src/applications/ivc-champva/10-7959a/chapters/claimInformation.js
import React from 'react';
import {
titleUI,
titleSchema,
radioUI,
radioSchema,
yesNoUI,
yesNoSchema,
} from 'platform/forms-system/src/js/web-component-patterns';
import { fileUploadUi as fileUploadUI } from '../../shared/components/fileUploads/upload';
import { fileUploadBlurbCustom } from '../../shared/components/fileUploads/attachments';
import { nameWording } from '../../shared/utilities';
import FileFieldCustom from '../../shared/components/fileUploads/FileUpload';
import { blankSchema } from './sponsorInformation';
// Wrap shared fileFieldCustom so we can pass the form-specific
// list of required uploads (for use with MissingFileOverview)
function FileFieldWrapped(props) {
return FileFieldCustom({ ...props, requiredFiles: [] });
}
const additionalNotesClaims = (
<va-additional-info
trigger="Additional notes regarding claims"
class="vads-u-margin-bottom--4"
>
<ul>
<li>
You must file your claim within 1 year of when you got the care. And if
you stayed at a hospital for care, you must file your claim within 1
year of when you left the hospital.
</li>
<li>Please retain a copy of all documents submitted to CHAMPVA.</li>
</ul>
</va-additional-info>
);
export const claimTypeSchema = {
uiSchema: {
...titleUI('Claim type'),
claimType: radioUI({
title: 'What type of claim are you submitting?',
labels: {
medical: 'I’m submitting a claim for medical care from a provider',
pharmacy: 'I’m submitting a claim for prescription medications',
},
}),
},
schema: {
type: 'object',
required: ['claimType'],
properties: {
titleSchema,
claimType: radioSchema(['medical', 'pharmacy']),
},
},
};
export const claimWorkSchema = {
uiSchema: {
...titleUI('Claim relation to work'),
claimIsWorkRelated: yesNoUI({
title: 'Is this a claim for a work-related injury or condition?',
updateUiSchema: formData => {
return {
'ui:options': {
hint: `Depending on your answer, we may contact ${nameWording(
formData,
true,
false,
true,
)} workers’ compensation insurance provider to determine if they paid any amount for this care.`,
},
};
},
}),
},
schema: {
type: 'object',
required: ['claimIsWorkRelated'],
properties: {
titleSchema,
claimIsWorkRelated: yesNoSchema,
},
},
};
export const claimAutoSchema = {
uiSchema: {
...titleUI('Claim relation to an auto-related accident'),
claimIsAutoRelated: yesNoUI({
title:
'Is this a claim for an injury or condition caused by an auto-related accident?',
updateUiSchema: formData => {
return {
'ui:options': {
hint: `Depending on your answer, we may contact ${nameWording(
formData,
true,
false,
true,
)} auto insurance provider to determine if they paid any amount for this care.`,
},
};
},
}),
},
schema: {
type: 'object',
required: ['claimIsAutoRelated'],
properties: {
titleSchema,
claimIsAutoRelated: yesNoSchema,
},
},
};
export const medicalClaimUploadSchema = {
CustomPage: FileFieldWrapped,
CustomPageReview: null,
uiSchema: {
...titleUI('Upload supporting documents', ({ formData }) => (
<>
You’ll need to submit a copy of an itemized billing statement for this
claim.
<br />
<p>
<b>Documentation must include all of this information:</b>
</p>
<ul>
<li>
{nameWording(formData, true, true, true)} full name, date of birth,
and Social Security Number.
</li>
<li>
{nameWording(formData, true, true, true)} provider’s full name,
medical title, office address, billing address, and tax
identification number.
</li>
<li>
A list of diagnosis and procedure codes for the care. This includes
DX, CPT, or HCPS codes.
</li>
<li>
A list of charges for {nameWording(formData, true, false, true)}{' '}
care, and the dates when {nameWording(formData, false, false, true)}{' '}
got the care.
</li>
</ul>
<p>
<b>Note:</b>
You may need to ask your provider for a statement that has all
of the information listed here. The statement must include all of this
information in order for us to process this claim.
<br />
<br />
You can also submit any other documents you think may be relevant to
this claim.
</p>
</>
)),
...fileUploadBlurbCustom(null, additionalNotesClaims),
medicalUpload: fileUploadUI({
label: 'Upload supporting document',
attachmentName: true,
}),
},
schema: {
type: 'object',
required: ['medicalUpload'],
properties: {
titleSchema,
'view:fileUploadBlurb': blankSchema,
medicalUpload: {
type: 'array',
minItems: 1,
items: {
type: 'object',
properties: {
name: {
type: 'string',
},
},
},
},
},
},
};
export const eobUploadSchema = isPrimary => {
const keyName = isPrimary ? 'primaryEob' : 'secondaryEob';
return {
CustomPage: FileFieldWrapped,
CustomPageReview: null,
uiSchema: {
...titleUI(
({ formData }) => {
// If `isPrimary`, show first health insurance co. name. Else, show 2nd.
return `Upload explanation of benefits from ${
formData?.policies?.[isPrimary ? 0 : 1]?.name
}`;
},
({ formData }) => {
const name = nameWording(formData, true, false, true);
const yourOrTheir = name.toLowerCase() === 'your' ? name : 'their';
return (
<>
You’ll need to submit a copy of the explanation of benefits from{' '}
{name} insurance provider. This document lists what {yourOrTheir}{' '}
other health insurance already paid for {yourOrTheir} care.
<br />
<p>
<b>
The explanation of benefits must include all of this
information:
</b>
</p>
<ul>
<li>Date of service that matches the date of care.</li>
<li>The health care provider’s name.</li>
<li>What the insurance provider paid for and the amount.</li>
<li>NPI codes. This is usually a 10-digit number.</li>
<li>CPT codes. This is usually a 5-digit code.</li>
</ul>
<p>
<b>Note:</b>
An explanation of benefits is usually sent by mail or
email. Contact {name} insurance provider if you have more
questions about where to find this document.
<br />
<br />
You can also submit any other documents you think may be
relevant to this claim.
</p>
</>
);
},
),
...fileUploadBlurbCustom(undefined, additionalNotesClaims),
[keyName]: fileUploadUI({
label: 'Upload explanation of benefits',
attachmentName: true,
}),
},
schema: {
type: 'object',
required: [keyName],
properties: {
titleSchema,
'view:fileUploadBlurb': blankSchema,
[keyName]: {
type: 'array',
minItems: 1,
items: {
type: 'object',
properties: {
name: {
type: 'string',
},
},
},
},
},
},
};
};
// TODO: Pharmacy upload page
export const pharmacyClaimUploadSchema = {
CustomPage: FileFieldWrapped,
CustomPageReview: null,
uiSchema: {
...titleUI(
'Upload supporting document for prescription claim',
<>
You’ll need to submit a copy of a document from the pharmacy with
information about the prescription medication.
<br />
<p>
<b>Here’s what the document must include:</b>
</p>
<ul>
<li>Name, address, and phone number of the pharmacy.</li>
<li>Name, dosage, strength, and quantity of the medication.</li>
<li>Cost of the medication and the copay amount.</li>
<li>
National Drug Code (NDC) for each medication. This is an 11-digit
number that’s different froom the Rx number.
</li>
<li>Date the pharmacy filled the prescription.</li>
<li>Name of the provider who wrote the prescription.</li>
</ul>
<p>
<b>Note:</b>
The papers attached to the medication usually include this
information. Or you can ask the pharmacy to print a document with this
information.
<br />
<br />
You can also submit any other documents you think may be relevant to
this claim.
</p>
</>,
),
...fileUploadBlurbCustom(null, additionalNotesClaims),
pharmacyUpload: fileUploadUI({
label: 'Upload supporting document',
attachmentName: true,
}),
},
schema: {
type: 'object',
required: ['pharmacyUpload'],
properties: {
titleSchema,
'view:fileUploadBlurb': blankSchema,
pharmacyUpload: {
type: 'array',
minItems: 1,
items: {
type: 'object',
properties: {
name: {
type: 'string',
},
},
},
},
},
},
};