{% extends 'base.html' %}
{% load static %}

{% block title %}{% if claim %}Edit Claim {{ claim.claim_number }}{% else %}New Insurance Claim{% endif %}{% endblock %}

{% block extra_css %}
<link href="{% static 'assets/plugins/select2/dist/css/select2.min.css' %}" rel="stylesheet" />
<style>
    .form-section {
        background: #fff;
        border-radius: 15px;
        box-shadow: 0 5px 15px rgba(0, 0, 0, 0.08);
        margin-bottom: 2rem;
        overflow: hidden;
    }
    .form-section-header {
        background: linear-gradient(135deg, #667eea 0%, #764ba2 100%);
        color: white;
        padding: 1.5rem;
        margin: 0;
    }
    .form-section-body {
        padding: 2rem;
    }
    .form-floating > label {
        color: #6c757d;
    }
    .form-floating > .form-control:focus ~ label,
    .form-floating > .form-control:not(:placeholder-shown) ~ label {
        color: #007bff;
    }
    .btn-add-item {
        border: 2px dashed #007bff;
        color: #007bff;
        background: transparent;
        transition: all 0.3s ease;
    }
    .btn-add-item:hover {
        background: #007bff;
        color: white;
        border-color: #007bff;
    }
    .dynamic-item {
        border: 1px solid #e9ecef;
        border-radius: 10px;
        padding: 1rem;
        margin-bottom: 1rem;
        background: #f8f9fa;
        position: relative;
    }
    .remove-item {
        position: absolute;
        top: 10px;
        right: 10px;
        background: #dc3545;
        color: white;
        border: none;
        border-radius: 50%;
        width: 30px;
        height: 30px;
        display: flex;
        align-items: center;
        justify-content: center;
        font-size: 12px;
    }
    .priority-indicator {
        width: 12px;
        height: 12px;
        border-radius: 50%;
        display: inline-block;
        margin-right: 8px;
    }
    .priority-low { background-color: #28a745; }
    .priority-normal { background-color: #17a2b8; }
    .priority-high { background-color: #ffc107; }
    .priority-urgent { background-color: #fd7e14; }
    .priority-emergency { background-color: #dc3545; }
    .auto-save-indicator {
        position: fixed;
        top: 20px;
        right: 20px;
        z-index: 1050;
        display: none;
    }
    .form-help {
        font-size: 0.875rem;
        color: #6c757d;
        margin-top: 0.25rem;
    }
    .required-field::after {
        content: " *";
        color: #dc3545;
    }
</style>
{% endblock %}

{% block content %}
<div id="content" class="app-content">
    <!-- Auto-save indicator -->
    <div class="auto-save-indicator">
        <div class="alert alert-success alert-dismissible fade show" role="alert" id="autoSaveAlert">
            <i class="fas fa-check-circle me-2"></i>
            <span id="autoSaveMessage">Draft saved automatically</span>
            <button type="button" class="btn-close" data-bs-dismiss="alert"></button>
        </div>
    </div>

    <!-- Breadcrumb -->
    <ol class="breadcrumb">
        <li class="breadcrumb-item"><a href="{% url 'core:dashboard' %}">Dashboard</a></li>
        <li class="breadcrumb-item"><a href="{% url 'patients:patient_list' %}">Patients</a></li>
        <li class="breadcrumb-item"><a href="{% url 'patients:insurance_claims_list' %}">Claims</a></li>
        <li class="breadcrumb-item active">{% if claim %}Edit Claim{% else %}New Claim{% endif %}</li>
    </ol>

    <!-- Page Header -->
    <div class="d-flex align-items-center justify-content-between mb-4">
        <div>
            <h1 class="page-header mb-0">
                <i class="fas fa-file-medical me-3"></i>
                {% if claim %}Edit Claim {{ claim.claim_number }}{% else %}New Insurance Claim{% endif %}
            </h1>
            <p class="text-muted mb-0">
                {% if claim %}Update the insurance claim details{% else %}Create a new insurance claim for patient services{% endif %}
            </p>
        </div>
        <div>
            <a href="{% if claim %}{% url 'patients:insurance_claim_detail' claim.id %}{% else %}{% url 'patients:insurance_claims_list' %}{% endif %}" 
               class="btn btn-outline-secondary me-2">
                <i class="fas fa-arrow-left me-2"></i>Cancel
            </a>
            <button type="button" class="btn btn-info me-2" onclick="saveDraft()">
                <i class="fas fa-save me-2"></i>Save Draft
            </button>
        </div>
    </div>

    <form method="post" id="claimForm" novalidate>
        {% csrf_token %}
        
        <!-- Basic Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-info-circle me-2"></i>Basic Information
            </h4>
            <div class="form-section-body">
                <div class="row g-3">
                    <div class="col-md-6">
                        <div class="form-floating">
                            <select class="form-select" id="patient" name="patient" required onchange="loadPatientInsurance()">
                                <option value="">Select Patient</option>
                                {% for patient in patients %}
                                <option value="{{ patient.id }}" 
                                        {% if claim and claim.patient.id == patient.id %}selected{% endif %}>
                                    {{ patient.get_full_name }} ({{ patient.mrn }})
                                </option>
                                {% endfor %}
                            </select>
                            <label for="patient" class="required-field">Patient</label>
                        </div>
                        <div class="form-help">Select the patient for this claim</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <select class="form-select" id="insurance_info" name="insurance_info" required>
                                <option value="">Select Insurance Policy</option>
                                {% if claim %}
                                <option value="{{ claim.insurance_info.id }}" selected>
                                    {{ claim.insurance_info.insurance_company }} - {{ claim.insurance_info.policy_number }}
                                </option>
                                {% endif %}
                            </select>
                            <label for="insurance_info" class="required-field">Insurance Policy</label>
                        </div>
                        <div class="form-help">Select the insurance policy to use for this claim</div>
                    </div>
                    
                    <div class="col-md-4">
                        <div class="form-floating">
                            <select class="form-select" id="claim_type" name="claim_type" required>
                                <option value="">Select Claim Type</option>
                                {% for value, label in type_choices %}
                                <option value="{{ value }}" 
                                        {% if claim and claim.claim_type == value %}selected{% endif %}>
                                    {{ label }}
                                </option>
                                {% endfor %}
                            </select>
                            <label for="claim_type" class="required-field">Claim Type</label>
                        </div>
                    </div>
                    
                    <div class="col-md-4">
                        <div class="form-floating">
                            <select class="form-select" id="priority" name="priority" onchange="updatePriorityIndicator()">
                                {% for value, label in priority_choices %}
                                <option value="{{ value }}" 
                                        {% if claim and claim.priority == value %}selected{% elif not claim and value == 'NORMAL' %}selected{% endif %}>
                                    {{ label }}
                                </option>
                                {% endfor %}
                            </select>
                            <label for="priority">Priority</label>
                        </div>
                        <div class="form-help">
                            <span class="priority-indicator priority-normal" id="priorityIndicator"></span>
                            <span id="priorityText">Normal priority claim</span>
                        </div>
                    </div>
                    
                    <div class="col-md-4">
                        <div class="form-floating">
                            <input type="date" class="form-control" id="service_date" name="service_date" 
                                   value="{% if claim %}{{ claim.service_date|date:'Y-m-d' }}{% endif %}" required>
                            <label for="service_date" class="required-field">Service Date</label>
                        </div>
                        <div class="form-help">Date when the service was provided</div>
                    </div>
                </div>
            </div>
        </div>

        <!-- Service Provider Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-user-md me-2"></i>Service Provider Information
            </h4>
            <div class="form-section-body">
                <div class="row g-3">
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="service_provider" name="service_provider" 
                                   value="{% if claim %}{{ claim.service_provider }}{% endif %}" required>
                            <label for="service_provider" class="required-field">Service Provider Name</label>
                        </div>
                        <div class="form-help">Name of the healthcare provider</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="service_provider_license" name="service_provider_license" 
                                   value="{% if claim %}{{ claim.service_provider_license }}{% endif %}" 
                                   placeholder="SML12345">
                            <label for="service_provider_license">Provider License Number</label>
                        </div>
                        <div class="form-help">Saudi Medical License number (optional)</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="facility_name" name="facility_name" 
                                   value="{% if claim %}{{ claim.facility_name }}{% endif %}">
                            <label for="facility_name">Healthcare Facility</label>
                        </div>
                        <div class="form-help">Name of the healthcare facility</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="facility_license" name="facility_license" 
                                   value="{% if claim %}{{ claim.facility_license }}{% endif %}" 
                                   placeholder="MOH123456">
                            <label for="facility_license">Facility License Number</label>
                        </div>
                        <div class="form-help">MOH facility license number (optional)</div>
                    </div>
                </div>
            </div>
        </div>

        <!-- Medical Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-stethoscope me-2"></i>Medical Information
            </h4>
            <div class="form-section-body">
                <div class="row g-3">
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="primary_diagnosis_code" name="primary_diagnosis_code" 
                                   value="{% if claim %}{{ claim.primary_diagnosis_code }}{% endif %}" 
                                   placeholder="E11.9" required>
                            <label for="primary_diagnosis_code" class="required-field">Primary Diagnosis Code</label>
                        </div>
                        <div class="form-help">ICD-10 diagnosis code</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="primary_diagnosis_description" name="primary_diagnosis_description" 
                                   value="{% if claim %}{{ claim.primary_diagnosis_description }}{% endif %}" required>
                            <label for="primary_diagnosis_description" class="required-field">Primary Diagnosis Description</label>
                        </div>
                        <div class="form-help">Description of the primary diagnosis</div>
                    </div>
                </div>

                <!-- Secondary Diagnoses -->
                <div class="mt-4">
                    <div class="d-flex justify-content-between align-items-center mb-3">
                        <h6 class="mb-0">Secondary Diagnoses</h6>
                        <button type="button" class="btn btn-sm btn-add-item" onclick="addSecondaryDiagnosis()">
                            <i class="fas fa-plus me-2"></i>Add Secondary Diagnosis
                        </button>
                    </div>
                    <div id="secondaryDiagnoses">
                        {% if claim and claim.secondary_diagnosis_codes %}
                        {% for diagnosis in claim.secondary_diagnosis_codes %}
                        <div class="dynamic-item">
                            <button type="button" class="remove-item" onclick="removeItem(this)">
                                <i class="fas fa-times"></i>
                            </button>
                            <div class="row g-2">
                                <div class="col-md-4">
                                    <div class="form-floating">
                                        <input type="text" class="form-control secondary-diagnosis-code" 
                                               value="{{ diagnosis.code }}" placeholder="ICD-10 Code">
                                        <label>Diagnosis Code</label>
                                    </div>
                                </div>
                                <div class="col-md-8">
                                    <div class="form-floating">
                                        <input type="text" class="form-control secondary-diagnosis-desc" 
                                               value="{{ diagnosis.description }}" placeholder="Description">
                                        <label>Description</label>
                                    </div>
                                </div>
                            </div>
                        </div>
                        {% endfor %}
                        {% endif %}
                    </div>
                </div>

                <!-- Procedures -->
                <div class="mt-4">
                    <div class="d-flex justify-content-between align-items-center mb-3">
                        <h6 class="mb-0">Procedures</h6>
                        <button type="button" class="btn btn-sm btn-add-item" onclick="addProcedure()">
                            <i class="fas fa-plus me-2"></i>Add Procedure
                        </button>
                    </div>
                    <div id="procedures">
                        {% if claim and claim.procedure_codes %}
                        {% for procedure in claim.procedure_codes %}
                        <div class="dynamic-item">
                            <button type="button" class="remove-item" onclick="removeItem(this)">
                                <i class="fas fa-times"></i>
                            </button>
                            <div class="row g-2">
                                <div class="col-md-3">
                                    <div class="form-floating">
                                        <input type="text" class="form-control procedure-code" 
                                               value="{{ procedure.code }}" placeholder="CPT Code">
                                        <label>Procedure Code</label>
                                    </div>
                                </div>
                                <div class="col-md-6">
                                    <div class="form-floating">
                                        <input type="text" class="form-control procedure-desc" 
                                               value="{{ procedure.description }}" placeholder="Description">
                                        <label>Description</label>
                                    </div>
                                </div>
                                <div class="col-md-3">
                                    <div class="form-floating">
                                        <input type="number" class="form-control procedure-cost" 
                                               value="{{ procedure.cost|default:'' }}" step="0.01" placeholder="0.00">
                                        <label>Cost (SAR)</label>
                                    </div>
                                </div>
                            </div>
                        </div>
                        {% endfor %}
                        {% endif %}
                    </div>
                </div>
            </div>
        </div>

        <!-- Financial Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-calculator me-2"></i>Financial Information
            </h4>
            <div class="form-section-body">
                <div class="row g-3">
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="number" class="form-control" id="billed_amount" name="billed_amount" 
                                   value="{% if claim %}{{ claim.billed_amount }}{% endif %}" 
                                   step="0.01" min="0" required>
                            <label for="billed_amount" class="required-field">Billed Amount (SAR)</label>
                        </div>
                        <div class="form-help">Total amount billed for services</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="authorization_number" name="authorization_number" 
                                   value="{% if claim %}{{ claim.authorization_number }}{% endif %}" 
                                   placeholder="AUTH123456">
                            <label for="authorization_number">Prior Authorization Number</label>
                        </div>
                        <div class="form-help">Required for certain procedures (optional)</div>
                    </div>
                </div>
            </div>
        </div>

        <!-- Saudi-specific Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-id-card me-2"></i>Saudi-specific Information
            </h4>
            <div class="form-section-body">
                <div class="row g-3">
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="saudi_id_number" name="saudi_id_number" 
                                   value="{% if claim %}{{ claim.saudi_id_number }}{% endif %}" 
                                   placeholder="1234567890" maxlength="10">
                            <label for="saudi_id_number">Saudi ID/Iqama Number</label>
                        </div>
                        <div class="form-help">10-digit Saudi National ID or Iqama number</div>
                    </div>
                    
                    <div class="col-md-6">
                        <div class="form-floating">
                            <input type="text" class="form-control" id="insurance_card_number" name="insurance_card_number" 
                                   value="{% if claim %}{{ claim.insurance_card_number }}{% endif %}" 
                                   placeholder="IC123456789">
                            <label for="insurance_card_number">Insurance Card Number</label>
                        </div>
                        <div class="form-help">Insurance card number from physical card</div>
                    </div>
                </div>
            </div>
        </div>

        <!-- Additional Information -->
        <div class="form-section">
            <h4 class="form-section-header">
                <i class="fas fa-sticky-note me-2"></i>Additional Information
            </h4>
            <div class="form-section-body">
                <div class="form-floating">
                    <textarea class="form-control" id="notes" name="notes" style="height: 120px" 
                              placeholder="Enter any additional notes or comments about this claim...">{% if claim %}{{ claim.notes }}{% endif %}</textarea>
                    <label for="notes">Notes</label>
                </div>
                <div class="form-help">Additional notes or comments about this claim</div>
            </div>
        </div>

        <!-- Form Actions -->
        <div class="d-flex justify-content-between align-items-center">
            <div>
                <a href="{% if claim %}{% url 'patients:insurance_claim_detail' claim.id %}{% else %}{% url 'patients:insurance_claims_list' %}{% endif %}" 
                   class="btn btn-outline-secondary">
                    <i class="fas fa-times me-2"></i>Cancel
                </a>
            </div>
            <div>
                <button type="button" class="btn btn-info me-2" onclick="saveDraft()">
                    <i class="fas fa-save me-2"></i>Save as Draft
                </button>
                <button type="submit" class="btn btn-primary">
                    <i class="fas fa-check me-2"></i>
                    {% if claim %}Update Claim{% else %}Create Claim{% endif %}
                </button>
            </div>
        </div>
    </form>
</div>

<!-- Hidden fields for JSON data -->
<input type="hidden" id="secondary_diagnosis_codes" name="secondary_diagnosis_codes">
<input type="hidden" id="procedure_codes" name="procedure_codes">
{% endblock %}

{% block extra_js %}
<script src="{% static 'assets/plugins/select2/dist/js/select2.min.js' %}"></script>

<script>
$(document).ready(function() {
    // Initialize Select2
    $('#patient, #insurance_info').select2({
        theme: 'bootstrap-5',
        width: '100%'
    });

    // Auto-save every 30 seconds
    setInterval(saveDraft, 30000);
    
    // Update priority indicator on load
    updatePriorityIndicator();
});

function loadPatientInsurance() {
    const patientId = $('#patient').val();
    if (!patientId) {
        $('#insurance_info').empty().append('<option value="">Select Insurance Policy</option>');
        return;
    }
    
    $.ajax({
        url: `/patients/ajax/patient/${patientId}/insurance/`,
        method: 'GET',
        success: function(response) {
            if (response.success) {
                const insuranceSelect = $('#insurance_info');
                insuranceSelect.empty().append('<option value="">Select Insurance Policy</option>');
                
                response.insurance_policies.forEach(function(policy) {
                    insuranceSelect.append(`
                        <option value="${policy.id}">
                            ${policy.insurance_company} - ${policy.policy_number} (${policy.insurance_type})
                        </option>
                    `);
                });
            }
        },
        error: function() {
            alert('Error loading insurance policies. Please try again.');
        }
    });
}

function updatePriorityIndicator() {
    const priority = $('#priority').val().toLowerCase();
    const indicator = $('#priorityIndicator');
    const text = $('#priorityText');
    
    // Remove all priority classes
    indicator.removeClass('priority-low priority-normal priority-high priority-urgent priority-emergency');
    
    // Add appropriate class and update text
    indicator.addClass(`priority-${priority}`);
    
    const priorityTexts = {
        'low': 'Low priority claim',
        'normal': 'Normal priority claim',
        'high': 'High priority claim',
        'urgent': 'Urgent priority claim',
        'emergency': 'Emergency priority claim'
    };
    
    text.text(priorityTexts[priority] || 'Normal priority claim');
}

function addSecondaryDiagnosis() {
    const container = $('#secondaryDiagnoses');
    const item = $(`
        <div class="dynamic-item">
            <button type="button" class="remove-item" onclick="removeItem(this)">
                <i class="fas fa-times"></i>
            </button>
            <div class="row g-2">
                <div class="col-md-4">
                    <div class="form-floating">
                        <input type="text" class="form-control secondary-diagnosis-code" placeholder="ICD-10 Code">
                        <label>Diagnosis Code</label>
                    </div>
                </div>
                <div class="col-md-8">
                    <div class="form-floating">
                        <input type="text" class="form-control secondary-diagnosis-desc" placeholder="Description">
                        <label>Description</label>
                    </div>
                </div>
            </div>
        </div>
    `);
    container.append(item);
}

function addProcedure() {
    const container = $('#procedures');
    const item = $(`
        <div class="dynamic-item">
            <button type="button" class="remove-item" onclick="removeItem(this)">
                <i class="fas fa-times"></i>
            </button>
            <div class="row g-2">
                <div class="col-md-3">
                    <div class="form-floating">
                        <input type="text" class="form-control procedure-code" placeholder="CPT Code">
                        <label>Procedure Code</label>
                    </div>
                </div>
                <div class="col-md-6">
                    <div class="form-floating">
                        <input type="text" class="form-control procedure-desc" placeholder="Description">
                        <label>Description</label>
                    </div>
                </div>
                <div class="col-md-3">
                    <div class="form-floating">
                        <input type="number" class="form-control procedure-cost" step="0.01" placeholder="0.00">
                        <label>Cost (SAR)</label>
                    </div>
                </div>
            </div>
        </div>
    `);
    container.append(item);
}

function removeItem(button) {
    $(button).closest('.dynamic-item').remove();
}

function collectSecondaryDiagnoses() {
    const diagnoses = [];
    $('#secondaryDiagnoses .dynamic-item').each(function() {
        const code = $(this).find('.secondary-diagnosis-code').val();
        const description = $(this).find('.secondary-diagnosis-desc').val();
        if (code && description) {
            diagnoses.push({ code, description });
        }
    });
    return diagnoses;
}

function collectProcedures() {
    const procedures = [];
    $('#procedures .dynamic-item').each(function() {
        const code = $(this).find('.procedure-code').val();
        const description = $(this).find('.procedure-desc').val();
        const cost = $(this).find('.procedure-cost').val();
        if (code && description) {
            procedures.push({ 
                code, 
                description, 
                cost: cost ? parseFloat(cost) : null 
            });
        }
    });
    return procedures;
}

function saveDraft() {
    // Collect dynamic data
    const secondaryDiagnoses = collectSecondaryDiagnoses();
    const procedures = collectProcedures();
    
    // Update hidden fields
    $('#secondary_diagnosis_codes').val(JSON.stringify(secondaryDiagnoses));
    $('#procedure_codes').val(JSON.stringify(procedures));
    
    // Prepare form data
    const formData = new FormData($('#claimForm')[0]);
    
    $.ajaxSetup({
        beforeSend: function(xhr, settings) {
            if (!this.crossDomain) {
                xhr.setRequestHeader("X-CSRFToken", $('[name=csrfmiddlewaretoken]').val());
            }
        }
    });
    
    // Save draft via AJAX
    $.ajax({
        url: '{% url "patients:save_insurance_draft" %}',
        method: 'POST',
        data: formData,
        processData: false,
        contentType: false,
        success: function(response) {
            if (response.success) {
                showAutoSaveIndicator('Draft saved successfully');
            }
        },
        error: function() {
            console.log('Auto-save failed');
        }
    });
}

function showAutoSaveIndicator(message) {
    $('#autoSaveMessage').text(message);
    $('.auto-save-indicator').show();
    setTimeout(function() {
        $('.auto-save-indicator').hide();
    }, 3000);
}

// Form submission
$('#claimForm').submit(function(e) {
    // Collect dynamic data before submission
    const secondaryDiagnoses = collectSecondaryDiagnoses();
    const procedures = collectProcedures();
    
    // Update hidden fields
    $('#secondary_diagnosis_codes').val(JSON.stringify(secondaryDiagnoses));
    $('#procedure_codes').val(JSON.stringify(procedures));
    
    // Validate required fields
    const requiredFields = ['patient', 'insurance_info', 'claim_type', 'service_date', 
                           'service_provider', 'primary_diagnosis_code', 'primary_diagnosis_description', 
                           'billed_amount'];
    
    let isValid = true;
    requiredFields.forEach(function(fieldName) {
        const field = $(`[name="${fieldName}"]`);
        if (!field.val()) {
            field.addClass('is-invalid');
            isValid = false;
        } else {
            field.removeClass('is-invalid');
        }
    });
    
    if (!isValid) {
        e.preventDefault();
        alert('Please fill in all required fields.');
        return false;
    }
});

// Remove validation errors on input
$('input, select, textarea').on('input change', function() {
    $(this).removeClass('is-invalid');
});
</script>
{% endblock %}