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>
<div class="container">
<div class="row"></div>
<div class="row results">
<div>
<h4 class="float-left" id="subtitleone">Submission Details</h4>
<div class="icon-function">
<!-- <div>
<label for="print" id="printLabel">Print 277 RFAI</label>
<img title="Print 277 RFAI" id="print" name="print" src="../../assets/images/ic_print_blue_24.svg"
appAutofocus [tabindex]="tabIdx" [class.disabled]="disablePrint" (click)="print()" (keydown.enter)="print()">
</div> -->
<div *ngIf="showUpdate">
<label for="update" id="updateLabel">Update 277 RFAI</label>
<img title="Update 277 RFAI" id="update" name="update" src="../../assets/images/ic_edit_table_blue_24.svg"
[tabindex]="tabIdx" [class.disabled]="disableUpdate" (click)="update()" (keydown.enter)="update()">
</div>
<div *ngIf="!showUpdate">
<label for="save" id="saveLabel">Save/Cancel Update</label>
<img title="Save/Cancel Update" id="save" name="save" src="../../assets/images/ic_edit_table_blue_24.svg"
[tabindex]="tabIdx" (click)="onModalOpen()" (keydown.enter)="onModalOpen()">
</div>
</div>
</div>

<form [formGroup]="form" (ngSubmit)="saveUpdates()" novalidate>
<div class="row col three">
<div class="card low">
<table>
<tbody>
<tr>
<th>PDI or Claim ID</th>
<th>RFAI Status</th>
<th>RFAI Submission Date</th>
<th>Response Due Date</th>
</tr>
<tr>
<td>{{model.claimId || dummy}}</td>
<td>
<ng-container *ngIf="hideRfaiStatusDropDown || showUpdate">
{{model.rfaiStatus || dummy }}
</ng-container>
<ng-container *ngIf="!hideRfaiStatusDropDown && !showUpdate">
<select id="status" name="status" [(ngModel)]="updateRequest.submissionStatus" formControlName="status"
appAutofocus [tabindex]="tabIdx">
<!-- <option value="" selected>Select RFAI Status</option> -->
<option *ngFor="let rfaiStatusValue of rfaiStatusValues" [value]="rfaiStatusValue">{{rfaiStatusValue}}</option>
</select>
</ng-container>
</td>
<td>{{model.rfaiSubmissionDate || dummy}}</td>
<td>
<ng-container *ngIf="showUpdate">
{{model.responseDate}}
</ng-container>
<ng-container *ngIf="!showUpdate">
<input type="text" id="responseDate" name="responseDate" [(ngModel)]="updateRequest.responseDate"
formControlName="responseDate" [tabindex]="tabIdx">
</ng-container>
</td>
</tr>
<tr>
<th>Payer Name</th>
<th>Payer ID</th>
<th>Payer Claim Control Number</th>
<th>Contact Information</th>
</tr>
<tr>
<td>{{model.payerName || dummy}}</td>
<td>{{model.payerId || dummy}}</td>
<td>{{model.payerClaimControlNumber || dummy}}</td>
<td>{{model.contactInfo || dummy}}</td>
</tr>
<tr>
<th>Billing Provider</th>
<th>Billing Provider NPI</th>
<th>Billing Provider TIN</th>
<th>Submitted By</th>
</tr>
<tr>
<td>{{model.billingProvider || dummy}}</td>
<td>{{model.providerNpi || dummy}}</td>
<td>{{model.providerTin || dummy}}</td>
<td>{{model.submittedBy || dummy}}</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>{{model.patientLastname || dummy}}</td>
<td>{{model.patientFirstName || dummy}}</td>
<td>{{model.patientIdentifier || dummy}}</td>
<td>{{model.patientcontrolNumber || dummy}}</td>
</tr>
<tr>
<th>Information Receiver</th>
<th>Bill Type</th>
<th>Clearinghouse ID</th>
<th>Medical Record Number</th>
</tr>
<tr>
<td>{{model.informationReceiver || dummy}}</td>
<td>{{model.billType || dummy}}</td>
<td>{{model.clearingHouseId || dummy}}</td>
<td>{{model.medicalRecordNumber || dummy}}</td>
</tr>
<tr>
<th>Service From</th>
<th>Service To</th>
</tr>

<tr>
<td>{{model.serviceFromDate || dummy }}</td>
<td>{{model.serviceToDate || dummy}}</td>
</tr>
</tbody>
</table>
</div>
</div>
<div class="col three">
<h4 id="subtitletwo">Attachments Requested</h4>
<div class="row col three">
<table class="clean-table">
<thead>
<tr>
<th>HCCS Category Code</th>
<th>LOINC Code</th>
<th>LOINC Modifier1</th>
<th>LOINC Modifier2</th>
<th>Level</th>
<th>Service Line</th>
<th>Attachment(s)</th>
</tr>
</thead>
<tbody>
<tr *ngFor="let attachment of attachments">
<td>{{attachment.statusCode || dummy}}</td>
<td>{{attachment.loincCodes || dummy}}</td>
<td>{{attachment.loincModCodes1 || dummy}}</td>
<td>{{attachment.loincModCodes2 || dummy}}</td>
<td>{{attachment.claimLevel || dummy}}</td>
<td>{{attachment.serviceLine || dummy}}</td>
<td>
<ng-container *ngIf="showUpdate">
{{attachment.attachments || dummy}}
</ng-container>
<ng-container *ngIf="!showUpdate">
<input type="text" (change)="attachment.attachments=$event.target.value" [tabindex]="tabIdx">
</ng-container>
</td>
</tr>
</tbody>
</table>
<div class="row"></div>
</div>
</div>
</form>
<div class="col three">
<h4 class="section-head" id="subtitlethree">Affected Service Lines</h4>
</div>
<div class="row col three">
<table class="clean-table">
<thead>
<tr>
<th>Service Line</th>
<th>Service From</th>
<th>Service To</th>
<th>Revenue Code</th>
<th>Procedure Code</th>
<th>Modifiers</th>
<th>Charge Amount</th>
</tr>
</thead>
<tbody>
<tr *ngFor="let line of lines">
<td>{{line.serviceLineId || dummy}}</td>
<td>{{line.serviceFrom || dummy}}</td>
<td>{{line.serviceTo || dummy}}</td>
<td>{{line.revenueCode || dummy}}</td>
<td>{{line.procedureCode || dummy}}</td>
<td>{{line.modifiers || dummy}}</td>
<td>{{line.chargeAmount? (line.chargeAmount| currency:'USD':true:'1.2-2'):dummy}}</td>
</tr>
</tbody>
</table>
<div class="row"></div>
</div>
<div class="col three">
<h4 class="section-head" id="subtitlefour">Related 277 RFAIs</h4>
</div>
<div class="row col three">
<app-table [columns]="tableColumns" [loading]="loading" [rows]="relatedRFAIs" [paginationSettings]="paginationSettings"
[tableSettings]=tableSettings></app-table>
</div>
<!-- <div class="col three">
<h4 class="section-head">Record Updated</h4>
<table class="clean-table">
<thead>
<tr>
<th>Date</th>
<th>User</th>
<th>Notes</th>
</tr>
</thead>
<tbody>
<tr>
<td>01/01/2018</td>
<td>VHAUSERNAME</td>
<td>Lorem ipsum dolor sit amet consequetor e pluripus unum.</td>
</tr>
</tbody>
</table>
</div> -->
</div>
</div>
</article>
<!-- Modal for Notes -->
<app-modal (modalClosed)="onModalClose($event)" [hidden]="modalClosed">
<div class="results round-corners">
<div class="left-align">
<h4>
Update Comments</h4>
</div>
<div class="left-align">
<label class="label text-field" for="codeDescription">Comments
<span class="required" *ngIf="!modalError">Required</span>
<span class="error" role="alert" aria-live="assertive" *ngIf="modalError">Enter a Valid Comment</span>
</label>

<textarea rows="3" name="notes" placeholder="Please enter comments regarding your update." [(ngModel)]="updateRequest.submissionNote"></textarea>
<button class="button primary small" type="submit" (click)="saveUpdates()">Save</button>
<button class="button secondary small" type="button" (click)="cancelModal()">Cancel</button>

</div>
</div>
</app-modal>
</app-ars-base>
<!-- </div> -->