Summary Table
Categories |
Total Count |
PII |
0 |
URL |
0 |
DNS |
0 |
EKL |
0 |
IP |
0 |
PORT |
0 |
VsID |
0 |
CF |
0 |
AI |
0 |
VPD |
0 |
PL |
0 |
Other |
0 |
File Content
<app-ars-base [title]="title" [tabIdx]="tabIdx">
<app-messages [errorStatus]="errorStatus" [errorMsg]="errorMsg" [successStatus]="successStatus" [successMsg]="successMsg"></app-messages>
<article>
<!-- Adds Cushion -->
<div class="row"></div>
<div class="container fade-in">
<!-- Card Tabs -->
<div class="card-tabs blue-tab">
<section>
<!-- Tab 1 -->
<input checked id="TAB_autoFill_rfaiSubmission_1" type="radio" name="tabs" (click)="onResetManual()" [tabindex]="tabIdx"
role="tab" aria-label="Auto-Fill Tab. To switch tabs, use arrow keys." />
<!-- ARIA-Lavel tells screen reader which keys control tabs. Must include tab name; tag pre-empts content. -->
<label for="TAB_autoFill_rfaiSubmission_1" class="tab-label">Auto-Fill</label>
<!-- Tab 1 Contnet -->
<div class="tab-content">
<div class="col three">
<div class="card-head">
<h3 id="HDG_pagetitle_rfaiSubmission_1">Generate and Submit 277 RFAI</h3>
<span>Auto-fill RFAI using claim number or PDI.</span>
</div>
<!-- Form Begins -->
<form [formGroup]="autoFillform" (ngSubmit)="populateInfo()" novalidate>
<div class="col two">
<label class="label text-field" for="IPT_pdiClaimId_rfaiSubmission_1">PDI or Claim ID
<!-- <span *ngIf="!(autoFillform.controls['claimId'].invalid && autoFillform.controls['claimId'].touched)" class="required">Required</span> -->
<span class="error" *ngIf="autoFillform.controls['claimId'].invalid && autoFillform.controls['claimId'].touched" role="alert"
aria-live="assertive">Enter a Valid Number</span>
</label>
<input appAutofocus formControlName="claimId" type="text" placeholder="Enter PDI or Claim Number" id="IPT_pdiClaimId_rfaiSubmission_1"
name="pdiClaimId" [(ngModel)]="autoFormModel.claimId" maxlength="15" class="big-box" [tabindex]="tabIdx">
</div>
<div class="row bottom col two">
<button class="button secondary button-align" type="submit" id="BTN_populate_277submit_1" [disabled]="disablePopulateInfo?disablePopulateInfo:autoFillform.get('claimId').invalid"
[class.disabled]="disablePopulateInfo?disablePopulateInfo:autoFillform.get('claimId').invalid" [tabindex]="tabIdx">Populate Claim Info</button>
</div>
</form>
<!-- Form Ends -->
</div>
</div>
<!-- Tab 2 -->
<input id="TAB_manualEntry_rfaiSubmission_1" type="radio" name="tabs" (click)="onResetPrepopulated(); validateDates()" [tabindex]="tabIdx"
role="tab" />
<label for="TAB_manualEntry_rfaiSubmission_1" class="tab-label">Manual Entry</label>
<!-- Tab 2 Contnet -->
<div class="tab-content">
<div class="col three">
<div class="card-head">
<h3>Generate and Submit 277 RFAI
</h3>
<span> Manually enter claim data in the fields below.</span>
</div>
<!-- Manual Entry Form -->
<form [formGroup]="manualForm" (ngSubmit)="onSubmitManual()" novalidate>
<div class="row">
<div class="col one">
<label class="label text-field" for="IPT_payerClaimCtlNum_277Submit_1">Payer Claim Control Number
<span class="required">Required</span>
<span class="error" *ngIf="manualForm.get('payerClaimControlNumber').invalid && manualForm.get('payerClaimControlNumber').touched"
role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="payerClaimControlNumber" type="text" placeholder="Enter Claim Control Number" id="IPT_payerClaimCtlNum_277Submit_1"
name="payerClaimControlNumber" [(ngModel)]="pdiInfoModel.payerClaimControlNumber" (blur)="checkPending($event, false)"
[tabindex]="tabIdx">
</div>
<div class="col one">
<!-- <label class="label text-field" for="responseDueDateManual">Response Due Date
<span class="info" *ngIf="manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').valid || !manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').touched">mm/dd/yyyy</span>
<img *ngIf="manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').valid || !manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').touched"
id="IMG_required_277submit_1" src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required"
title="Required">
<span class="error" *ngIf="manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').invalid && manualForm.controls['responseDueDateManualCalendar'].get('responseDueDateManual').touched"
role="alert" aria-live="assertive">Valid Future Date Required</span>
</label> -->
<app-calendar [monthId]="'SPN_currentmonth-1'" [required]="true" [label]="'Response Due Date'" [id]="'responseDueDateManual'"
[calendarTabIndex]="errorModalClosed && warningModalClosed?'0':'-1'" [parentFormGroup]="manualForm" [parentControlName]="'responseDueDateManual'"></app-calendar>
</div>
<div class="col one no-flow">
<label class="label text-field" for="IPT_contactInfo_277submit_1">Contact Information
<img *ngIf="manualForm.get('contactInfo').valid || !manualForm.get('contactInfo').touched" id="IMG_required_277submit_2"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('contactInfo').invalid && manualForm.get('contactInfo').touched" role="alert" aria-live="assertive">Enter Valid Email</span>
</label>
<input formControlName="contactInfo" type="text" placeholder="Enter Contact Info" id="IPT_contactInfo_277submit_1" name="contactInfo"
[(ngModel)]="manualFormModel.contactInformation" [tabindex]="tabIdx">
</div>
</div>
<div class="col three">
<h4 class="section-head">Claim Information Manual Entry
</h4>
<div class="row col three" role="radiogroup" aria-labelledby="LBL_levelGroup_277submit_1">
<label id="LBL_levelGroup_277submit_1">Select One: </label>
<input formControlName="level" [value]="'C'" [(ngModel)]="pdiInfoModel.level" type="radio" name="level" id="IPT_claimLevel_277submit_1"
(change)="toggleLines()" [tabindex]="tabIdx" checked>
<label for="IPT_claimLevel_277submit_1" style="padding-right: 15px;">Claim-Level</label>
<input formControlName="level" [value]="'L'" [(ngModel)]="pdiInfoModel.level" type="radio" name="level" id="IPT_lineLevel_277submit_1"
(change)="toggleLines()" [tabindex]="tabIdx">
<label for="IPT_lineLevel_277submit_1" style="padding-right: 15px;">Line-Level</label>
</div>
</div>
<div class="col one">
<label class="label text-field" for="IPT_payerID_277Submit_1">Payer
<img *ngIf="!(manualForm.get('payerID').invalid && manualForm.get('payerID').touched)" id="IMG_required_277submit_3" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('payerID').invalid && manualForm.get('payerID').touched" role="alert" aria-live="assertive">Select a Valid Payer</span>
</label>
<!-- <input formControlName="payerName" type="text" placeholder="Enter Name" id="payerName" name="payerName" [(ngModel)]="pdiInfoModel.payerName"> -->
<select formControlName="payerID" id="IPT_payerID_277Submit_1" name="payerID" [(ngModel)]="pdiInfoModel.payerId" [tabindex]="tabIdx">
<option value="" selected>Select Payer</option>
<option *ngFor="let payer of payers" [value]="payer.payerIdentifier">{{payer.payerIdentifier + " "+ payer.payerIdentifierDesc}}
</option>
</select>
</div>
<!-- <div class="col one">
<label class="label text-field" for="payerID">Payer ID
<span class="required" *ngIf="!(manualForm.get('payerID').invalid && manualForm.get('payerID').touched)">Required</span>
<span class="error" *ngIf="manualForm.get('payerID').invalid && manualForm.get('payerID').touched">Enter a valid Number.</span>
</label>
<input formControlName="payerID" type="text" placeholder="Enter ID" id="payerID" name="payerID" [(ngModel)]="pdiInfoModel.payerId">
</div> -->
<div class="col one">
<label class="label text-field" for="IPT_billType_277submit_1">Bill Type
<img *ngIf="!(manualForm.get('billType').invalid && manualForm.get('billType').touched)" id="IMG_required_277submit_4" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('billType').invalid && manualForm.get('billType').touched" role="alert" aria-live="assertive">Enter Valid Bill Type</span>
</label>
<input formControlName="billType" type="text" placeholder="Enter Bill Type" id="IPT_billType_277submit_1" name="billType"
[(ngModel)]="pdiInfoModel.billType" [tabindex]="tabIdx">
</div>
<div class="col one no-flow">
<label class="label text-field" for="IPT_billProv_277submit_1">Billing Provider Name
<img *ngIf="!(manualForm.get('billingProvider').invalid && manualForm.get('billingProvider').touched)" id="IMG_required_277submit_5"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('billingProvider').invalid && manualForm.get('billingProvider').touched" role="alert"
aria-live="assertive">Enter Valid Provider Name</span>
</label>
<input formControlName="billingProvider" type="text" placeholder="Enter Provider" id="IPT_billProv_277submit_1" name="billingProvider"
[(ngModel)]="pdiInfoModel.providerInformation" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="IPT_provNpi_277submit_1">Billing Provider NPI
<img *ngIf="!(manualForm.get('providerNpi').invalid && manualForm.get('providerNpi').touched)" id="IMG_required_277submit_6"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('providerNpi').invalid && manualForm.get('providerNpi').touched" role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="providerNpi" type="text" placeholder="Enter NPI" id="IPT_provNpi_277submit_1" name="providerNpi"
[(ngModel)]="pdiInfoModel.providerNpi" maxlength="10" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="billingProviderTIN">Billing Provider TIN
<img *ngIf="!(manualForm.get('billingProviderTIN').invalid && manualForm.get('billingProviderTIN').touched)" id="IMG_required_277submit_7"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('billingProviderTIN').invalid && manualForm.get('billingProviderTIN').touched"
role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="billingProviderTIN" type="text" placeholder="Enter TIN" id="billingProviderTIN" name="billingProviderTIN"
[(ngModel)]="pdiInfoModel.providerTin" maxlength="9" [tabindex]="tabIdx">
</div>
<div class="col one no-flow">
<label class="label text-field" for="IPT_lastName_277submit_1">Patient Last Name
<img *ngIf="!(manualForm.get('lastName').invalid && manualForm.get('lastName').touched)" id="IMG_required_277submit_8" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('lastName').invalid && manualForm.get('lastName').touched" role="alert" aria-live="assertive">Enter Valid Last Name</span>
</label>
<input formControlName="lastName" type="text" placeholder="Enter Last Name" id="IPT_lastName_277submit_1" name="lastName"
[(ngModel)]="pdiInfoModel.patientLastname" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="IPT_firstName_277submit_1">Patient First Name
<img *ngIf="!(manualForm.get('firstName').invalid && manualForm.get('firstName').touched)" id="IMG_required_277submit_9"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('firstName').invalid && manualForm.get('firstName').touched" role="alert" aria-live="assertive">Enter Valid First Name</span>
</label>
<input formControlName="firstName" type="text" placeholder="Enter First Name" id="IPT_firstName_277submit_1" name="firstName"
[(ngModel)]="pdiInfoModel.patientFirstName" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="IPT_patientID_277submit_1">Patient Identifier
<img *ngIf="!(manualForm.get('patientID').invalid && manualForm.get('patientID').touched)" id="IMG_required_277submit_10"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('patientID').invalid && manualForm.get('patientID').touched" role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="patientID" type="text" placeholder="Enter Identifier" id="IPT_patientID_277submit_1" name="patientID"
[(ngModel)]="pdiInfoModel.patientIdentifier" [tabindex]="tabIdx">
</div>
<div class="col one no-flow">
<label class="label text-field" for="IPT_patientCtllNum_277submit_1">Patient Control Number
<img *ngIf="!(manualForm.get('patientControlNumber').invalid && manualForm.get('patientControlNumber').touched)" id="IMG_required_277submit_11"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('patientControlNumber').invalid && manualForm.get('patientControlNumber').touched"
role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="patientControlNumber" type="text" placeholder="Enter Control Number" id="IPT_patientCtllNum_277submit_1"
name="patientControlNumber" [(ngModel)]="pdiInfoModel.patientcontrolNumber" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="IPT_infoReceiver_277submit_1">Information Receiver
<img *ngIf="!(manualForm.get('informationReceiver').invalid && manualForm.get('informationReceiver').touched)" id="IMG_required_277submit_12"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('informationReceiver').invalid && manualForm.get('informationReceiver').touched"
role="alert" aria-live="assertive">Enter a Valid Name</span>
</label>
<input formControlName="informationReceiver" type="text" placeholder="Enter Information Receiver" id="IPT_infoReceiver_277submit_1"
name="informationReceiver" [(ngModel)]="pdiInfoModel.informationReceiver" [tabindex]="tabIdx">
</div>
<div class="col one">
<label class="label text-field" for="IPT_medRecordNum_277submit_1">Medical Record Number
<img *ngIf="!(manualForm.get('medicalRecordNumber').invalid && manualForm.get('medicalRecordNumber').touched)" id="IMG_required_277submit_13"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('medicalRecordNumber').invalid && manualForm.get('medicalRecordNumber').touched"
role="alert" aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="medicalRecordNumber" type="text" placeholder="Enter Record Number" id="IPT_medRecordNum_277submit_1"
name="medicalRecordNumber" [(ngModel)]="pdiInfoModel.medicalRecordNumber" [tabindex]="tabIdx">
</div>
<div class="col one no-flow">
<label class="label text-field" for="IPT_clearingHouseID_277submit_1">Clearinghouse ID
<img *ngIf="!(manualForm.get('clearingHouseID').invalid && manualForm.get('clearingHouseID').touched)" id="IMG_required_277submit_14"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="manualForm.get('clearingHouseID').invalid && manualForm.get('clearingHouseID').touched" role="alert"
aria-live="assertive">Enter a Valid Number</span>
</label>
<input formControlName="clearingHouseID" type="text" placeholder="Enter ID" id="IPT_clearingHouseID_277submit_1" name="clearingHouseID"
[(ngModel)]="pdiInfoModel.clearingHouseId" [tabindex]="tabIdx">
</div>
<div class="col one" [ngClass]="{hideDiv: pdiInfoModel.level ==='L'}">
<!-- <label class="label text-field" for="serviceFromDate">Service From Date
<img id="IMG_required_277submit_15" src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="info" *ngIf="manualForm.controls['serviceFromDateCalendar'].get('serviceFromDate').valid || !manualForm.controls['serviceFromDateCalendar'].get('serviceFromDate').touched">mm/dd/yyyy</span>
<span class="error" *ngIf="manualForm.controls['serviceFromDateCalendar'].get('serviceFromDate').invalid && manualForm.controls['serviceFromDateCalendar'].get('serviceFromDate').touched"
role="alert" aria-live="assertive">Enter a Valid Date</span>
</label> -->
<app-calendar [monthId]="'SPN-currentmonth_2'" [dateRangeError]="dateRangeError" [required]="true" [label]="'Service From Date'"
[id]="'serviceFromDate'" [parentFormGroup]="manualForm" [parentControlName]="'serviceFromDate'"></app-calendar>
</div>
<div class="col one" [ngClass]="{hideDiv: pdiInfoModel.level ==='L'}">
<!-- <label class="label text-field" for="serviceToDate">Service To Date
<span class="info" *ngIf="manualForm.controls['serviceToDateCalendar'].get('serviceToDate').valid || !manualForm.controls['serviceToDateCalendar'].get('serviceToDate').touched">mm/dd/yyyy</span>
<span class="error" *ngIf="manualForm.controls['serviceToDateCalendar'].get('serviceToDate').invalid && manualForm.controls['serviceToDateCalendar'].get('serviceToDate').touched"
role="alert" aria-live="assertive">Enter a Valid Date</span>
</label> -->
<app-calendar [monthId]="'SPN_currentMonth_3'" [dateRangeError]="dateRangeError" [required]="true" [label]="'Service To Date'"
[id]="'serviceToDate'" [parentFormGroup]="manualForm" [parentControlName]="'serviceToDate'"></app-calendar>
</div>
<!-- Set 3 -->
<div class="row col three hideDiv" #linesDiv>
<div class="row"></div>
<!-- <div *ngIf="pdiInfoModel.level ==='C'" style="position: absolute; display: block; background-color: white; opacity: 0.7; width: 1196px; height: 153px; z-index: 51;"></div> -->
<div>
<h4 class="float-left">Service Line Information
<!-- <span class="required" style="font-size: 14px;">All line information is required to submit line-level request.</span> -->
<!-- <span class="error" *ngIf="manualForm.controls['linesFormArray'].touched && manualForm.controls['linesFormArray'].invalid">Please fix below errors </span> -->
</h4>
<div class="icon-function" style="margin-right: 12px;" [class.disabled]="this.manualForm.get('linesFormArray').invalid">
<label for="IMG_addCode_277_submit_1">Add New Line</label>
<img id="IMG_addCode_277submit_1" src="./../../assets/images/ic_add_circle_blue_24px.svg" (click)="addLineRow()" (keydown.enter)="addLineRow()"
[tabIndex]="(!this.manualForm.get('linesFormArray').invalid&&errorModalClosed&&warningModalClosed)?'0':'-1'"
title="Add New Line" alt="add new line">
<!-- Need to define "disabled" look/function -->
</div>
</div>
<table role="presentation" class="clean-table">
<thead>
<th>
<label *ngIf="!showError('serviceLine')" for="IPT_serviceLine_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Service Line #
<img *ngIf="!showError('serviceLine')" id="IMG_required_277submit_16" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
</label>
<span class="error" *ngIf="showError('serviceLine')" role="alert" aria-live="assertive">Enter Valid Number</span>
</th>
<th>
<label *ngIf="!showError('lineServiceFrom')" for="IPT_lineServiceFrom_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Svc. From
<span class="info small" *ngIf="!showError('lineServiceFrom')">mm/dd/yyyy</span>
<img *ngIf="!showError('lineServiceFrom')" id="IMG_required_277submit_17" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
</label>
<span class="error" *ngIf="showError('lineServiceFrom')" role="alert" aria-live="assertive">Enter Valid Date</span>
</th>
<th>
<label *ngIf="!showError('lineServiceTo')" for="IPT_lineServiceTo_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Svc. To
<span class="info small" *ngIf="!showError('lineServiceTo')">mm/dd/yyyy</span>
</label>
<span class="error" *ngIf="showError('lineServiceTo')" role="alert" aria-live="assertive">Enter Valid Date</span>
</th>
<th>
<label *ngIf="!showError('revenueCode')" for="IPT_revenueCode_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Revenue Code
<img *ngIf="!showError('revenueCode')" id="IMG_required_277submit_18" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
</label>
<span class="error" *ngIf="showError('revenueCode')" role="alert" aria-live="assertive">Enter Valid Code</span>
</th>
<th>
<label *ngIf="!showError('procedureCode')" for="IPT_procedureCode_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Procedure Code
<img *ngIf="!showError('procedureCode')" id="IMG_required_277submit_19" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
</label>
<span class="error" *ngIf="showError('procedureCode')" role="alert" aria-live="assertive">Enter Valid Code</span>
</th>
<th>
<label for="IPT_modifiers_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Modifiers</label>
</th>
<th>
<label *ngIf="!showError('chargeAmount')" for="IPT_chargeAmount_277submit_{{ manualForm.controls['linesFormArray']['controls'].length-1 }}">Charge Amount
<img *ngIf="!showError('chargeAmount')" id="IMG_required_277submit_20" src="./../../../assets/images/ic_asterisk_red_16px.svg"
alt="Required" title="Required">
</label>
<span class="error" *ngIf="showError('chargeAmount')" role="alert" aria-live="assertive">Enter Valid Amount</span>
</th>
<th style="width: 24px;"> </th>
</thead>
<tbody>
<ng-container formArrayName="linesFormArray" *ngFor="let item of manualForm.controls['linesFormArray']['controls']; let i= index;">
<ng-container [formGroupName]="i">
<tr>
<!-- Line Only -->
<td>
<input formControlName="serviceLine" id="IPT_serviceLine_277submit_{{ i }}" type="text" placeholder="Enter Line Number" [class.error-cell]="item['controls']['serviceLine'].touched && item['controls']['serviceLine'].invalid"
[tabindex]="tabIdx">
</td>
<td>
<input formControlName="lineServiceFrom" id="IPT_lineServiceFrom_277submit_{{ i }}" type="text" placeholder="Enter Date"
[class.error-cell]="item['controls']['lineServiceFrom'].touched && item['controls']['lineServiceFrom'].invalid"
[tabindex]="tabIdx">
</td>
<td>
<input formControlName="lineServiceTo" id="IPT_lineServiceTo_277submit_{{ i }}" type="text" placeholder="Enter Date" [class.error-cell]="item['controls']['lineServiceTo'].touched && item['controls']['lineServiceTo'].invalid"
[tabindex]="tabIdx">
</td>
<td>
<input formControlName="revenueCode" id="IPT_revenueCode_277submit_{{ i }}" type="text" placeholder="Enter Code" [class.error-cell]="item['controls']['revenueCode'].touched && item['controls']['revenueCode'].invalid"
[tabindex]="tabIdx">
</td>
<td>
<input formControlName="procedureCode" id="IPT_procedureCode_277submit_{{ i }}" type="text" placeholder="Enter Code" [class.error-cell]="item['controls']['procedureCode'].touched && item['controls']['procedureCode'].invalid"
[tabindex]="tabIdx">
</td>
<td>
<input formControlName="modifiers" id="IPT_modifiers_277submit_{{ i }}" type="text" placeholder="Enter Modifier" [tabindex]="tabIdx">
</td>
<td>
<input formControlName="chargeAmount" id="IPT_chargeAmount_277submit_{{ i }}" type="text" placeholder="Enter Amount" [class.error-cell]="item['controls']['chargeAmount'].touched && item['controls']['chargeAmount'].invalid"
[tabindex]="tabIdx">
</td>
<td style="width: 24px;">
<div class="remove" *ngIf="i>0" (click)="removeLineRow(i)" (keydown.enter)="removeLineRow(i)" title="Remove Service Line"
[tabindex]="tabIdx">×</div>
</td>
</tr>
</ng-container>
</ng-container>
</tbody>
</table>
</div>
<div class="row"></div>
<!-- Document-Code Section -->
<app-request-codes [resetForm]="resetChild" [levelCode]="pdiInfoModel.level" [healthCareClaimStatusCodes]="healthCareClaimStatusCodes"
[loincCodesLineLevel]="loincCodesLineLevel" [loincCodesClaimLevel]="loincCodesClaimLevel" [loincCodeModifiers]="loincCodeModifiers"
(notifyReset)="resetChild=$event" [lineIdArray]="manualLineIdArray" [tabbable]="errorModalClosed && warningModalClosed"
#manualCodes>
</app-request-codes>
<!-- Document-Code Section Ends -->
<div class="row bottom col two">
<button type="submit" class="button primary" id="BTN_submitRequest" [disabled]="disableSubmitInfo?disableSubmitInfo:(manualForm.invalid|| manualCodes.form.invalid)"
[class.disabled]="disableSubmitInfo?disableSubmitInfo:(manualForm.invalid|| manualCodes.form.invalid)"
[tabindex]="tabIdx">Submit RFAI</button>
<button type="button" (click)="onResetManual()" class="button secondary" id="BTN_resetManual_rfaiSubmission_1" [tabindex]="tabIdx">Reset Form</button>
</div>
<!-- Manual Entry form Ends here -->
</form>
</div>
</div>
</section>
</div>
</div>
<!-- Tab2 ends here -->
<div class="container" #populatedInfo>
<!-- Claim Prepoulation -->
<div class="row results">
<div class="col three">
<div class="card-head">
<h4>Claim {{ autoFormModel.claimId }} Information</h4>
</div>
</div>
<form [formGroup]="prepopulateForm" (ngSubmit)="onSubmitPrepopulated()">
<div class="row">
<div class="col one">
<!-- <label class="label text-field" for="responseDueDate">Response Due Date
<span class="info" *ngIf="prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').valid || !prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').touched">mm/dd/yyyy</span>
<img *ngIf="prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').valid || !prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').touched"
id="IMG_required_277submit_21" src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').invalid && prepopulateForm.controls['responseDueDateAutoCalendar'].get('responseDueDateAuto').touched"
role="alert" aria-live="assertive">Valid Future Date Required</span>
</label> -->
<app-calendar [monthId]="'SPN_currentMonth_4'" [required]="true" [label]="'Response Due Date'" [calendarTabIndex]="errorModalClosed && warningModalClosed?'0':'-1'"
[calendarId]="'responseDueDate'" [parentFormGroup]="prepopulateForm.controls['responseDueDateAutoCalendar']"
[parentControlName]="'responseDueDateAuto'" role="alert" aria-live="assertive"></app-calendar>
</div>
<div class="col one">
<label class="label text-field" for="IPT_contactInfo_277submit_1">Contact Information
<img *ngIf="prepopulateForm.get('contactInfo').valid || !prepopulateForm.get('contactInfo').touched" id="IMG_required_277submit_22"
src="./../../../assets/images/ic_asterisk_red_16px.svg" alt="Required" title="Required">
<span class="error" *ngIf="prepopulateForm.get('contactInfo').invalid && prepopulateForm.get('contactInfo').touched" role="alert"
aria-live="assertive">Enter Valid Email</span>
</label>
<input formControlName="contactInfo" type="text" placeholder="Enter Contact Info" id="IPT_contactInfo_277submit_1" name="contactInfo"
[(ngModel)]="autoFormModel.contactInformation" [tabindex]="tabIdx">
</div>
</div>
<div class="col three">
<div class="card low">
<table id="TBL_prePopDetail">
<tbody>
<tr>
<th>Payer Name</th>
<th>Payer ID</th>
<th>Payer Claim Control Number</th>
<th>Medical Record Number</th>
</tr>
<tr>
<td>{{prepopulatedInfo.payerName?prepopulatedInfo.payerName:'\u2013\u2013\u2013'}}</td>
<td>{{prepopulatedInfo.payerId?prepopulatedInfo.payerId:'\u2013\u2013\u2013' }}</td>
<td>{{prepopulatedInfo.payerClaimControlNumber?prepopulatedInfo.payerClaimControlNumber:'\u2013\u2013\u2013'}}</td>
<td>{{prepopulatedInfo.medicalRecordNumber?prepopulatedInfo.medicalRecordNumber:'\u2013\u2013\u2013' }}
</td>
</tr>
<tr>
<th>Billing Provider</th>
<th>Billing Provider NPI</th>
<th>Billing Provider TIN</th>
<th>Bill Type</th>
</tr>
<tr>
<td>{{prepopulatedInfo.providerInformation?prepopulatedInfo.providerInformation: '\u2013\u2013\u2013'}}
</td>
<td>{{ prepopulatedInfo.providerNpi?prepopulatedInfo.providerNpi: '\u2013\u2013\u2013' }}</td>
<td>{{ prepopulatedInfo.providerTin?prepopulatedInfo.providerTin: '\u2013\u2013\u2013' }}</td>
<td>{{ prepopulatedInfo.billType?prepopulatedInfo.billType:'\u2013\u2013\u2013'}}</td>
</tr>
<tr>
<th>Patient Last Name</th>
<th>Patient First Name</th>
<th>Patient Identifier</th>
<th>Patient Control Number</th>
</tr>
<tr>
<td>{{ prepopulatedInfo.patientLastname?prepopulatedInfo.patientLastname:'\u2013\u2013\u2013' }}</td>
<td>{{ prepopulatedInfo.patientFirstName?prepopulatedInfo.patientFirstName:'\u2013\u2013\u2013' }}</td>
<td>{{ prepopulatedInfo.patientIdentifier?prepopulatedInfo.patientIdentifier:'\u2013\u2013\u2013' }}
</td>
<td>{{ prepopulatedInfo.patientcontrolNumber?prepopulatedInfo.patientcontrolNumber:'\u2013\u2013\u2013'}}
</td>
</tr>
<tr>
<th>Information Receiver</th>
<th>Clearinghouse ID</th>
<th> </th>
<th> </th>
</tr>
<tr>
<td>{{ prepopulatedInfo.informationReceiver?prepopulatedInfo.informationReceiver:'\u2013\u2013\u2013' }}</td>
<td>{{ prepopulatedInfo.clearingHouseId?prepopulatedInfo.clearingHouseId:'\u2013\u2013\u2013'}}</td>
<td> </td>
<td> </td>
</tr>
<tr *ngIf="!prepopulatedInfo.rfaiLineItemResponse">
<th>Service From Date</th>
<th>Service To Date</th>
</tr>
<tr *ngIf="!prepopulatedInfo.rfaiLineItemResponse">
<td>{{ prepopulatedInfo.serviceFromDate }}</td>
<td>{{ prepopulatedInfo.serviceToDate }}</td>
</tr>
</tbody>
</table>
</div>
</div>
<div class="col three">
<h4 class="section-head">Service Line Information</h4>
</div>
<div class="row col three">
<table class="clean-table">
<thead>
<!-- Checkbox Not Needed <th>
<input type="checkBox" (click)="selectAll($event.target.checked)" id="selectAll " #selectAllLines>
</th> -->
<th>Service Line #</th>
<th>Svc. From</th>
<th>Svc. To</th>
<th>Revenue Code</th>
<th>Procedure Code</th>
<th>Modifiers</th>
<th>Charge Amount</th>
</thead>
<tbody>
<tr *ngFor="let line of prepopulatedInfo.rfaiLineItemResponse ">
<!-- Checkboxes Not Needed <td>
<input type="checkBox" [checked]="line.selected" (change)="line.selected = $event.target.checked">
</td> -->
<td>{{line.serviceLineId}}</td>
<td>{{line.serviceFrom}}</td>
<td>{{line.serviceTo}}</td>
<td>{{line.revenueCode}}</td>
<td>{{line.procedureCode}}</td>
<td>{{line.modifiers}}</td>
<td>{{line.chargeAmount | currency:'USD':true:'1.2-2'}}</td>
</tr>
</tbody>
</table>
<div class="row"></div>
</div>
<app-request-codes [levelCode]="prepopulatedInfo.level" [healthCareClaimStatusCodes]="healthCareClaimStatusCodes" [loincCodesLineLevel]="loincCodesLineLevel"
[loincCodesClaimLevel]="loincCodesClaimLevel" [loincCodeModifiers]="loincCodeModifiers" [lineIdArray]="prepopulatedLineIdArray"
#autoCodes [tabbable]="errorModalClosed && warningModalClosed"></app-request-codes>
<div class="row col three">
<button type="submit" class="button primary" id="BTN_submitRequest_277submit_1" [disabled]="disableSubmitInfo?disableSubmitInfo:(prepopulateForm.invalid || autoCodes.form.invalid)"
[class.disabled]="disableSubmitInfo?disableSubmitInfo:(prepopulateForm.invalid || autoCodes.form.invalid)" [tabindex]="tabIdx">Submit RFAI</button>
<button type="button" (click)="onResetPrepopulated()" class="button secondary" id="BTN_resetPrepopulated_277submit_1" [tabindex]="tabIdx">Reset Form</button>
</div>
</form>
</div>
</div>
</article>
<div class="container">
<app-modal (modalClosed)="closeErrorModal()" [hidden]="errorModalClosed" [tabIdx]="warningModalClosed? '0': '-1'">
<div class="results round-corners left-align error-modal">
<div class="row error-info">
<h3>Error</h3>
</div>
<div class="row"></div>
<p>
This PDI/Claim ID has missing information.
<br>A 277 Request cannot be submitted for this Claim/ PDI
</p>
<button class="button danger small" type="submit" id="BTN_Errormodel_RfaiSubmission_1" (click)="closeErrorModal()" [tabIndex]="warningModalClosed?'0':'-1'">Ok</button>
</div>
</app-modal>
</div>
<div class="container">
<app-modal (modalClosed)="closeWarningModal()" [hidden]="warningModalClosed" [tabIdx]="warningModalClosed? '-1': '0'">
<div class="results round-corners left-align info-modal">
<div class="row modal-info">
<h3>Attention</h3>
</div>
<div class="row"></div>
<p>
This PDI/Claim ID currently has a pending 277 RFAI.
<br>If you proceed, you will generate an additional request.
<br>Do you want to continue?
</p>
<button class="button primary small" type="submit" id="BTN_Attentionmodel_RfaiSubmission_1" (click)="closeWarningModal()"
[tabindex]="!warningModalClosed?'0':'-1'">Continue</button>
<button class="button secondary small" type="button" (click)="cancel()" [tabIndex]="!warningModalClosed?'0':'-1'">Cancel</button>
</div>
</app-modal>
</div>
</app-ars-base>
<!-- </div> -->