File: /home/imensosw/www/imenso.co/dev/transunion/Eligibility.html
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
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<title>Eligibility</title>
</head>
<body>
<div class="container p-4">
<div class="text-center">
<h2>Eligibility Verification</h2>
</div>
<div class="mt-3">
<div class="row mt-3">
<!-- <div class="col-4">
<label for="type">Type:</label><br>
<input class="form-control" placeholder="Type" type="text" id="type" name="type">
</div> -->
<div class="col-6">
<label for="firstName">First Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="First Name" type="text" id="firstName" name="firstName">
</div>
<div class="col-6">
<label for="lastName">Last Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Last Name" type="text" id="lastName" name="lastName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="dateOfBirth">Date of Birth</label><span class="text-danger"> *</span><br>
<input class="form-control" type="date" id="dateOfBirth" name="dateOfBirth">
</div>
<div class="col-6">
<label for="memberId">Member Id</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Member Id" type="text" id="memberId" name="memberId">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="serviceDate">Service Date</label><br>
<input class="form-control" type="date" id="serviceDate" name="serviceDate">
</div>
<div class="col-6">
<label for="payerId">Payer Id</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Payer Id" type="text" id="payerId" name="payerId">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="transactionId">Transaction Id</label><br>
<input class="form-control" placeholder="Transaction Id" type="text" id="transactionId" name="transactionId">
</div>
<div class="col-6">
<label for="npi">NPI</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="NPI" type="text" id="npi" name="npi">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="payerProviderId">Payer Provider Id</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Payer Provider Id" type="text" id="payerProviderId" name="payerProviderId">
</div>
<div class="col-6">
<label for="organizationName">Organization Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Organization Name" type="text" id="organizationName" name="organizationName">
</div>
</div>
<div class="row mt-3">
<div class="col-6">
<label for="receiverorganizationName">Receiver Organization Name</label><span class="text-danger"> *</span><br>
<input class="form-control" placeholder="Receiver Organization Name" type="text" id="receiverorganizationName" name="receiverorganizationName">
</div>
</div>
</div>
<div class="text-center mt-4">
<button type="button" class="btn btn-primary" id="submitButton" onclick="submitRequest()"> Submit </button>
</div>
<div id="responseDiv" class="mt-5" style="display: none;">
<h5>Response: </h5>
<div id="showResponse" class="mt-2">
</div>
</div>
</div>
</body>
</html>
<script type="text/javascript">
function submitRequest() {
//var type = $('#type').val();
var payerId = $('#payerId').val();
var organizationName = $('#organizationName').val();
var transactionId = $('#transactionId').val();
var serviceDate = $('#serviceDate').val();
var npi = $('#npi').val();
var payerProviderId = $('#payerProviderId').val();
var receiverorganizationName = $('#receiverorganizationName').val();
var lastName = $('#lastName').val();
var firstName = $('#firstName').val();
var memberId = $('#memberId').val();
var dateOfBirth = $('#dateOfBirth').val();
var eligibilityData = {
payerId : payerId,
organizationName : organizationName,
transactionId : transactionId,
serviceDate : serviceDate,
npi : npi,
payerProviderId : payerProviderId,
receiverorganizationName : receiverorganizationName,
lastName : lastName,
firstName : firstName,
memberId : memberId,
dateOfBirth : dateOfBirth
};
$.ajax({
type: "POST",
url: 'Eligibility.php',
data: eligibilityData,
success: function(response)
{
$("#showResponse").html(JSON.parse(response));
$("#responseDiv").css('display', 'block');
}
});
}
</script>