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+@extends ('layouts/template')
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+@section('content')
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+ <div class="p-3 mcp-theme-1">
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+ <div class="card border-0">
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+ <div class="card-body p-0">
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+ <table class="table table-striped table-bordered table-sm">
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+ <tbody>
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+ <tr>
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+ <td class="border-top-0 width-300px">Current Version</td>
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+ <td class="border-top-0">{{friendlier_date_time($mbClaim->currentVersion->created_at)}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Version</td>
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+ <td>{{friendlier_date_time($mbClaim->currentVersion->created_at)}}</td>
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+ </tr>
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+ <tr>
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+ <td>Is Submitted</td>
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+ <td>{{$mbClaim->is_submitted ? 'YES' : 'NO'}}</td>
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+ </tr>
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+ <tr>
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+ <td>Created At</td>
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+ <td>{{friendlier_date_time($mbClaim->created_at)}}</td>
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+ </tr>
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+ <tr>
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+ <td>Status</td>
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+ <td>{{$mbClaim->status}}</td>
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+ </tr>
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+ <tr>
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+ <td>Status Memo</td>
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+ <td>{{$mbClaim->status_memo}}</td>
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+ </tr>
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+ <tr>
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+ <td>Status Updated At</td>
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+ <td>{{$mbClaim->status_updated_at}}</td>
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+ </tr>
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+ <tr>
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+ <td>Vendor Identifier</td>
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+ <td>{{$mbClaim->vendor_identifier}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Date</td>
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+ <td>{{friendlier_date_time($mbClaim->claim_date)}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Tax ID</td>
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+ <td>{{$mbClaim->billing_provider_tax_id}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Tax ID Type</td>
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+ <td>{{$mbClaim->billing_provider_tax_id_type}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Entity</td>
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+ <td>{{$mbClaim->billing_provider_entity}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Phone Number</td>
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+ <td>{{$mbClaim->billing_provider_phone_number}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Organization Name</td>
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+ <td>{{$mbClaim->billing_provider_organization_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Last Name</td>
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+ <td>{{$mbClaim->billing_provider_last_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider First Name</td>
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+ <td>{{$mbClaim->billing_provider_first_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Middle Name</td>
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+ <td>{{$mbClaim->billing_provider_middle_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Address Street Line 1</td>
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+ <td>{{$mbClaim->billing_provider_address_street_line1}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Address Street Line 2</td>
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+ <td>{{$mbClaim->billing_provider_address_street_line2}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Address City</td>
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+ <td>{{$mbClaim->billing_provider_address_city}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Address State</td>
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+ <td>{{$mbClaim->billing_provider_address_state}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Address Zip</td>
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+ <td>{{$mbClaim->billing_provider_address_zip}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider NPI</td>
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+ <td>{{$mbClaim->billing_provider_npi}}</td>
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+ </tr>
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+ <tr>
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+ <td>Billing Provider Taxonomy Code</td>
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+ <td>{{$mbClaim->billing_provider_taxonomy_code}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Identifier ID</td>
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+ <td>{{$mbClaim->payer_identifier_id}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Name</td>
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+ <td>{{$mbClaim->payer_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Address Street Line 1</td>
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+ <td>{{$mbClaim->payer_address_street_line1}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Address Street Line 2</td>
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+ <td>{{$mbClaim->payer_address_street_line2}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Address City</td>
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+ <td>{{$mbClaim->payer_address_city}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Address State</td>
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+ <td>{{$mbClaim->payer_address_state}}</td>
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+ </tr>
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+ <tr>
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+ <td>Payer Address Zip</td>
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+ <td>{{$mbClaim->payer_address_zip}}</td>
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+ </tr>
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+ <tr>
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+ <td>Patient Chart Number</td>
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+ <td>{{$mbClaim->patient_chart_number}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Identifier</td>
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+ <td>{{$mbClaim->subscriber_identifier}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber First Name</td>
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+ <td>{{$mbClaim->subscriber_first_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Last Name</td>
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+ <td>{{$mbClaim->subscriber_last_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Middle Name</td>
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+ <td>{{$mbClaim->subscriber_middle_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Address Street Line 1</td>
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+ <td>{{$mbClaim->subscriber_address_street_line1}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Address Street Line 2</td>
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+ <td>{{$mbClaim->subscriber_address_street_line2}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Address City</td>
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+ <td>{{$mbClaim->subscriber_address_city}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Address State</td>
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+ <td>{{$mbClaim->subscriber_address_state}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Address Zip</td>
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+ <td>{{$mbClaim->subscriber_address_zip}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Phone Number</td>
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+ <td>{{$mbClaim->subscriber_phone_number}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Group ID</td>
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+ <td>{{$mbClaim->subscriber_group_id}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber DOB</td>
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+ <td>{{$mbClaim->subscriber_dob}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Gender</td>
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+ <td>{{$mbClaim->subscriber_gender}}</td>
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+ </tr>
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+ <tr>
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+ <td>Subscriber Group Name</td>
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+ <td>{{$mbClaim->subscriber_group_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Direct Payment Authorized</td>
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+ <td>{{$mbClaim->claim_direct_payment_authorized}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Frequency</td>
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+ <td>{{$mbClaim->claim_frequency}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Prior Authorization Number</td>
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+ <td>{{$mbClaim->claim_prior_authorization_number}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Accept Assignment Code</td>
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+ <td>{{$mbClaim->claim_accept_assignment_code}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Total Charge</td>
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+ <td>{{$mbClaim->claim_total_charge}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Patient Amount Paid</td>
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+ <td>{{$mbClaim->claim_patient_amount_paid}}</td>
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+ </tr>
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+ <tr>
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+ <td>Claim Diagnosis Codes</td>
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+ <td>{{str_replace("|", ", ", $mbClaim->claim_diagnosis_codes)}}</td>
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+ </tr>
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+ <tr>
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+ <td>Attending Provider First Name</td>
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+ <td>{{$mbClaim->attending_provider_first_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Attending Provider Last Name</td>
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+ <td>{{$mbClaim->attending_provider_last_name}}</td>
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+ </tr>
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+ <tr>
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+ <td>Attending Provider NPI</td>
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+ <td>{{$mbClaim->attending_provider_npi}}</td>
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+ </tr>
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+ </tbody>
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+ </table>
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+ </div>
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+ </div>
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+ </div>
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+@endsection
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