167 lines
7.3 KiB
HTML
167 lines
7.3 KiB
HTML
{% extends "base.html" %}
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{% load i18n static %}
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{% block title %}
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{% if form.instance.pk %}
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{% trans "Edit Payer Contract" %}
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{% else %}
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{% trans "New Payer Contract" %}
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{% endif %} - {{ block.super }}
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{% endblock %}
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{% block content %}
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<div class="container-fluid">
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<div class="d-flex justify-content-between align-items-center mb-4">
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<h1 class="h3 mb-0">
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<i class="fa fa-handshake me-2"></i>
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{% if form.instance.pk %}
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{% trans "Edit Payer Contract" %}
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{% else %}
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{% trans "New Payer Contract" %}
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{% endif %}
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</h1>
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<a href="{% url 'integrations:payer-list' %}" class="btn btn-secondary">
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<i class="fa fa-arrow-left me-1"></i>{% trans "Back to List" %}
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</a>
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</div>
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<div class="card">
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<div class="card-body">
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<form method="post" novalidate>
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{% csrf_token %}
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<div class="row">
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<div class="col-md-6">
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<h5 class="mb-3">{% trans "Basic Information" %}</h5>
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<div class="mb-3">
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<label for="{{ form.payer_name.id_for_label }}" class="form-label">
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{{ form.payer_name.label }} <span class="text-danger">*</span>
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</label>
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{{ form.payer_name }}
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{% if form.payer_name.errors %}
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<div class="invalid-feedback d-block">
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{{ form.payer_name.errors }}
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</div>
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{% endif %}
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{% if form.payer_name.help_text %}
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<small class="form-text text-muted">{{ form.payer_name.help_text }}</small>
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{% endif %}
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</div>
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<div class="mb-3">
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<label for="{{ form.payer_code.id_for_label }}" class="form-label">
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{{ form.payer_code.label }} <span class="text-danger">*</span>
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</label>
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{{ form.payer_code }}
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{% if form.payer_code.errors %}
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<div class="invalid-feedback d-block">
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{{ form.payer_code.errors }}
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</div>
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{% endif %}
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{% if form.payer_code.help_text %}
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<small class="form-text text-muted">{{ form.payer_code.help_text }}</small>
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{% endif %}
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</div>
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<div class="mb-3">
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<label class="form-label">{% trans "Status" %}</label>
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<div class="form-check form-switch">
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{{ form.is_active }}
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<label class="form-check-label" for="{{ form.is_active.id_for_label }}">
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{{ form.is_active.label }}
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</label>
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</div>
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</div>
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</div>
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<div class="col-md-6">
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<h5 class="mb-3">{% trans "Capabilities" %}</h5>
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<div class="mb-3">
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<div class="form-check">
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{{ form.supports_eligibility }}
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<label class="form-check-label" for="{{ form.supports_eligibility.id_for_label }}">
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{{ form.supports_eligibility.label }}
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</label>
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</div>
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</div>
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<div class="mb-3">
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<div class="form-check">
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{{ form.supports_prior_auth }}
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<label class="form-check-label" for="{{ form.supports_prior_auth.id_for_label }}">
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{{ form.supports_prior_auth.label }}
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</label>
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</div>
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</div>
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<div class="mb-3">
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<div class="form-check">
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{{ form.supports_claims }}
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<label class="form-check-label" for="{{ form.supports_claims.id_for_label }}">
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{{ form.supports_claims.label }}
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</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 class="my-4">
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<div class="row">
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<div class="col-md-12">
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<h5 class="mb-3">{% trans "Credentials" %}</h5>
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<div class="mb-3">
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<label for="{{ form.credentials.id_for_label }}" class="form-label">
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{{ form.credentials.label }}
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</label>
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{{ form.credentials }}
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{% if form.credentials.errors %}
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<div class="invalid-feedback d-block">
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{{ form.credentials.errors }}
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</div>
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{% endif %}
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<small class="form-text text-muted">
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{% trans "Enter credentials as JSON (e.g., OAuth2 tokens, mTLS certificates)" %}
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</small>
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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="col-md-12">
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<h5 class="mb-3">{% trans "API Endpoints" %}</h5>
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<div class="mb-3">
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<label for="{{ form.endpoints.id_for_label }}" class="form-label">
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{{ form.endpoints.label }}
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</label>
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{{ form.endpoints }}
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{% if form.endpoints.errors %}
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<div class="invalid-feedback d-block">
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{{ form.endpoints.errors }}
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</div>
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{% endif %}
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<small class="form-text text-muted">
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{% trans "Enter API endpoints as JSON (e.g., eligibility_url, claim_url, etc.)" %}
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</small>
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</div>
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</div>
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</div>
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<div class="d-flex justify-content-end gap-2 mt-4">
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<a href="{% url 'integrations:payer-list' %}" class="btn btn-secondary">
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<i class="fa fa-times me-1"></i>{% trans "Cancel" %}
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</a>
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<button type="submit" class="btn btn-primary">
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<i class="fa fa-save me-1"></i>{% trans "Save" %}
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</button>
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</div>
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</form>
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</div>
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</div>
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</div>
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{% endblock %}
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