
+					<div class="form-check form-check-inline">
+					  <label class="form-check-label"><input class="form-check-input" type="radio" v-model="insuranceCardType" name="insuranceCardType" value="commercial">Commercial / Third Party (Primary)</label>
+					</div>
+				</div>
+			</div>
+
+			<div class="row" v-if="insuranceCardType == 'commercial'">
+				<div class="form-group col-md-12">
+					<label for="" class="control-label">Commercial Payer</label>
+					<select name="commercialPayerUid" id="" class="form-control input-sm">
+						<option value="">--</option>
+					</select>
+				</div>
+			</div>
+
+
+			<div class="row" v-if="insuranceCardType">
+					<div class="col-md-12 bg-light p-3 mb-2">
+						<h5 class="m-0 font-weight-bold">Patient Name / Demographics:</h5>
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient First Name</label>
+						<input type="text" name="patientNameFirst" value="{{$patient->name_first}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient Middle Name / MI</label>
+						<input type="text" name="patientNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient Last Name</label>
+						<input type="text" name="patientNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient Suffix</label>
+						<input type="text" name="patientNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient Sex</label>
+						<select class="form-control input-sm" name="patientSex">
+							<option value="">--</option>
+							<option value="M">Male</option>
+							<option value="F">Female</option>
+							<option value="UNKNOWN">Unknown</option>
+						</select>
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Patient Dob</label>
+						<input type="date" name="patientDob" value="{{$patient->dob}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-6">
+						<label class="control-label">Date Of Service</label>
+						<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
+					</div>
+			</div>
+			<div class="row">
+				<div class="form-group col-md-12" v-if="insuranceCardType == 'medicaid' || insuranceCardType == 'commercial'">
+					<p class="mb-1">Is Patient The Subscriber?</p>
+					<label class="mr-2">
+						<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="1"> Yes
+					</label>
+					<label class="">
+						<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="0"> No
+					</label>
+				</div>
+			</div>
+
+			<div v-if="isPatientSubscriber == 0 && (insuranceCardType == 'medicaid' || insuranceCardType == 'commercial')" class="row">
+				<div class="col-md-12 bg-light p-3 mb-2">
+					<h5 class="m-0 font-weight-bold">Subscriber Details:</h5>
+				</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Subscriber First Name</label>
+						<input type="text" name="subscriberNameFirst" value="{{$patient->name_first}}" 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="subscriberNameMiddle" value="{{$patient->name_middle}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Subscriber Last Name</label>
+						<input type="text" name="subscriberNameLast" value="{{$patient->name_last}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Subscriber Suffix</label>
+						<input type="text" name="subscriberNameSuffix" value="{{$patient->name_suffix}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Subscriber Sex</label>
+						<select class="form-control input-sm" name="subscriberSex">
+							<option value="">--</option>
+							<option value="MALE">Male</option>
+							<option value="FEMALE">Female</option>
+							<option value="UNKNOWN">Unknown</option>
+						</select>
+					</div>
+					<div class="form-group col-md-4">
+						<label class="control-label">Subscriber Dob</label>
+						<input type="date" name="subscriberDob" value="{{$patient->dob}}" class="form-control input-sm">
+					</div>
+					<div class="form-group col-md-6">
+						<label class="control-label">Patient Relationship To Subscriber</label>
+						<select name="patientRelationshipToSubscriber" class="form-control input-sm">
+							<option value="">--</option>
+							<option value="SPOUSE">Spouse</option>
+							<option value="CHILD">Child</option>
+							<option value="EMPLOYEE">Employee</option>
+							<option value="ORGAN_DONOR">Organ Donor</option>
+							<option value="CADAVER_DONOR">Cadaver Donor</option>
+							<option value="LIFE_PARTNER">Life Partner</option>
+							<option value="OTHER_RELATIONSHIP">Other Relationship</option>
+							<option value="UNKNOWN">Unknown</option>
+						</select>
+					</div>
+			</div>
+			<div class="row" v-if="insuranceCardType == 'medicaid' || insuranceCardType == 'commercial'">
+				<div class="col-md-12 bg-light p-3 mb-2">
+					<h5 class="m-0 font-weight-bold">Medicaid Information:</h5>
+				</div>
+				<div class="form-group col-md-6">
+					<label for="" class="control-label">Medicaid Payer</label>
+					<select name="mcdPayerUid" id="" class="form-control input-sm">
+						<option value="">--</option>
+						<option>MEDICAID ALABAMA</option>
+						<option>MEDICAID ALASKA</option>
+						<option>MEDICAID ARIZONA</option>
+						<option>MEDICAID ARKANSAS</option>
+						<option>MEDICAID CALIFORNIA MEDI-CAL</option>
+						<option>MEDICAID COLORADO</option>
+						<option>MEDICAID CONNECTICUT</option>
+						<option>MEDICAID DELAWARE</option>
+						<option>MEDICAID DISTRICT OF COLUMBIA</option>
+						<option>MEDICAID FLORIDA</option>
+						<option>MEDICAID GEORGIA</option>
+						<option>MEDICAID HAWAII</option>
+						<option>MEDICAID IDAHO</option>
+						<option>MEDICAID ILLINOIS</option>
+						<option>MEDICAID INDIANA</option>
+						<option>MEDICAID IOWA</option>
+						<option>MEDICAID KANSAS</option>
+						<option>MEDICAID KENTUCKY</option>
+						<option>MEDICAID LOUISIANA</option>
+						<option>MEDICAID MAINE</option>
+						<option>MEDICAID MARYLAND</option>
+						<option>MEDICAID MARYLAND DHMH</option>
+						<option>MEDICAID MASSACHUSETTS</option>
+						<option>MEDICAID MICHIGAN</option>
+						<option>MEDICAID MINNESOTA</option>
+						<option>MEDICAID MISSISSIPPI</option>
+						<option>MEDICAID MISSISSIPPI</option>
+						<option>MEDICAID MISSOURI</option>
+						<option>MEDICAID MONTANA</option>
+						<option>MEDICAID NEBRASKA</option>
+						<option>MEDICAID NEVADA</option>
+						<option>MEDICAID NEW HAMPSHIRE</option>
+						<option>MEDICAID NEW JERSEY</option>
+						<option>MEDICAID NEW MEXICO</option>
+						<option>MEDICAID NEW YORK</option>
+						<option>MEDICAID NEW YORK</option>
+						<option>MEDICAID NORTH CAROLINA</option>
+						<option>MEDICAID NORTH DAKOTA</option>
+						<option>MEDICAID OHIO</option>
+						<option>MEDICAID OKLAHOMA</option>
+						<option>MEDICAID OREGON</option>
+						<option>MEDICAID OREGON (DHS OMAP)</option>
+						<option>MEDICAID PENNSYLVANIA</option>
+						<option>MEDICAID RHODE ISLAND</option>
+						<option>MEDICAID SOUTH CAROLINA</option>
+						<option>MEDICAID SOUTH DAKOTA</option>
+						<option>MEDICAID TENNESSEE</option>
+						<option>MEDICAID TEXAS</option>
+						<option>MEDICAID TEXAS AND TEXAS HEALTH STEPS</option>
+						<option>MEDICAID UTAH</option>
+						<option>MEDICAID VERMONT</option>
+						<option>MEDICAID VIRGINIA</option>
+						<option>MEDICAID WASHINGTON (PROVIDER ONE)</option>
+						<option>MEDICAID WEST VIRGINIA</option>
+						<option>MEDICAID WISCONSIN</option>
+						<option>MEDICAID WYOMING</option>
+					</select>
+				</div>
+
+				<div class="form-group col-md-6">
+					<label class="control-label">Medicaid Number</label>
+					<input type="text" name="mcdNumber"  class="form-control input-sm">
+				</div>
+			</div>
+
+			<div class="row" v-if="insuranceCardType == 'medicare' || insuranceCardType == 'commercial'">
+				<div class="col-md-12 bg-light p-3 mb-2">
+					<h5 class="m-0 font-weight-bold">Medicare Information:</h5>
+				</div>
+				<div class="form-group col-md-6" >
+					<label class="control-label">Medicare Number</label>
+					<input type="text" name="mcrNumber" class="form-control input-sm">
+				</div>
+
+			</div>
+
+			<div class="form-group text-nowrap mb-0">
+				<button class="btn btn-sm btn-primary" type="submit">Submt</button>
+			</div>
+		</form>
+	</div>
+</div>
+<script>
+    (function() {
+        function init() {
+            new Vue({
+                el: '#new-coverage-form-{{$patient->uid}}',
+								delimiters:['@{{','}}'],
+								data: {
+									url: '',
+									insuranceCardType: '',
+									isPatientSubscriber: 1
+								}
+            });
+        }
+        addMCInitializer('new-coverage-form-{{$patient->uid}}', init, '#new-coverage-form-{{$patient->uid}}')
+    }).call(window);
+</script>

resources/views/app/patient/primary-coverage-new-commercial.blade.php

@@ -54,7 +54,7 @@
 				<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
 			</div>
 			<div class="form-group col-md-12">
-				<p class="mb-1">Is Patient Subscriber?</p>
+				<p class="mb-1">Is Patient The Subscriber?</p>
 				<label class="mr-2">
 					<input type="radio" name="isPatientSubscriber" v-model="isPatientSubscriber" value="1"> Yes
 				</label>

resources/views/app/patient/primary-coverage.blade.php

@@ -4,11 +4,13 @@
 <div class="d-flex align-items-baseline">
     <h4 class="font-weight-bold m-0 font-size-16 text-nowrap">Client Latest Coverage</h4>
     <div class="ml-4 d-inline-flex justify-content-center">
-        @include('app.patient.primary-coverage-new-medicare')
-        <span class="mx-2 text-secondary text-sm">|</span>
-        @include('app.patient.primary-coverage-new-medicaid')
-        <span class="mx-2 text-secondary text-sm">|</span>
-        @include('app.patient.primary-coverage-new-commercial')
+        <a native target="_blank"
+           open-in-stag-popup
+           mc-initer="new-coverage-form-{{$patient->uid}}"
+           title="Add/Update New Primary Insurance"
+           href="/patients/view/primary-coverage-form/{{$patient->uid}}">
+            + Add/Update New Primary Insurance
+        </a>
     </div>
 </div>
 
@@ -41,7 +43,136 @@
             @endif
         </div>
 
-        <div>
+        <div class="mt-4">
+          <div class="row">
+            <div class="col-md-8">
+              <h4 class="font-weight-bold">Patient Information</h4>
+              <div class="table-responsive">
+                <table class="table table-bordered table-striped">
+                  <tbody>
+                    <tr>
+                      <td>Patient First Name</td>
+                      <td>{{$cpc->patient_name_first}}</td>
+                    </tr>
+                    <tr>
+                      <td>Patient Middle Name / MI</td>
+                      <td>{{$cpc->patient_name_middle}}</td>
+                    </tr>
+                    <tr>
+                      <td>Patient Last Name</td>
+                      <td>{{$cpc->patient_name_last}}</td>
+                    </tr>
+                    <tr>
+                      <td>Patient Suffix</td>
+                      <td>{{$cpc->patient_name_suffix}}</td>
+                    </tr>
+                    <tr>
+                      <td>Patient Dob</td>
+                      <td>{{$cpc->patient_dob ? date_format(date_create($cpc->patient_dob), 'm/d/Y') : '-'}}</td>
+                    </tr>
+                    <tr>
+                      <td>Date of Service</td>
+                      <td>{{$cpc->date_of_service ? date_format(date_create($cpc->date_of_service), 'm/d/Y') : '-'}}</td>
+                    </tr>
+                  </tbody>
+                </table>
+              </div>
+
+              <h4 class="font-weight-bold">Latest Coverage</h4>
+              <div class="table-responsive">
+                <table class="table table-bordered table-striped">
+                  <tbody>
+                    <tr>
+                      <td>Plan Type</td>
+                      <td>{{$cpc->plan_type}}</td>
+                    </tr>
+
+                    @if($cpc->plan_type == 'COMMERCIAL')
+                      <tr>
+                        <td>Commercial Payer</td>
+                        <td>{{$cpc->commercial_payer_id}}</td>
+                      </tr>
+                      <tr>
+                        <td>Patient Member Identifier</td>
+                        <td>{{$cpc->commercial_member_identifier}}</td>
+                      </tr>
+                      <tr>
+                        <td>Patient Group Number</td>
+                        <td>{{$cpc->commercial_payer_name}}</td>
+                      </tr>
+                      <tr>
+                        <td>Is Patient Subsriber</td>
+                        <td>{{$cpc->is_patient_subscriber ? 'Yes' : 'No'}}</td>
+                      </tr>
+                      @if(!$cpc->is_patient_subscriber)
+                      <tr>
+                        <td>Patient Relationship To Subscriber</td>
+                        <td>{{$cpc->patient_relationship_to_subscriber}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber First Name</td>
+                        <td>{{$cpc->subscriber_name_first}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber Middle Name / MI</td>
+                        <td>{{$cpc->subscriber_name_middle}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber Last Name</td>
+                        <td>{{$cpc->subscriber_name_last}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber Suffix</td>
+                        <td>{{$cpc->subscriber_name_suffix}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber Sex</td>
+                        <td>{{$cpc->subscriber_sex}}</td>
+                      </tr>
+                      <tr>
+                        <td>Subscriber Dob</td>
+                        <td>{{$cpc->subscriber_dob ? date_format(date_create($cpc->subscriber_dob), 'm/d/Y') : '-'}}</td>
+                      </tr>
+                      @endif
+                    @endif
+
+                    @if($cpc->plan_type == 'MEDICARE' || $cpc->plan_type == 'COMMERCIAL')
+                      <tr>
+                        <td>Medicare Number</td>
+                        <td>{{$cpc->mcr_number}}</td>
+                      </tr>
+                    @endif
+                    @if($cpc->plan_type == 'MEDICAID' || $cpc->plan_type == 'COMMERCIAL')
+                      <tr>
+                        <td>Medicaid Number</td>
+                        <td>{{$cpc->mcd_number}}</td>
+                      </tr>
+                      <tr>
+                        <td>Medicaid Payer</td>
+                        <td>{{$cpc->mcd_payer_id}}</td>
+                      </tr>
+                    @endif
+                  </tbody>
+                </table>
+              </div>
+
+              <h4 class="font-weight-bold">Manual Determination</h4>
+              <div class="table-responsive">
+                <table class="table table-bordered table-striped">
+                  <tbody>
+                    <tr>
+                      <td>Manual Determination Strategy</td>
+                      <td>{{$cpc->manual_determination_strategy}}</td>
+                    </tr>
+                    <tr>
+                      <td>Manual Determination Category</td>
+                      <td>{{$cpc->manual_determination_category}}</td>
+                    </tr>
+                  </tbody>
+                </table>
+              </div>
+            </div>
+          </div>
             @php
                 dump(json_decode($cpc->toJson(JSON_PRETTY_PRINT | JSON_UNESCAPED_UNICODE | JSON_UNESCAPED_SLASHES)));
             @endphp

routes/web.php

@@ -218,6 +218,7 @@ Route::middleware('pro.auth')->group(function () {
         Route::get('patients/view/insurance-coverage/{patient}', 'PatientController@insuranceCoverage')->name('patients.view.insurance-coverage');
         Route::get('patients/view/client-primarycoverages/{patient}', 'PatientController@clientPrimaryCoverages')->name('patients.view.client-primary-coverages');
         Route::get('patients/view/primary-coverage/{patient}', 'PatientController@primaryCoverage')->name('patients.view.primary-coverage');
+        Route::get('patients/view/primary-coverage-form/{patient}', 'PatientController@primaryCoverageForm')->name('patients.view.primary-coverage-form');
     });
 
     Route::name('patients.view.')->prefix('patients/view/{patient}')->group(function () {
@@ -423,4 +424,3 @@ Route::post("/process_form_submit", 'NoteController@processFormSubmit')->name('p
 Route::get("/get-default-section-data/{patientID}/{sectionTemplateID}", 'NoteController@getDefaultValueForSection')->name('get_default_section_data');
 
 Route::get("/get-segment-html/{segmentUid}/{sessionKey}", 'NoteController@getHtmlForSegment')->name('get_segment_html');
-