https://curative.com/_next/static/chunks/3968.987d0227764c9e95.js

1"use strict";(self.webpackChunk_N_E=self.webpackChunk_N_E||[]).push([[3968],{33968:function(e,t,r){r.r(t),r.d(t,{default:function(){return x}});var a=r(74817),i=r(69764),l=r(36497),n=r(71248),s=r(71260),d=r(86271),o=r(46988),u=r(69277),c=r(93978);let m=[{fields:[{name:"firstName",fieldType:"text",label:"First Name",placeholder:"Enter first name",required:!0},{name:"lastName",fieldType:"text",label:"Last Name",placeholder:"Enter last name",required:!0}]},{fields:[{name:"email",fieldType:"text",label:"Email",placeholder:"Enter email",required:!0},{id:"56230",name:"Provider",fieldType:"text",label:"Provider",placeholder:"Enter provider name",required:!0}]},{fields:[{id:"56325",name:"NPI",fieldType:"text",label:"NPI",placeholder:"Enter NPI",required:!0},{id:"56232",name:"Provider Type",fieldType:"text",label:"Provider Type",placeholder:"Enter provider type",required:!0}]},{fields:[{id:"56236",name:"Submitted Claim Number",fieldType:"text",label:"Submitted Claim Number",placeholder:"Enter submitted claim number",required:!0},{id:"61079",name:"Payment Date",fieldType:"text",label:"Payment Date",description:"Use MM/DD/YYYY",placeholder:"MM/DD/YYYY",required:!0}]},{fields:[{id:"61768",name:"Submission Type",fieldType:"select",label:"Submission Type",required:!0,options:[{value:"338842",label:"Federal Open Negotiation"},{value:"338843",label:"Notice of IDR Initiation"}]}]}];var p=r(19727),h=r(42425),f=r(9860),y=r(11003);let b=e=>new Promise((t,r)=>{let a=new FileReader;a.onerror=()=>r(Error("Failed to read file")),a.onload=()=>{let r="string"==typeof a.result?a.result:"",i=r.includes(",")?r.split(",")[1]:r;t({fileName:e.name,mimeType:e.type||"application/pdf",data:i})},a.readAsDataURL(e)});var x=e=>{let{heading:t,redirectUrl:r}=e,x=t?.heading,g=(0,y.Z)(t?.headingElementType),j=t?.subhead,v=(0,l.useRouter)(),{executeRecaptcha:T}=(0,d.xX)(),{control:P,handleSubmit:N,formState:{errors:k},watch:w}=(0,s.cI)({mode:"onChange",reValidateMode:"onChange"}),S=w(),[q,D]=(0,n.useState)([]),[E,F]=(0,n.useState)(!1),[C,Y]=(0,n.useState)({}),[M,R]=(0,n.useState)([]),[O,Z]=(0,n.useState)(""),[I,_]=(0,n.use

1State)(!1),[z,W]=(0,n.useState)(),B=async(e,t)=>{if(t.preventDefault(),F(!0),Z(""),Y({}),0===M.length){F(!1),Z("Please upload the federal open negotiation form as a PDF.");return}if(M.length>10){F(!1),Z("You can upload up to 10 attachments.");return}let a=M.find(e=>e.size>5242880);if(a){F(!1),Z(`"${a.name}" exceeds the ${Math.floor(5)}MB limit.`);return}if(4/3*M.reduce((e,t)=>e+t.size,0)>26214400){F(!1),Z("Total attachment size exceeds 25MB. Please remove some files.");return}try{let t=M.length?await Promise.all(M.map(b)):void 0,a=T?await T("helpscout_idr"):void 0,l={...e,attachments:t,captchaToken:a},n=await i.Z.post("/api/forms/helpscout/idr-submit",l),{errors:s}=n?.data;if(s&&Object.keys(s).length>0){F(!1),Y(s);return}F(!1),W(n?.data?.ticketNumber),r?.startsWith("/")&&!r.startsWith("//")?v.push(r):_(!0)}catch(e){F(!1),e.response?.status===413?Z("Files too large. Please reduce file sizes or remove some attachments and try again."):e.response?.data?.error?e.response.data.error.includes("too large")||e.response.data.error.includes("Request too large")?Z("Files too large. Please reduce file sizes and try again."):Y({general:e.response.data.error}):e.message?.includes("Network Error")||e.message?.includes("Request failed")?Y({general:"Network error. Please check your connection and try again."}):Y({general:"Failed to submit form. Please try again."})}};return I?(0,a.jsx)(u.Z,{backgroundColor:"white",children:(0,a.jsxs)(h.Y2,{children:[(0,a.jsx)(h.MZ,{children:"Thank you!"}),(0,a.jsx)(h.CF,{children:"We received your submission"}),(0,a.jsx)(h.K0,{children:"We acknowledge receipt of your Open Negotiation submission. A representative from our team will c

1ontact you shortly for negotiation of eligible claims."}),z&&(0,a.jsxs)(h._K,{children:["Reference number: #",z]})]})}):(0,a.jsx)(u.Z,{backgroundColor:"clearBlue.800",children:(0,a.jsxs)(p.X2,{children:[(0,a.jsxs)(p.vs,{children:[x&&(0,a.jsx)(p.OT,{as:g,children:x}),j&&(0,a.jsx)(p.tr,{children:(0,f.Z)(j)})]}),(0,a.jsxs)(p.n5,{as:"form",onSubmit:N(B),children:[(0,c.Z)(m,P,k,S,q,D,!0),(0,a.jsxs)(h.DT,{children:[(0,a.jsx)(h.bT,{htmlFor:"idr-attachments",children:"Upload documentation (PDF only, required)"}),(0,a.jsx)(h.a6,{id:"idr-attachments",name:"idr-attachments",type:"file",multiple:!0,accept:"application/pdf,.pdf",required:!0,onChange:e=>{let t=Array.from(e.target.files||[]);if(t.filter(e=>!("application/pdf"===e.type||e.name.toLowerCase().endsWith(".pdf"))).length>0){R([]),Z("Only PDF files are allowed."),e.target.value="";return}R(t),Z("")}}),M.length>0&&(0,a.jsx)("ul",{children:M.map(e=>(0,a.jsx)("li",{children:e.name},e.name))}),O&&(0,a.jsx)(p.xv,{children:O})]}),(0,a.jsx)(p.aR,{children:(0,a.jsx)(o.default,{type:"submit",theme:"secondary.fill",label:E?"Submitting...":"Submit",disabled:E,isFormButton:!0})}),C&&Object.keys(C).length>0&&(0,a.jsxs)(p.aR,{children:[(0,a.jsx)(p.xv,{children:"There was an error submitting your form:"}),(0,a.jsx)("ul",{children:Object.keys(C).map((e,t)=>(0,a.jsx)("li",{children:(0,a.jsx)(p.xv,{children:C[e]})},t))})]})]})]})})}}}]);