434 lines
25 KiB
PHP
Executable File
434 lines
25 KiB
PHP
Executable File
<form role="form" id="billGenerate" action="<?php echo base_url(); ?>generate_bill/storeBill" method="post" enctype="multipart/form-data" >
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<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
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<input type="hidden" name="patient_id" value="<?php if (!empty($patient->id)) echo $patient->id; ?>" readonly>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>CONTRACT INFO</h4></label>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1" class="required-field"><?php echo lang('Contract ID'); ?></label>
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<input type="text" class="form-control" name="" value='<?php
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if (!empty($patient->patient_id)) {
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echo $patient->patient_id;
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}
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?>' readonly>
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Contract Name'); ?></label>
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<input type="text" class="form-control" name="" id="exampleInputEmail1" value='<?php
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$name = $patient->first_name." ".$patient->last_name;
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if (!empty($name)) {
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echo $name;
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}
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?>' readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Contract Person'); ?></label>
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<input type="text" class="form-control" name="" id="exampleInputEmail1" value='<?php
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$name = $patient->first_name." ".$patient->last_name;
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if (!empty($name)) {
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echo $name;
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}
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?>' readonly>
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</div>
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<div class="form-group col-md-4">
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<label ><?php echo lang('Address'); ?></label>
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<input type="text" class="form-control" name="" value='<?php
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$address = json_decode($patient->address);
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if (!empty($address)) {
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echo($address->address.",".$address->Apartment.",".$address->City.",".$address->State.",".$address->Zipcode.",".$address->County);
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}
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?>' placeholder="" readonly>
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</div>
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<div class="form-group col-md-4">
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<label ><?php echo lang('Telephone'); ?></label>
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<input type="text" class="form-control" value='<?php
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if (!empty($patient->telephone)) {
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echo $patient->telephone;
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}
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?>' placeholder="" readonly>
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</div>
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<div class="form-group col-md-4">
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<label ><?php echo lang('Other Telephone'); ?></label>
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<input type="text" class="form-control" value='<?php
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if (!empty($patient->other_no)) {
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echo $patient->other_no;
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}
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?>' placeholder="" readonly>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-4">
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<label ><?php echo lang('Fax Number'); ?></label>
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<input type="text" class="form-control" name="fax_no" >
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<section class="col-md-12 fax_no"></section>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Email'); ?></label>
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<input type="text" class="form-control" value='<?php
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if (!empty($patient->patient_email)) {
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echo $patient->patient_email;
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}
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?>' readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Web Address'); ?></label>
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<input type="text" class="form-control" name="web_address" value="">
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Ein Number'); ?></label>
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<input type="text" class="form-control" name="ein" value='<?php
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if (!empty($patient->ein)) {
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echo $patient->ein;
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}
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?>' readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('NPI Number'); ?></label>
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<input type="text" class="form-control" name="npi" value="<?php
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if (!empty($patient->primaryCarePhyMdNpi)) {
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echo $patient->primaryCarePhyMdNpi;
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}
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?>" readonly>
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</div>
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<div class="form-group col-md-4">
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<label class="required-field"><?php echo lang('Contract Type/Payer Type'); ?></label>
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<select class="form-control" name="payer_type">
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<?php foreach ($payerTypes as $payerType) { ?>
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<option value="<?php echo $payerType->id;?>" <?php if (!empty($patient->payer_type)) { if ($patient->payer_type == $payerType->id) { echo 'selected'; } } ?>><?php echo $payerType->name;?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Level of Service'); ?></label>
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<select class="form-control" readonly>
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<option value="<?= $patient->level_service ?>"><?= $patient->patient_level_service ?></option>
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</select>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1" class="required-field"><?php echo lang('Start Date'); ?></label>
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<input type="date" class="form-control futDateNonAccept" name="start_date" value="<?php
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if (!empty($patient->start_date)) {
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echo $patient->start_date;
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}
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?>" readonly>
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</div>
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<div class="form-group col-md-4">
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<label class="required-field"><?php echo lang('Expiration Date'); ?></label>
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<input type="date" class="form-control " name="end_date" value="<?php
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if (!empty($patient->end_date)) {
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echo $patient->end_date;
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}
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?>" readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Contract Status'); ?></label>
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<select class="form-control" name="contract_status" id="contract_status" onchange="getActiveOption();">
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<option value="">Select</option>
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<option value="1" <?php if (!empty($patient->insurance_auth_stat)) {
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if ($patient->insurance_auth_stat == 1) {
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echo 'selected';
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}
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} ?>>Active</option>
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<option value="0"<?php if (!empty($patient->insurance_auth_stat)) {
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if ($patient->insurance_auth_stat == 0) {
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echo 'selected';
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}
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} ?>>Inactive</option>
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</select>
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</div>
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<div class="form-group col-md-4" id="contract_status_type">
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Location'); ?></label>
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<input type="text" class="form-control" name="location" value="<?php
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if (!empty($patient->location)) {
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echo $patient->location;
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}
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?>" readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('ICD Code '); ?></label>
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<input type="text" class="form-control" name="icd" id="exampleInputEmail1" value='' >
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Authorization Required ? '); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="authorization_required" id="authorization_requiredYES" value="1" <?php if ($patient->patient_auth_stat==1) {
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echo "checked"; } ?> >
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<label class="form-check-label" for="authorization_requiredYES">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="authorization_required" id="authorization_requiredNO" value="0" <?php if ($patient->patient_auth_stat==0) {
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echo "checked"; } ?> >
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<label class="form-check-label" for="authorization_requiredNO">No</label>
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</div>
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</div>
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</div>
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<div class="row col-12">
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<!-- <div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Authorization Required ? '); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="authorization_required" id="authorization_requiredYES" value="1" >
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<label class="form-check-label" for="authorization_requiredYES">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="authorization_required" id="authorization_requiredNO" value="0" checked>
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<label class="form-check-label" for="authorization_requiredNO">No</label>
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</div>
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</div> -->
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<!-- <div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Wage Parity ?'); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="wage_parity" id="wage_parityYES" value="1" >
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<label class="form-check-label" for="wage_parityYES">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="wage_parity" id="wage_parityNO" value="0" checked>
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<label class="form-check-label" for="wage_parityNO">No</label>
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</div>
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</div> -->
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</div>
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<div class="row">
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<div class="form-group col-md-12">
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<label for="exampleInputEmail1"><?php echo lang('Notes'); ?></label>
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<input type="text" class="form-control" name="note"value="" placeholder="">
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</div>
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</div>
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<hr>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>COMPLIANCE REQUIREMENTS</h4></label>
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</div>
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('PLAN OF CARE COMPLIANCE'); ?></label>
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<select class="form-control" name="plan_of_care">
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<option value="1">Contract Compliance</option>
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<option value="2">Personal Care Compliance</option>
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<option value="3">No Compliance</option>
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<option value="4">Patient Plan of Care Compliance</option>
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<option value="5">-Long Term Care Compliance</option>
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</select>
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</div>
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Wage Parity'); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="compliance_wage_parity" id="compliance_wage_parityYES" value="1" >
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<label class="form-check-label" for="compliance_wage_parityYES">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="compliance_wage_parity" id="compliance_wage_parityNO" value="0" checked>
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<label class="form-check-label" for="compliance_wage_parityNO">No</label>
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</div>
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</div>
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</div>
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</div>
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<hr>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>BILLING RATES</h4></label>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Service Procedure Type/Service Activity Code'); ?></label>
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<select class="form-control" name="service_code">
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<?php if($patient->level_service == 4){ ?>
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<option value="1">S9123-RN Nursing</option>
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<option value="2">Hourly Visit</option>
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<option value="3">T1030-Nursing RN Per Diem</option>
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<option value="4">Additional Hourly Visit</option>
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<option value="5">Initial Assessment</option>
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<option value="6">Assessment</option>
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<option value="7">Midline Placement</option>
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<option value="8">Infusion</option>
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<?php } else if($patient->level_service == 5){ ?>
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<option value="1">S9124-LPN Nursing</option>
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<option value="2">Hourly Visit</option>
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<option value="3">Wound Care Visits</option>
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<?php } else if($patient->level_service == 6 || $patient->level_service == 7 ){ ?>
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<option value="1">T1019-HHA/PCA Personal Care Service</option>
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<option value="2">Housekeeping</option>
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<option value="3">Live-In Vist</option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Billing Units'); ?></label>
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<input type="text" class="form-control" name="bill_units" value="<?= $bill_units ?>" readonly>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Billing Period Start Date'); ?></label>
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<input type="date" class="form-control futDateNonAccept" name="billing_start" value="<?= $patient->minDate->date ?>" >
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Billing Period End Date'); ?></label>
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<input type="date" class="form-control futDateNonAccept" name="billing_end" value="<?= $patient->maxDate->date ?>" >
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Rate Type'); ?></label>
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<select class="form-control" name="rate_type">
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<option value="1">Visit</option>
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<option value="2">Hourly</option>
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<option value="3">Daily</option>
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</select>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1" class="required-field"><?php echo lang('Rate($)'); ?></label>
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<input type="number" class="form-control" name="rate" value="" required>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Rate Status'); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="rate_status" id="rate_statusYES" value="1" >
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<label class="form-check-label" for="rate_statusYES">Active</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="rate_status" id="rate_statusNO" value="0" checked >
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<label class="form-check-label" for="rate_statusNO">Inactive</label>
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</div>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Payment Terms'); ?></label>
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<select class="form-control" name="payment_terms">
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<option value="1">Net 30</option>
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<option value="2">Net 60</option>
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<option value="3">Weekly</option>
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<option value="4">Bi-Weekly</option>
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<option value="5">Hourly</option>
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<option value="6">Daily</option>
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</select>
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</div>
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<div class="form-group col-md-4">
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<label for="exampleInputEmail1"><?php echo lang('Contract Discounts'); ?></label>
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<input type="number" class="form-control" name="contract_discounts" value="">
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</div>
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</div>
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<hr>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>VERIFY ELIGIBILITY</h4></label>
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</div>
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Eligibility Check'); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="eligibility_check" id="eligibility_checkEnable" value="1" >
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<label class="form-check-label" for="eligibility_checkEnable" >Enable</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="eligibility_check"id="eligibility_checkdisable" value="0" checked>
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<label class="form-check-label" for="eligibility_checkdisable">Disable</label>
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</div>
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</div>
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Specific Eligiblity Check Dates'); ?></label>
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<input type="date" class="form-control futDateNonAccept" name="eligibility_date" value='<?php
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?>' >
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</div>
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</div>
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<hr>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>THIRD PARTY CONNECTIVITY</h4></label>
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</div>
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<div class="form-group col-md-6">
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<label for="exampleInputEmail1"><?php echo lang('Third Party Connectivity'); ?></label><br>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="third_party" id="third_party1" value="1" >
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<label class="form-check-label" for="third_party1" >Enable</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" name="third_party" id="third_party0" value="0" checked>
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<label class="form-check-label" for="third_party0">Disable</label>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-md-12">
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<label><h4>FILES/NOTES UPLOADS</h4></label>
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</div>
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<div class="form-group col-md-6">
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<label ><?php echo lang('FILES/NOTES UPLOADS (gif/jpg/png/jpeg/pdf)'); ?></label>
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<input type="file" class="form-control" name="uploads" allowedType="gif|jpg|png|jpeg|pdf">
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</div>
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</div>
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<div class="form-group col-md-12">
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<button type="submit" onClick="return validateForm()" name="submit" class="btn btn-info" <?php if($nurse->form_status==2) echo 'disabled'; ?> ><?php echo lang('submit'); ?></button>
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</div>
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</div>
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</form>
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<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
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<script>
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function validateForm() {
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// var end_date = document.forms["billGenerate"]["end_date"].value;
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// var fax_no = document.forms["billGenerate"]["fax_no"].value;
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// var payer_type = document.forms["billGenerate"]["payer_type"].value;
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// if (end_date == "" || fax_no == "" || payer_type == "") {
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// if (end_date == "") {
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// $(".end_date").html("<div class='alert alert-danger' role='alert'> Please enter a value</div>");
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// }
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// if (fax_no == "") {
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// $(".fax_no").html("<div class='alert alert-danger' role='alert'> Please enter a value</div>");
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// //return false;
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// }
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// if (payer_type == "") {
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// $(".payer_type").html("<div class='alert alert-danger' role='alert'> Please enter a value</div>");
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// }
|
|
// return false;
|
|
// }
|
|
// else{
|
|
// return true;
|
|
// }
|
|
return true;
|
|
}
|
|
$(document).ready(function () {
|
|
var todaysDate = new Date();
|
|
var year = todaysDate.getFullYear(); // YYYY
|
|
var month = ("0" + (todaysDate.getMonth() + 1)).slice(-2); // MM
|
|
var day = ("0" + todaysDate.getDate()).slice(-2); // DD
|
|
var maxDate = (year +"-"+ month +"-"+ day); // Results in "YYYY-MM-DD" for today's date
|
|
|
|
$('.futDateNonAccept').attr('max',maxDate);
|
|
|
|
});
|
|
function getActiveOption(){
|
|
var contract_status=$('#contract_status').val();
|
|
var option='<label for="exampleInputEmail1">Type</label>'
|
|
+'<select class="form-control" name="contract_status_type">'
|
|
+' <option value="1">Net 30</option>'
|
|
+' <option value="2">Net 60</option>'
|
|
+' <option value="3">Weekly</option>'
|
|
+' <option value="4">Bi-Weekly</option>'
|
|
+' <option value="5">Hourly</option>'
|
|
+' <option value="6">Daily</option>'
|
|
+'</select>';
|
|
if(contract_status=='Active'){
|
|
$('#contract_status_type').html(option);
|
|
}else{
|
|
$('#contract_status_type').html('');
|
|
}
|
|
|
|
}
|
|
</script>
|