<?php
/**
 * Britam Pre-Authorization Form
 * Based on: BRITAM CLAIM FORM New.pdf
 */

// Prevent direct access
if (!defined('PREAUTH_FORM_INCLUDE')) {
    exit('Direct access not allowed');
}
?>

<div class="form-section insurer-specific-section" id="briFormFields">
    <div class="form-section-title">
        <i class="ri-shield-check-line"></i> Britam Pre-Authorization Details
    </div>

    <!-- Member & Policy Details -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0"><i class="ri-user-follow-line me-2"></i>Member / Policy Information</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Patient's Relationship to Principal</label>
                        <select class="form-select" name="preauth_data[relationship]" required>
                            <option value="">Select Relationship</option>
                            <option value="Self">Self (Principal)</option>
                            <option value="Spouse">Spouse</option>
                            <option value="Son">Son</option>
                            <option value="Daughter">Daughter</option>
                        </select>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Employer Name / Scheme</label>
                        <input type="text" class="form-control" name="preauth_data[employer_name]"
                            placeholder="e.g. Kenya Power, Teachers Service Commission">
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Medical / Clinical Information -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0"><i class="ri-stethoscope-line me-2"></i>Medical Information</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-12">
                    <div class="mb-3">
                        <label class="form-label">Presenting Complaints / History of Illness</label>
                        <textarea class="form-control" name="preauth_data[clinical_history]" rows="3" required
                            placeholder="Describe the onset, duration and symptoms"></textarea>
                    </div>
                </div>
            </div>
            <div class="row">
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Diagnosis</label>
                        <textarea class="form-control" name="preauth_data[diagnosis_details]" rows="2"
                            placeholder="Provisional or Definitive Diagnosis"></textarea>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="mb-3">
                        <label class="form-label">Investigative Results</label>
                        <textarea class="form-control" name="preauth_data[investigations]" rows="2"
                            placeholder="Pertinent Lab/X-ray results"></textarea>
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Admission Details -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0"><i class="ri-hospital-line me-2"></i>Admission / Procedures</h6>
        </div>
        <div class="card-body">
            <div class="row">
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Room Category</label>
                        <select class="form-select" name="preauth_data[room_type]">
                            <option value="General Ward">General Ward</option>
                            <option value="Standard Private">Standard Private</option>
                            <option value="Ensuite">Ensuite</option>
                            <option value="HDU/ICU">HDU / ICU</option>
                        </select>
                    </div>
                </div>
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Estimated Length of Stay (Days)</label>
                        <input type="number" class="form-control" name="preauth_data[expected_stay]" min="1"
                            placeholder="e.g. 3">
                    </div>
                </div>
                <div class="col-md-4">
                    <div class="mb-3">
                        <label class="form-label">Admission Date</label>
                        <input type="date" class="form-control" name="preauth_data[admission_date]"
                            value="<?php echo date('Y-m-d'); ?>">
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Professional Fees & Costs -->
    <div class="card mb-4">
        <div class="card-header bg-light">
            <h6 class="mb-0"><i class="ri-money-dollar-circle-line me-2"></i>Estimated Cost Breakdown (KES)</h6>
        </div>
        <div class="card-body">
            <div class="row g-3">
                <div class="col-md-3">
                    <label class="form-label text-muted small">Surgeon's Fee</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[surgeon_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Anaesthetist's Fee</label>
                    <input type="number" step="0.01" class="form-control fee-input"
                        name="preauth_data[anaesthetist_fee]" placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Ward/Bed Charges</label>
                    <input type="number" step="0.01" class="form-control fee-input"
                        name="preauth_data[accommodation_fee]" placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Theatre Charges</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[theatre_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Pharmacy/Drugs</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[pharmacy_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-3">
                    <label class="form-label text-muted small">Lab/Radiology</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[lab_fee]"
                        placeholder="0.00">
                </div>
                <div class="col-md-6">
                    <label class="form-label text-muted small">Other Expenses</label>
                    <input type="number" step="0.01" class="form-control fee-input" name="preauth_data[other_fees]"
                        placeholder="0.00">
                </div>
            </div>
            <div class="row mt-4 pt-3 border-top">
                <div class="col-md-6 offset-md-6">
                    <div class="d-flex justify-content-between align-items-center">
                        <h5 class="mb-0">Total Estimated Cost:</h5>
                        <h4 class="mb-0 text-primary" id="briTotalDisplay">KES 0.00</h4>
                        <input type="hidden" name="preauth_data[total_breakdown]" id="briTotal">
                    </div>
                </div>
            </div>
        </div>
    </div>

    <!-- Declaration -->
    <div class="card mb-4 mb-4">
        <div class="card-body bg-light rounded">
            <div class="form-check">
                <input class="form-check-input" type="checkbox" name="preauth_data[declaration]" id="declCheck"
                    required>
                <label class="form-check-label" for="declCheck">
                    <strong>Medical Provider Declaration:</strong> I hereby certify that the treatment specified above
                    is medically necessary and appropriate.
                    I understand that authorization is not a guarantee of payment.
                </label>
            </div>
        </div>
    </div>
</div>

<script>
    document.addEventListener('DOMContentLoaded', function () {
        const feeInputs = document.querySelectorAll('#briFormFields .fee-input');
        const totalDisplay = document.getElementById('briTotalDisplay');
        const totalInput = document.getElementById('briTotal');

        function calculateTotal() {
            let total = 0;
            feeInputs.forEach(input => {
                total += parseFloat(input.value) || 0;
            });

            totalDisplay.textContent = 'KES ' + total.toLocaleString('en-US', { minimumFractionDigits: 2, maximumFractionDigits: 2 });
            totalInput.value = total.toFixed(2);

            const mainCostInput = document.querySelector('input[name="estimated_cost"]');
            if (mainCostInput && (mainCostInput.value === '' || mainCostInput.value == 0)) {
                mainCostInput.value = total.toFixed(2);
                mainCostInput.dispatchEvent(new Event('input'));
            }
        }

        feeInputs.forEach(input => {
            input.addEventListener('input', calculateTotal);
        });
    });
</script>