@mindbill/react 0.52.1 → 0.53.1

package/dist/index.js

@@ -348,7 +348,7 @@ function organizationProfileOptions(profile) {
 
 // src/index.tsx
 import "@mindbill/embed";
-import { createElement, useEffect as useEffect16, useRef as useRef11 } from "react";
+import { createElement, useEffect as useEffect16, useRef as useRef12 } from "react";
 
 // src/native-bill-review.tsx
 import { sanitizeBillReviewSaveInput } from "@mindbill/browser";
@@ -6980,6 +6980,15 @@ function billTeamNotes(data) {
   const legacy = (data.history ?? []).filter((entry) => entry.kind === "note" && !canonicalIds.has(entry.id) && !notes.some((note) => entry.id.endsWith(`:ev-${note.id}`)));
   return [...legacy, ...notes.map((note) => ({ id: note.id, summary: note.body, actor: note.author, date: note.createdAt }))].sort((left, right) => right.date.localeCompare(left.date));
 }
+function billLifecycleSubmissionSelection(data, selectedSubmissionId) {
+  const mappedRibbonItems = billSubmissionsRibbonFromHistory(data.history ?? [], data.attempts);
+  const activeSubmissionId = (mappedRibbonItems.some((item) => item.id === selectedSubmissionId) ? selectedSubmissionId : null) ?? mappedRibbonItems.find((item) => item.active)?.id ?? mappedRibbonItems[mappedRibbonItems.length - 1]?.id;
+  const ribbonItems = mappedRibbonItems.map((item) => ({ ...item, active: item.id === activeSubmissionId }));
+  const selectedAttempt = data.attempts?.find((attempt) => attempt.id === activeSubmissionId);
+  const historical = selectedAttempt ? !selectedAttempt.isCurrent : !!activeSubmissionId && activeSubmissionId !== mappedRibbonItems.at(-1)?.id;
+  const selectedDetail = selectedAttempt ? data.submissionDetails?.find((item) => item.attemptId === activeSubmissionId && item.billId === selectedAttempt.billId) : null;
+  return { activeSubmissionId, ribbonItems, selectedAttempt, historical, selectedDetail };
+}
 function reservePreviewWindow() {
   const preview = window.open("about:blank", "_blank");
   if (preview) {
@@ -7560,12 +7569,7 @@ function ConnectedBillLifecycle({ appearance, actorName, claimsAdministratorHint
   const viewEor = data.lifecycle.actions.find((action) => action.id === "view_eor" && action.enabled);
   const supportedActions = /* @__PURE__ */ new Set(["resubmit", "submit_new_bill", "second_review", "independent_bill_review", "post_payment", "close", "reopen", "send_duplicate", "report_bill_status"]);
   const actions = data.lifecycle.actions.filter((action) => action.enabled && supportedActions.has(action.id));
-  const mappedRibbonItems = data.history ? billSubmissionsRibbonFromHistory(data.history, data.attempts) : [];
-  const activeSubmissionId = (mappedRibbonItems.some((item) => item.id === selectedSubmissionId) ? selectedSubmissionId : null) ?? mappedRibbonItems.find((item) => item.active)?.id ?? mappedRibbonItems[mappedRibbonItems.length - 1]?.id;
-  const ribbonItems = mappedRibbonItems.map((item) => ({ ...item, active: item.id === activeSubmissionId }));
-  const selectedAttempt = data.attempts?.find((attempt) => attempt.id === activeSubmissionId);
-  const historical = selectedAttempt ? !selectedAttempt.isCurrent : !!activeSubmissionId && activeSubmissionId !== mappedRibbonItems.at(-1)?.id;
-  const selectedDetail = historical && selectedAttempt ? data.submissionDetails?.find((item) => item.attemptId === activeSubmissionId && item.billId === selectedAttempt.billId) : null;
+  const { activeSubmissionId, ribbonItems, selectedAttempt, historical, selectedDetail } = billLifecycleSubmissionSelection(data, selectedSubmissionId);
   const activePanel = historical ? "" : panel;
   const showSandboxControls = shouldShowSandboxControls(data.environment, sandboxControls) && !historical;
   const simulations = showSandboxControls ? sandboxScenarios(data.lifecycle.state) : [];
@@ -7648,7 +7652,7 @@ function ConnectedBillLifecycle({ appearance, actorName, claimsAdministratorHint
       ] }) : null,
       historical ? /* @__PURE__ */ jsx21("p", { className: "mb-lifecycle-card", children: selectedDetail?.source === "submission_snapshot" ? "Saved as submitted. This previous submission is read-only; payment balances and current actions are shown on the current bill." : displayedData ? "Historical bill record. An exact as-submitted snapshot was not recorded for this older attempt; these are the stored bill values, not a guaranteed copy of the original packet." : "Detailed values were not saved for this historical submission. Select the current submission to see the current bill. We will not substitute current data for this older attempt." }) : null,
       displayedData ? /* @__PURE__ */ jsx21(BillReadOnlyForm, { data: displayedData, ...!historical ? { onOpenAttachment: lifecycle.openAttachment } : {}, ...appearance ? { appearance } : {} }, activeSubmissionId) : null,
-      historical && selectedAttempt ? /* @__PURE__ */ jsxs21("section", { className: "mb-lifecycle-card", "aria-label": "Retained submission files", children: [
+      selectedAttempt ? /* @__PURE__ */ jsxs21("section", { className: "mb-lifecycle-card", "aria-label": "Retained submission files", children: [
         /* @__PURE__ */ jsx21("h3", { children: "Retained submission files" }),
         /* @__PURE__ */ jsx21("p", { children: "Exact files saved for this submission. These downloads do not include a regenerated current bill or a later EOR." }),
         selectedDetail?.artifacts?.length ? selectedDetail.artifacts.map((artifact) => /* @__PURE__ */ jsxs21("button", { type: "button", className: "mb-lifecycle-button secondary", onClick: () => void lifecycle.downloadSubmissionArtifact(selectedAttempt.id, artifact.id, artifact.label).catch(() => void 0), children: [
@@ -8401,9 +8405,408 @@ function ConnectedBillingWorkspace({ appearance, className, style, initialView =
   ] });
 }
 
+// src/dental-draft-editor.tsx
+import { useState as useState20 } from "react";
+
+// src/treatment-draft-shared.tsx
+import { useRef as useRef11, useState as useState19 } from "react";
+import { jsx as jsx23, jsxs as jsxs23 } from "react/jsx-runtime";
+function useDraftSave(onSave) {
+  const pending = useRef11(false);
+  const [busy, setBusy] = useState19(false);
+  const [message, setMessage] = useState19("");
+  const [error, setError] = useState19(null);
+  const clear = () => {
+    setMessage("");
+    setError(null);
+  };
+  const save = async (value, failure) => {
+    if (pending.current) return;
+    clear();
+    if (failure) {
+      setError(failure);
+      return;
+    }
+    pending.current = true;
+    setBusy(true);
+    try {
+      await onSave(value);
+      setMessage("Draft saved.");
+    } catch {
+      setError("The draft could not be saved. Review its status before retrying.");
+    } finally {
+      pending.current = false;
+      setBusy(false);
+    }
+  };
+  return { busy, message, error, clear, save };
+}
+function TreatmentDraftShell({ title, description, children, appearance, className = "", style }) {
+  return /* @__PURE__ */ jsxs23("section", { className: `mbtd ${className}`.trim(), "aria-label": title, style: { ...mindBillAppearanceStyle(appearance), ...style }, children: [
+    /* @__PURE__ */ jsx23("style", { children: `.mbtd{font:14px/1.5 ui-sans-serif,system-ui,sans-serif;color:var(--mb-text);min-width:0}.mbtd *{box-sizing:border-box}.mbtd h2{font-size:22px;margin:0 0 6px}.mbtd p{margin:6px 0 16px;color:var(--mb-muted)}.mbtd form{display:grid;gap:16px}.mbtd fieldset{margin:0;padding:16px;border:1px solid var(--mb-border);border-radius:var(--mb-radius);background:var(--mb-surface);min-width:0}.mbtd legend{font-weight:600;padding:0 6px}.mbtd .mbtd-grid{display:grid;grid-template-columns:repeat(2,minmax(0,1fr));gap:12px}.mbtd label{display:grid;gap:5px;font-size:13px;min-width:0}.mbtd input,.mbtd select,.mbtd textarea,.mbtd button{font:inherit;max-width:100%;min-width:0;border:1px solid var(--mb-border);border-radius:var(--mb-control-radius);padding:9px 11px;color:var(--mb-text);background:var(--mb-input);min-height:40px}.mbtd textarea{resize:vertical;min-height:76px}.mbtd button{cursor:pointer;background:var(--mb-surface)}.mbtd button:disabled{opacity:.55;cursor:default}.mbtd .mbtd-primary{background:var(--mb-accent);color:var(--mb-accent-contrast);border-color:var(--mb-accent)}.mbtd .mbtd-actions{display:flex;gap:10px;align-items:center;flex-wrap:wrap;margin-top:12px}.mbtd .mbtd-wide{grid-column:1/-1}.mbtd [role=alert]{color:var(--mb-danger)}.mbtd [role=status]{margin:0}.mbtd :is(input,select,textarea,button):focus-visible{outline:2px solid var(--mb-accent);outline-offset:2px}.mbtd .mbtd-note{padding:12px;background:var(--mb-soft);border-radius:var(--mb-control-radius)}.mbtd .mbtd-attribution{font-size:12px;text-align:right}.mbtd a{color:var(--mb-accent)}@media(max-width:520px){.mbtd .mbtd-grid{grid-template-columns:minmax(0,1fr)}.mbtd fieldset{padding:12px}}` }),
+    /* @__PURE__ */ jsx23("h2", { children: title }),
+    /* @__PURE__ */ jsx23("p", { children: description }),
+    children,
+    /* @__PURE__ */ jsx23("p", { className: "mbtd-attribution", children: /* @__PURE__ */ jsx23("a", { href: "https://mindbill.org", target: "_blank", rel: "noopener noreferrer", children: "Powered by MindBill" }) })
+  ] });
+}
+function isDraftDate(value) {
+  return /^\d{4}-\d{2}-\d{2}$/.test(value) && Number.isFinite(Date.parse(value)) && new Date(value).toISOString().slice(0, 10) === value;
+}
+
+// src/dental-draft-editor.tsx
+import { jsx as jsx24, jsxs as jsxs24 } from "react/jsx-runtime";
+function dentalDraftChargeSummary(lines) {
+  const knownChargeCents = lines.reduce((sum, line) => sum + (line.chargeCents ?? 0), 0);
+  return { knownChargeCents, totalChargeCents: lines.some((line) => line.chargeCents === null) ? null : knownChargeCents };
+}
+function parseDentalCharge(value) {
+  if (!value.trim()) return null;
+  if (!/^\d+(?:\.\d{1,2})?$/.test(value)) throw new Error("Enter a positive charge with at most two decimal places, or leave it blank.");
+  const [whole = "0", fraction = ""] = value.split(".");
+  const cents = Number(whole) * 100 + Number(fraction.padEnd(2, "0"));
+  if (!Number.isSafeInteger(cents) || cents < 1 || cents > 1e9) throw new Error("Enter a charge between $0.01 and $10,000,000, or leave it blank.");
+  return cents;
+}
+function validateDentalDraftContent(content) {
+  if (!content.renderingProviderId.trim() || content.renderingProviderId.length > 255) return "Choose a rendering provider in the host application.";
+  if (content.billingProviderId != null && (!content.billingProviderId.trim() || content.billingProviderId.length > 255)) return "Choose a valid billing provider in the host application.";
+  if (content.lines.length > 100) return "A draft can contain up to 100 service lines.";
+  if (content.diagnosisCodes.length > 12 || content.diagnosisCodes.some((code) => !code.trim() || code.length > 20)) return "Enter up to 12 diagnosis codes of at most 20 characters each.";
+  if (content.notes !== null && (!content.notes.trim() || content.notes.length > 5e3)) return "Notes must contain between 1 and 5,000 characters.";
+  for (const [index, line] of content.lines.entries()) {
+    const prefix = `Line ${index + 1}: `;
+    if (line.code !== null && !/^D[0-9]{4}$/.test(line.code)) return prefix + "enter D followed by four digits, or leave the code blank.";
+    if (!Number.isInteger(line.quantity) || line.quantity < 1 || line.quantity > 1e5) return prefix + "enter a whole quantity between 1 and 100,000.";
+    if (line.chargeCents !== null && (!Number.isSafeInteger(line.chargeCents) || line.chargeCents < 1 || line.chargeCents > 1e9)) return prefix + "enter a positive extended charge, or leave it unknown.";
+    if (line.serviceDate !== null && !isDraftDate(line.serviceDate)) return prefix + "enter a valid service date.";
+    if (line.editionYear !== null && (!Number.isInteger(line.editionYear) || line.editionYear < 1900 || line.editionYear > 2200)) return prefix + "enter an edition year between 1900 and 2200.";
+    for (const [value, limit] of [[line.description, 1e3], [line.chargeReference, 1e3], [line.oralCavity, 100], [line.prosthesisNotes, 2e3]]) {
+      if (value !== null && (!value.trim() || value.length > limit)) return prefix + `text must contain between 1 and ${limit} characters.`;
+    }
+    if (line.teeth.length > 32 || line.surfaces.length > 10 || [...line.teeth, ...line.surfaces].some((value) => !value.trim() || value.length > 20)) return prefix + "check tooth and surface entries (up to 32 teeth and 10 surfaces, 20 characters each).";
+  }
+  return null;
+}
+var blankLine2 = () => ({ code: null, description: null, editionYear: null, serviceDate: null, quantity: 1, chargeCents: null, chargeReference: null, teeth: [], surfaces: [], oralCavity: null, prosthesisNotes: null });
+var nullable = (value) => value === "" ? null : value;
+var split = (value) => value.split(",").map((part) => part.trim()).filter(Boolean);
+var currency2 = (cents) => new Intl.NumberFormat("en-US", { style: "currency", currency: "USD" }).format(cents / 100);
+function DentalDraftEditor({ initialContent, onSave, disabled = false, ...appearance }) {
+  const [content, setContent] = useState20(() => structuredClone(initialContent));
+  const [charges, setCharges] = useState20(() => initialContent.lines.map((line) => line.chargeCents === null ? "" : (line.chargeCents / 100).toFixed(2)));
+  const [diagnoses, setDiagnoses] = useState20(() => initialContent.diagnosisCodes.join(", "));
+  const [teeth, setTeeth] = useState20(() => initialContent.lines.map((line) => line.teeth.join(", ")));
+  const [surfaces, setSurfaces] = useState20(() => initialContent.lines.map((line) => line.surfaces.join(", ")));
+  const action = useDraftSave(onSave);
+  const locked = disabled || action.busy;
+  const updateLine = (index, patch) => {
+    action.clear();
+    setContent((current) => ({ ...current, lines: current.lines.map((line, position) => position === index ? { ...line, ...patch } : line) }));
+  };
+  const parsed = () => ({ ...content, diagnosisCodes: split(diagnoses), lines: content.lines.map((line, index) => ({ ...line, teeth: split(teeth[index] ?? ""), surfaces: split(surfaces[index] ?? ""), chargeCents: parseDentalCharge(charges[index] ?? "") })) });
+  let summary = null;
+  try {
+    summary = dentalDraftChargeSummary(parsed().lines);
+  } catch {
+  }
+  return /* @__PURE__ */ jsxs24(TreatmentDraftShell, { ...appearance, title: "Dental draft", description: "Record dental services, tooth details, and practice charges for review.", children: [
+    /* @__PURE__ */ jsx24("p", { className: "mbtd-note", children: "Codes and prices need review. Saving does not send a dental claim. A blank charge remains unknown." }),
+    /* @__PURE__ */ jsxs24("form", { onSubmit: (event) => {
+      event.preventDefault();
+      if (locked) return;
+      let next;
+      try {
+        next = parsed();
+      } catch {
+        void action.save(content, "Enter positive charges with at most two decimal places, or leave them blank.");
+        return;
+      }
+      void action.save(next, validateDentalDraftContent(next));
+    }, children: [
+      /* @__PURE__ */ jsxs24("fieldset", { disabled: locked, children: [
+        /* @__PURE__ */ jsx24("legend", { children: "Claim details" }),
+        /* @__PURE__ */ jsxs24("div", { className: "mbtd-grid", children: [
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Diagnosis codes, comma separated",
+            /* @__PURE__ */ jsx24("input", { value: diagnoses, onChange: (event) => {
+              action.clear();
+              setDiagnoses(event.target.value);
+            } })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Notes",
+            /* @__PURE__ */ jsx24("textarea", { maxLength: 5e3, value: content.notes ?? "", onChange: (event) => {
+              action.clear();
+              setContent({ ...content, notes: nullable(event.target.value) });
+            } })
+          ] })
+        ] })
+      ] }),
+      content.lines.map((line, index) => /* @__PURE__ */ jsxs24("fieldset", { disabled: locked, children: [
+        /* @__PURE__ */ jsxs24("legend", { children: [
+          "Service ",
+          index + 1
+        ] }),
+        /* @__PURE__ */ jsxs24("div", { className: "mbtd-grid", children: [
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Dental code",
+            /* @__PURE__ */ jsx24("input", { placeholder: "D0120", maxLength: 5, value: line.code ?? "", onChange: (event) => updateLine(index, { code: nullable(event.target.value.toUpperCase()) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Code edition year",
+            /* @__PURE__ */ jsx24("input", { type: "number", min: 1900, max: 2200, value: line.editionYear ?? "", onChange: (event) => updateLine(index, { editionYear: event.target.value === "" ? null : Number(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Date of service",
+            /* @__PURE__ */ jsx24("input", { type: "date", value: line.serviceDate ?? "", onChange: (event) => updateLine(index, { serviceDate: nullable(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Quantity",
+            /* @__PURE__ */ jsx24("input", { type: "number", min: 1, max: 1e5, step: 1, value: line.quantity, onChange: (event) => updateLine(index, { quantity: Number(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Extended line charge ($)",
+            /* @__PURE__ */ jsx24("input", { inputMode: "decimal", placeholder: "Unknown", value: charges[index] ?? "", onChange: (event) => {
+              action.clear();
+              setCharges(charges.map((value, position) => position === index ? event.target.value : value));
+            } }),
+            /* @__PURE__ */ jsx24("small", { children: "Includes all units. This is the practice charge, not a fee allowance." })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Charge source / reference",
+            /* @__PURE__ */ jsx24("input", { maxLength: 1e3, value: line.chargeReference ?? "", onChange: (event) => updateLine(index, { chargeReference: nullable(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Teeth, comma separated",
+            /* @__PURE__ */ jsx24("input", { value: teeth[index] ?? "", onChange: (event) => {
+              action.clear();
+              setTeeth(teeth.map((value, position) => position === index ? event.target.value : value));
+            } })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Surfaces, comma separated",
+            /* @__PURE__ */ jsx24("input", { value: surfaces[index] ?? "", onChange: (event) => {
+              action.clear();
+              setSurfaces(surfaces.map((value, position) => position === index ? event.target.value.toUpperCase() : value));
+            } })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Oral cavity",
+            /* @__PURE__ */ jsx24("input", { maxLength: 100, value: line.oralCavity ?? "", onChange: (event) => updateLine(index, { oralCavity: nullable(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { children: [
+            "Service description",
+            /* @__PURE__ */ jsx24("input", { maxLength: 1e3, value: line.description ?? "", onChange: (event) => updateLine(index, { description: nullable(event.target.value) }) })
+          ] }),
+          /* @__PURE__ */ jsxs24("label", { className: "mbtd-wide", children: [
+            "Prosthesis notes",
+            /* @__PURE__ */ jsx24("textarea", { maxLength: 2e3, value: line.prosthesisNotes ?? "", onChange: (event) => updateLine(index, { prosthesisNotes: nullable(event.target.value) }) })
+          ] })
+        ] }),
+        /* @__PURE__ */ jsx24("div", { className: "mbtd-actions", children: /* @__PURE__ */ jsxs24("button", { type: "button", onClick: () => {
+          action.clear();
+          setContent({ ...content, lines: content.lines.filter((_, position) => position !== index) });
+          setCharges(charges.filter((_, position) => position !== index));
+          setTeeth(teeth.filter((_, position) => position !== index));
+          setSurfaces(surfaces.filter((_, position) => position !== index));
+        }, children: [
+          "Remove service ",
+          index + 1
+        ] }) })
+      ] }, index)),
+      /* @__PURE__ */ jsx24("div", { children: /* @__PURE__ */ jsx24("button", { type: "button", disabled: locked || content.lines.length >= 100, onClick: () => {
+        action.clear();
+        setContent({ ...content, lines: [...content.lines, blankLine2()] });
+        setCharges([...charges, ""]);
+        setTeeth([...teeth, ""]);
+        setSurfaces([...surfaces, ""]);
+      }, children: "Add dental service" }) }),
+      /* @__PURE__ */ jsx24("p", { role: "status", children: summary ? summary.totalChargeCents === null ? `Known charges: ${currency2(summary.knownChargeCents)} \xB7 Total incomplete` : `Total practice charge: ${currency2(summary.totalChargeCents)}` : "Review charge amounts before saving." }),
+      action.error ? /* @__PURE__ */ jsx24("p", { role: "alert", children: action.error }) : null,
+      /* @__PURE__ */ jsxs24("div", { className: "mbtd-actions", children: [
+        /* @__PURE__ */ jsx24("button", { type: "submit", className: "mbtd-primary", disabled: locked, children: action.busy ? "Saving\u2026" : "Save dental draft" }),
+        /* @__PURE__ */ jsx24("p", { role: "status", children: action.message })
+      ] })
+    ] })
+  ] });
+}
+
+// src/rfa-draft-form.tsx
+import { useState as useState21 } from "react";
+import { jsx as jsx25, jsxs as jsxs25 } from "react/jsx-runtime";
+function normalizeRfaDraft(draft) {
+  const copy = structuredClone(draft);
+  for (const item of copy.items) {
+    for (const key of ["externalId", "procedureCode", "frequency", "duration", "requestedFrom", "requestedTo"]) {
+      if (item[key] !== void 0 && !item[key]?.trim()) delete item[key];
+    }
+  }
+  delete copy.signedAt;
+  return copy;
+}
+function validateRfaDraft(draft) {
+  for (const value of [draft.claimId, draft.patientId, draft.renderingProviderId]) if (!value.trim() || value.length > 255) return "Select a claim, patient, and rendering provider in the host application.";
+  for (const value of [draft.externalId, draft.claimsAdminId]) if (value !== void 0 && (!value.trim() || value.length > 255)) return "Check the request and claims administrator identifiers.";
+  for (const value of [draft.employeeName, draft.providerName]) if (!value.trim() || value.length > 200) return "Employee and provider names are required (up to 200 characters).";
+  if (draft.requestType !== void 0 && !["new", "resubmission_material_change", "oral_authorization_confirmation"].includes(draft.requestType)) return "Choose a valid request type.";
+  if (draft.reviewType !== void 0 && !["prospective", "concurrent", "retrospective"].includes(draft.reviewType)) return "Choose a valid review type.";
+  if (draft.requestType === "resubmission_material_change" && !draft.materialChange?.trim()) return "Describe the material change for this resubmission.";
+  if ((draft.rationale?.length ?? 0) > 2e4 || (draft.materialChange?.length ?? 0) > 2e4) return "Rationale and material change must each be at most 20,000 characters.";
+  if (draft.placeOfServiceCode !== void 0 && !/^\d{2}$/.test(draft.placeOfServiceCode)) return "Place of service must contain two digits.";
+  if ((draft.providerNpi?.length ?? 0) > 20 || (draft.providerPhone?.length ?? 0) > 30 || (draft.claimNumber?.length ?? 0) > 100) return "Check provider contact and claim number lengths.";
+  if (draft.providerFax && (draft.providerFax.length > 30 || !/^[+\d().\s-]+$/.test(draft.providerFax) || !/^\d{10,15}$/.test(draft.providerFax.replace(/\D/g, "")))) return "Enter a return fax with 10 to 15 digits, or leave it blank.";
+  if (draft.dateOfInjury !== void 0 && !isDraftDate(draft.dateOfInjury)) return "Check the injury date in the host application.";
+  if (draft.items.length < 1 || draft.items.length > 100) return "Include between 1 and 100 requested services.";
+  for (const [index, item] of draft.items.entries()) {
+    const prefix = `Service ${index + 1}: `;
+    if (!item.diagnosisCode.trim() || item.diagnosisCode.length > 16 || !item.serviceDescription.trim() || item.serviceDescription.length > 1e3) return prefix + "a diagnosis code and service description are required.";
+    for (const [value, max] of [[item.externalId, 255], [item.procedureCode, 16], [item.frequency, 200], [item.duration, 200]]) if (value !== void 0 && (!value.trim() || value.length > max)) return prefix + `optional text must contain 1 to ${max} characters.`;
+    if (item.units !== void 0 && (!Number.isInteger(item.units) || item.units < 1 || item.units > 1e5)) return prefix + "units must be a whole number between 1 and 100,000.";
+    if (item.quantity !== void 0 && (!Number.isFinite(item.quantity) || item.quantity <= 0 || item.quantity > 1e5)) return prefix + "quantity must be positive and at most 100,000.";
+    if (item.requestedFrom !== void 0 && !isDraftDate(item.requestedFrom) || item.requestedTo !== void 0 && (!isDraftDate(item.requestedTo) || !item.requestedFrom || item.requestedTo < item.requestedFrom)) return prefix + "enter valid dates with the end on or after the start.";
+  }
+  return null;
+}
+function RfaDraftForm({ initialDraft, onSave, disabled = false, ...appearance }) {
+  const [draft, setDraft] = useState21(() => normalizeRfaDraft(initialDraft));
+  const action = useDraftSave(onSave), locked = disabled || action.busy;
+  const update = (patch) => {
+    action.clear();
+    setDraft((current) => ({ ...current, ...patch }));
+  };
+  const updateItem = (index, patch) => {
+    action.clear();
+    setDraft((current) => ({ ...current, items: current.items.map((item, position) => position === index ? { ...item, ...patch } : item) }));
+  };
+  const updateNumber = (index, key, value) => {
+    action.clear();
+    setDraft((current) => ({ ...current, items: current.items.map((item, position) => {
+      if (position !== index) return item;
+      const next = { ...item };
+      if (value === "") delete next[key];
+      else next[key] = Number(value);
+      return next;
+    }) }));
+  };
+  return /* @__PURE__ */ jsxs25(TreatmentDraftShell, { ...appearance, title: "Request for authorization", description: "Prepare services and supporting rationale for utilization review.", children: [
+    /* @__PURE__ */ jsx25("p", { className: "mbtd-note", children: "Saving creates an unsigned draft. It does not send the request or authorize treatment." }),
+    /* @__PURE__ */ jsxs25("form", { onSubmit: (event) => {
+      event.preventDefault();
+      if (locked) return;
+      const next = normalizeRfaDraft(draft);
+      void action.save(next, validateRfaDraft(next));
+    }, children: [
+      /* @__PURE__ */ jsxs25("fieldset", { disabled: locked, children: [
+        /* @__PURE__ */ jsx25("legend", { children: "Request details" }),
+        /* @__PURE__ */ jsxs25("div", { className: "mbtd-grid", children: [
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Employee",
+            /* @__PURE__ */ jsx25("input", { readOnly: true, value: draft.employeeName })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Requesting provider",
+            /* @__PURE__ */ jsx25("input", { readOnly: true, value: draft.providerName })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Request type",
+            /* @__PURE__ */ jsxs25("select", { value: draft.requestType ?? "new", onChange: (event) => update({ requestType: event.target.value }), children: [
+              /* @__PURE__ */ jsx25("option", { value: "new", children: "New request" }),
+              /* @__PURE__ */ jsx25("option", { value: "resubmission_material_change", children: "Resubmission with material change" }),
+              /* @__PURE__ */ jsx25("option", { value: "oral_authorization_confirmation", children: "Confirm oral authorization" })
+            ] })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Review type",
+            /* @__PURE__ */ jsxs25("select", { value: draft.reviewType ?? "prospective", onChange: (event) => update({ reviewType: event.target.value }), children: [
+              /* @__PURE__ */ jsx25("option", { value: "prospective", children: "Prospective \u2014 before treatment" }),
+              /* @__PURE__ */ jsx25("option", { value: "concurrent", children: "Concurrent \u2014 during treatment" }),
+              /* @__PURE__ */ jsx25("option", { value: "retrospective", children: "Retrospective \u2014 after treatment" })
+            ] })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Review priority",
+            /* @__PURE__ */ jsxs25("select", { value: draft.expedited ? "expedited" : "standard", onChange: (event) => update({ expedited: event.target.value === "expedited" }), children: [
+              /* @__PURE__ */ jsx25("option", { value: "standard", children: "Standard" }),
+              /* @__PURE__ */ jsx25("option", { value: "expedited", children: "Expedited review requested" })
+            ] })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Return fax",
+            /* @__PURE__ */ jsx25("input", { maxLength: 30, value: draft.providerFax ?? "", onChange: (event) => update({ providerFax: event.target.value }) }),
+            /* @__PURE__ */ jsx25("small", { children: "Review the return contact. Organization defaults are not applied automatically." })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { className: "mbtd-wide", children: [
+            "Clinical rationale",
+            /* @__PURE__ */ jsx25("textarea", { maxLength: 2e4, value: draft.rationale ?? "", onChange: (event) => update({ rationale: event.target.value }) })
+          ] }),
+          draft.requestType === "resubmission_material_change" ? /* @__PURE__ */ jsxs25("label", { className: "mbtd-wide", children: [
+            "Material change (required)",
+            /* @__PURE__ */ jsx25("textarea", { required: true, maxLength: 2e4, value: draft.materialChange ?? "", onChange: (event) => update({ materialChange: event.target.value }) })
+          ] }) : null
+        ] })
+      ] }),
+      draft.items.map((item, index) => /* @__PURE__ */ jsxs25("fieldset", { disabled: locked, children: [
+        /* @__PURE__ */ jsxs25("legend", { children: [
+          "Requested service ",
+          index + 1
+        ] }),
+        /* @__PURE__ */ jsxs25("div", { className: "mbtd-grid", children: [
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Diagnosis code",
+            /* @__PURE__ */ jsx25("input", { required: true, maxLength: 16, value: item.diagnosisCode, onChange: (event) => updateItem(index, { diagnosisCode: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Procedure code",
+            /* @__PURE__ */ jsx25("input", { maxLength: 16, value: item.procedureCode ?? "", onChange: (event) => updateItem(index, { procedureCode: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { className: "mbtd-wide", children: [
+            "Service description",
+            /* @__PURE__ */ jsx25("textarea", { required: true, maxLength: 1e3, value: item.serviceDescription, onChange: (event) => updateItem(index, { serviceDescription: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Quantity",
+            /* @__PURE__ */ jsx25("input", { type: "number", min: 1e-3, max: 1e5, step: "any", value: item.quantity ?? "", onChange: (event) => updateNumber(index, "quantity", event.target.value) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Units",
+            /* @__PURE__ */ jsx25("input", { type: "number", min: 1, max: 1e5, step: 1, value: item.units ?? "", onChange: (event) => updateNumber(index, "units", event.target.value) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Frequency",
+            /* @__PURE__ */ jsx25("input", { maxLength: 200, value: item.frequency ?? "", onChange: (event) => updateItem(index, { frequency: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Duration",
+            /* @__PURE__ */ jsx25("input", { maxLength: 200, value: item.duration ?? "", onChange: (event) => updateItem(index, { duration: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Requested from",
+            /* @__PURE__ */ jsx25("input", { type: "date", value: item.requestedFrom ?? "", onChange: (event) => updateItem(index, { requestedFrom: event.target.value }) })
+          ] }),
+          /* @__PURE__ */ jsxs25("label", { children: [
+            "Requested through",
+            /* @__PURE__ */ jsx25("input", { type: "date", value: item.requestedTo ?? "", onChange: (event) => updateItem(index, { requestedTo: event.target.value }) })
+          ] })
+        ] }),
+        /* @__PURE__ */ jsxs25("button", { type: "button", disabled: draft.items.length === 1, onClick: () => update({ items: draft.items.filter((_, position) => position !== index) }), children: [
+          "Remove requested service ",
+          index + 1
+        ] })
+      ] }, index)),
+      /* @__PURE__ */ jsx25("div", { children: /* @__PURE__ */ jsx25("button", { type: "button", disabled: locked || draft.items.length >= 100, onClick: () => update({ items: [...draft.items, { diagnosisCode: "", serviceDescription: "" }] }), children: "Add requested service" }) }),
+      action.error ? /* @__PURE__ */ jsx25("p", { role: "alert", children: action.error }) : null,
+      /* @__PURE__ */ jsxs25("div", { className: "mbtd-actions", children: [
+        /* @__PURE__ */ jsx25("button", { type: "submit", className: "mbtd-primary", disabled: locked, children: action.busy ? "Saving\u2026" : "Save RFA draft" }),
+        /* @__PURE__ */ jsx25("p", { role: "status", children: action.message })
+      ] })
+    ] })
+  ] });
+}
+
 // src/index.tsx
 function widget(tagName, props) {
-  const ref = useRef11(null);
+  const ref = useRef12(null);
   const { onMindBill, onMindBillError } = props;
   useEffect16(() => {
     const element = ref.current;
@@ -8492,6 +8895,7 @@ export {
   DEFAULT_BILL_SUBMISSION_MODIFIERS,
   DEFAULT_BILL_SUBMISSION_PROCEDURES,
   DEFAULT_BILL_SUBMISSION_TAXONOMIES,
+  DentalDraftEditor,
   MED_LEGAL_REPORT_TYPE_CODE,
   MindBillBillReview,
   MindBillBillTimeline,
@@ -8501,6 +8905,7 @@ export {
   PSYCH_QME_DEFAULT_DIAGNOSIS,
   REPORT_BILL_STATUS_OPTIONS2 as REPORT_BILL_STATUS_OPTIONS,
   ReportBillStatusDialog,
+  RfaDraftForm,
   SECOND_REVIEW_REASON_TEMPLATE,
   SECOND_REVIEW_REASON_TEMPLATES,
   SECOND_REVIEW_WINDOW_DAYS,
@@ -8529,6 +8934,7 @@ export {
   createBillLifecycleClient2 as createBillLifecycleClient,
   createBillStatusClient,
   createBillingOperationsClient,
+  dentalDraftChargeSummary,
   ensureTrailingBillSubmissionLine,
   ensureTrailingProcedureLine,
   exactClaimsAdministratorMatch,
@@ -8539,8 +8945,10 @@ export {
   mindBillAppearanceStyle,
   mindBillThemePresets,
   normalizeClaimsAdministratorName,
+  normalizeRfaDraft,
   organizationProfileOptions,
   parseBillSubmissionDate,
+  parseDentalCharge,
   prepareBillSubmissionDocuments,
   reportBillStatusContacts2 as reportBillStatusContacts,
   resolveMindBillAppearance,
@@ -8550,6 +8958,8 @@ export {
   useBillLifecycle,
   useBillStatus,
   validateBillSubmission,
+  validateDentalDraftContent,
+  validateRfaDraft,
   visibleBillLifecycleActions
 };
 //# sourceMappingURL=index.js.map