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claim-page.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" />
<meta name="viewport" content="initial-scale=1.0, width=device-width" />
<title>Data Grid</title>
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-giJF6kkoqNQ00vy+HMDP7azOuL0xtbfIcaT9wjKHr8RbDVddVHyTfAAsrekwKmP1" crossorigin="anonymous" />
<link href="css/style.css" rel="stylesheet" />
<link href="vendor/RemixIcon/remixicon.css" rel="stylesheet" />
<link href="css/Fluid/temp/fluid.css" rel="stylesheet" />
<link href="css/Fluid/temp/custom.css" rel="stylesheet" />
</head>
<body>
<div class="global-wrapper global-indent sidebar-hidden">
<header class="header-block sticky right-0 z-100">
<div class="flex justify-between align-middle">
<h1 class="header-title">Individual</h1>
<div class="header-menu">
<div class="header-alert">
<a class="header-alert_button">
<div class="header-alert_button_svg">
<svg viewBox="0 0 16 20" xmlns="http://www.w3.org/2000/svg">
<path fill-rule="evenodd" clip-rule="evenodd" d="M14.88 12.88L15.71 13.71C15.8947 13.8963 15.9989 14.1477 16 14.41V15C16 15.5523 15.5523 16 15 16H1C0.447715 16 0 15.5523 0 15V14.41C0.00110462 14.1477 0.105256 13.8963 0.29 13.71L1.12 12.88C1.68277 12.3179 1.9993 11.5554 2 10.76V8C2 6.70178 2.42107 5.43858 3.2 4.4L4.1 3.2C4.66656 2.44458 5.55573 2 6.5 2H7V0.5C7 0.223858 7.22386 0 7.5 0H8.5C8.77614 0 9 0.223858 9 0.5V2H9.5C10.4443 2 11.3334 2.44458 11.9 3.2L12.8 4.4C13.5789 5.43858 14 6.70178 14 8V10.76C14.0007 11.5554 14.3172 12.3179 14.88 12.88ZM8 20C9.10457 20 10 19.1046 10 18H6C6 19.1046 6.89543 20 8 20Z" />
</svg>
</div>
<div class="header-alert_button_number"><span>1</span></div>
</a>
<div class="header-alert_list">
<div class="header-alert_title-clear-wrap">
<div class="header-alert_title">Notifications</div>
<a class="header-alert_clear">Clear all</a>
</div>
<ul>
<li class="header-alert_list_item header-alert_successfull">
<div class="header-alert_list_item_svg">
<svg viewBox="0 0 18 18" xmlns="http://www.w3.org/2000/svg">
<path fill-rule="evenodd" clip-rule="evenodd" d="M9 18C13.9706 18 18 13.9706 18 9C18 4.02944 13.9706 0 9 0C4.02944 0 0 4.02944 0 9C0 13.9706 4.02944 18 9 18Z" fill="#33AC2E" />
<path fill-rule="evenodd" clip-rule="evenodd" d="M11.8838 8.03496L8.66236 11.4793C8.38243 11.7736 7.92924 11.7736 7.65002 11.4793L5.83441 9.57132C5.5552 9.27704 5.5552 8.80061 5.83441 8.50633C6.11434 8.21279 6.56753 8.21279 6.84674 8.50633L8.15619 9.88292L10.8715 6.97071C11.1507 6.67643 11.6039 6.67643 11.8838 6.97071C12.1637 7.26425 12.1637 7.74067 11.8838 8.03496Z" fill="white" />
</svg>
</div>
<div class="header-alert_list_item_text">Successfull message</div>
<div class="header-alert_list_item_close">
<svg viewBox="0 0 10 10" xmlns="http://www.w3.org/2000/svg">
<path
d="M9.87496 8.69996C9.95384 8.77819 9.99821 8.88469 9.99821 8.99579C9.99821 9.10689 9.95384 9.21339 9.87496 9.29163L9.29163 9.87496C9.21339 9.95384 9.10689 9.99821 8.99579 9.99821C8.88469 9.99821 8.77819 9.95384 8.69996 9.87496L4.99996 6.17496L1.29996 9.87496C1.22172 9.95384 1.11522 9.99821 1.00412 9.99821C0.893026 9.99821 0.786528 9.95384 0.708292 9.87496L0.124958 9.29163C0.046078 9.21339 0.00170898 9.10689 0.00170898 8.99579C0.00170898 8.88469 0.046078 8.77819 0.124958 8.69996L3.82496 4.99996L0.124958 1.29996C0.046078 1.22172 0.00170898 1.11522 0.00170898 1.00412C0.00170898 0.893026 0.046078 0.786528 0.124958 0.708292L0.708292 0.124958C0.786528 0.046078 0.893026 0.00170898 1.00412 0.00170898C1.11522 0.00170898 1.22172 0.046078 1.29996 0.124958L4.99996 3.82496L8.69996 0.124958C8.77819 0.046078 8.88469 0.00170898 8.99579 0.00170898C9.10689 0.00170898 9.21339 0.046078 9.29163 0.124958L9.87496 0.708292C9.95384 0.786528 9.99821 0.893026 9.99821 1.00412C9.99821 1.11522 9.95384 1.22172 9.87496 1.29996L6.17496 4.99996L9.87496 8.69996Z"
/>
</svg>
</div>
</li>
<li class="header-alert_list_item header-alert_error">
<div class="header-alert_list_item_svg">
<svg viewBox="0 0 18 18" xmlns="http://www.w3.org/2000/svg">
<path fill-rule="evenodd" clip-rule="evenodd" d="M18 9C18 13.9706 13.9706 18 9 18C4.02944 18 0 13.9706 0 9C0 4.02944 4.02944 0 9 0C13.9706 0 18 4.02944 18 9ZM9 3.375C8.38609 3.375 7.89543 3.88568 7.91996 4.4991L8.12253 9.56317C8.14137 10.0341 8.52865 10.4062 9 10.4062C9.47135 10.4062 9.85863 10.0341 9.87747 9.56318L10.08 4.4991C10.1046 3.88568 9.61391 3.375 9 3.375ZM7.70636 13.0781C7.70636 12.3791 8.273 11.8125 8.97198 11.8125C9.67097 11.8125 10.2376 12.3791 10.2376 13.0781C10.2376 13.7771 9.67097 14.3438 8.97198 14.3438C8.273 14.3438 7.70636 13.7771 7.70636 13.0781Z" fill="#FF0B37" />
</svg>
</div>
<div class="header-alert_list_item_text">Error message</div>
<div class="header-alert_list_item_close">
<svg viewBox="0 0 10 10" xmlns="http://www.w3.org/2000/svg">
<path
d="M9.87496 8.69996C9.95384 8.77819 9.99821 8.88469 9.99821 8.99579C9.99821 9.10689 9.95384 9.21339 9.87496 9.29163L9.29163 9.87496C9.21339 9.95384 9.10689 9.99821 8.99579 9.99821C8.88469 9.99821 8.77819 9.95384 8.69996 9.87496L4.99996 6.17496L1.29996 9.87496C1.22172 9.95384 1.11522 9.99821 1.00412 9.99821C0.893026 9.99821 0.786528 9.95384 0.708292 9.87496L0.124958 9.29163C0.046078 9.21339 0.00170898 9.10689 0.00170898 8.99579C0.00170898 8.88469 0.046078 8.77819 0.124958 8.69996L3.82496 4.99996L0.124958 1.29996C0.046078 1.22172 0.00170898 1.11522 0.00170898 1.00412C0.00170898 0.893026 0.046078 0.786528 0.124958 0.708292L0.708292 0.124958C0.786528 0.046078 0.893026 0.00170898 1.00412 0.00170898C1.11522 0.00170898 1.22172 0.046078 1.29996 0.124958L4.99996 3.82496L8.69996 0.124958C8.77819 0.046078 8.88469 0.00170898 8.99579 0.00170898C9.10689 0.00170898 9.21339 0.046078 9.29163 0.124958L9.87496 0.708292C9.95384 0.786528 9.99821 0.893026 9.99821 1.00412C9.99821 1.11522 9.95384 1.22172 9.87496 1.29996L6.17496 4.99996L9.87496 8.69996Z"
/>
</svg>
</div>
</li>
<li class="header-alert_list_item header-alert_warning">
<div class="header-alert_list_item_svg">
<svg viewBox="0 0 16 16" xmlns="http://www.w3.org/2000/svg">
<path fill-rule="evenodd" clip-rule="evenodd" d="M2.375 5.75C2.375 2.6434 4.8934 0.125 8 0.125C11.1066 0.125 13.625 2.6434 13.625 5.75V9.125H14.1875C15.1195 9.125 15.875 9.88052 15.875 10.8125C15.875 11.7445 15.1195 12.5 14.1875 12.5H1.8125C0.88052 12.5 0.125 11.7445 0.125 10.8125C0.125 9.88052 0.88052 9.125 1.8125 9.125H2.375V5.75ZM8 15.875C9.24264 15.875 10.25 14.8676 10.25 13.625H5.75C5.75 14.8676 6.75736 15.875 8 15.875Z" fill="#FFB800" />
</svg>
</div>
<div class="header-alert_list_item_text">Warning message</div>
<div class="header-alert_list_item_close">
<svg viewBox="0 0 10 10" xmlns="http://www.w3.org/2000/svg">
<path
d="M9.87496 8.69996C9.95384 8.77819 9.99821 8.88469 9.99821 8.99579C9.99821 9.10689 9.95384 9.21339 9.87496 9.29163L9.29163 9.87496C9.21339 9.95384 9.10689 9.99821 8.99579 9.99821C8.88469 9.99821 8.77819 9.95384 8.69996 9.87496L4.99996 6.17496L1.29996 9.87496C1.22172 9.95384 1.11522 9.99821 1.00412 9.99821C0.893026 9.99821 0.786528 9.95384 0.708292 9.87496L0.124958 9.29163C0.046078 9.21339 0.00170898 9.10689 0.00170898 8.99579C0.00170898 8.88469 0.046078 8.77819 0.124958 8.69996L3.82496 4.99996L0.124958 1.29996C0.046078 1.22172 0.00170898 1.11522 0.00170898 1.00412C0.00170898 0.893026 0.046078 0.786528 0.124958 0.708292L0.708292 0.124958C0.786528 0.046078 0.893026 0.00170898 1.00412 0.00170898C1.11522 0.00170898 1.22172 0.046078 1.29996 0.124958L4.99996 3.82496L8.69996 0.124958C8.77819 0.046078 8.88469 0.00170898 8.99579 0.00170898C9.10689 0.00170898 9.21339 0.046078 9.29163 0.124958L9.87496 0.708292C9.95384 0.786528 9.99821 0.893026 9.99821 1.00412C9.99821 1.11522 9.95384 1.22172 9.87496 1.29996L6.17496 4.99996L9.87496 8.69996Z"
/>
</svg>
</div>
</li>
</ul>
</div>
</div>
<div class="header-language">
<a class="header-language_button">
<div class="header-language_img" style="background-image: url(img/header-language_img-1.png)"></div>
<div class="header-language_text">En</div>
<div class="header-language_arrow">
<svg viewBox="0 0 8 5" xmlns="http://www.w3.org/2000/svg">
<path d="M0.895104 1.29501C0.824112 1.2246 0.78418 1.12875 0.78418 1.02876C0.78418 0.928769 0.824112 0.832921 0.895104 0.762508L1.0451 0.612508C1.11566 0.539264 1.21341 0.498534 1.3151 0.500008H6.68511C6.78679 0.498534 6.88455 0.539264 6.95511 0.612508L7.10511 0.762508C7.1761 0.832921 7.21603 0.928769 7.21603 1.02876C7.21603 1.12875 7.1761 1.2246 7.10511 1.29501L4.2626 4.13751C4.19456 4.21002 4.09954 4.25115 4.0001 4.25115C3.90067 4.25115 3.80565 4.21002 3.7376 4.13751L0.895104 1.29501Z" fill="black" />
</svg>
</div>
</a>
<ul class="header-language_list">
<li>
<a class="language-ltr">
<div class="header-language_img" style="background-image: url(img/header-language_img-2.png)"></div>
<div class="header-language_text">De</div>
</a>
</li>
<li>
<a class="language-ltr">
<div class="header-language_img" style="background-image: url(img/header-language_img-3.png)"></div>
<div class="header-language_text">Ru</div>
</a>
</li>
<li>
<a class="language-ltr">
<div class="header-language_img" style="background-image: url(img/header-language_img-4.png)"></div>
<div class="header-language_text">Fr</div>
</a>
</li>
<li>
<a class="language-ltr">
<div class="header-language_img" style="background-image: url(img/header-language_img-5.png)"></div>
<div class="header-language_text">Cn</div>
</a>
</li>
<li>
<a class="language-rtl">
<div class="header-language_img" style="background-image: url(img/header-language_img-6.png)"></div>
<div class="header-language_text">SB</div>
</a>
</li>
</ul>
</div>
<div class="dropdown">
<button class="dropdown-trigger sidebar_link btn shadow-none">
<div class="dropdown_img" style="background-image: url(img/header-user_img.png)"></div>
Marcus Mango
</button>
<ul class="menu">
<li><a href="#">Edit Profile</a></li>
<li><a href="#">Log out</a></li>
</ul>
</div>
</div>
</div>
<div class="flex justify-center align-middle p-0">
<ul class="sidebar_list flex align-middle flex-wrap px-0 mb-0">
<li class="sidebar_item">
<a class="sidebar_link" href="index.html">
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Create Claim & Insert Service
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data-bs-toggle="popover"
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data-bs-content='
<form>
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<label class="block"><span class="label mb-2 inline-block">Gross</span><input type="text" class="input"/></label>
<label class="block"><span class="label mb-2 inline-block">Rejected Reason</span><textarea rows="2" class="input"></textarea></label>
</form>'
>
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Reject All
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</div>
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<div>
<div class="tab-content tab-active">
<div class="table-block table-event-block data-grid-table">
<table class="table">
<thead>
<tr>
<th class="txt-nowrap table_filter">invoice no</th>
<th class="txt-nowrap table_filter">D.O.T</th>
<th class="txt-nowrap table_filter">Medical Service</th>
<th class="txt-nowrap table_filter">Gross</th>
<th class="txt-nowrap table_filter">Rejected</th>
<th class="table_filter">Rej Reason</th>
<th class="txt-nowrap w-4">Alert</th>
<th class="txt-nowrap w-2">Actions</th>
</tr>
</thead>
<tbody>
<tr class="data">
<td class="txt-nowrap">19194132HJJ</td>
<td class="txt-nowrap">11/20/2018</td>
<td class="txt-nowrap">Nursing care</td>
<td class="txt-nowrap">231</td>
<td class="txt-nowrap">
195
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
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<button class="btn is-sld is-error">Reject</button>
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<i class="icon ri-2x ri-forbid-line"></i>
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</td>
<td>Lorem ipsum dolor sit amet consectetur adipisicing elit. Rerum, iure facilis saepe, at fugiat unde ab recusandae animi</td>
<td>
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
<div class="txt-center">
<p>Lorem ipsum dolor, sit amet consectetur adipisicing elit. Autem voluptatum magni quasi porro neque repellendus accusamus</p>
<button class="btn is-sld is-error">Reject</button>
<button class="btn is-sld is-valid">Resolve</button>
<button class="btn is-sld is-warn">Ignore</button>
</div>'
>
<i class="icon ri-2x ri-forbid-line"></i>
</button>
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
<div class="txt-center">
<p>Lorem ipsum dolor, sit amet consectetur adipisicing elit. Autem voluptatum magni quasi porro neque repellendus accusamus</p>
<button class="btn is-sld is-error">Reject</button>
<button class="btn is-sld is-valid">Resolve</button>
<button class="btn is-sld is-warn">Ignore</button>
</div>'
>
<i class="icon ri-2x ri-question-line"></i>
</button>
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
<div class="txt-center">
<p>Lorem ipsum dolor, sit amet consectetur adipisicing elit. Autem voluptatum magni quasi porro neque repellendus accusamus</p>
<button class="btn is-sld is-error">Reject</button>
<button class="btn is-sld is-valid">Resolve</button>
<button class="btn is-sld is-warn">Ignore</button>
</div>'
>
<i class="icon ri-2x ri-question-line"></i>
</button>
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
<div class="txt-center">
<p>Lorem ipsum dolor, sit amet consectetur adipisicing elit. Autem voluptatum magni quasi porro neque repellendus accusamus</p>
<button class="btn is-sld is-error">Reject</button>
<button class="btn is-sld is-valid">Resolve</button>
<button class="btn is-sld is-warn">Ignore</button>
</div>'
>
<i class="icon ri-2x ri-error-warning-line"></i>
</button>
<button
type="button"
class="icon is-circle badge is-sm p-1rem btn is-error inline-flex align-middle"
data-bs-toggle="popover"
data-bs-placement="bottom"
data-bs-content='
<div class="txt-center">
<p>Lorem ipsum dolor, sit amet consectetur adipisicing elit. Autem voluptatum magni quasi porro neque repellendus accusamus</p>
<button class="btn is-sld is-error">Reject</button>
<button class="btn is-sld is-valid">Resolve</button>
<button class="btn is-sld is-warn">Ignore</button>
</div>'
>
<i class="icon ri-2x ri-error-warning-line"></i>
</button>
</td>
<td>
<button type="button" data-button="edit" class="btn is-sld inline-flex align-middle is-secondary">Edit <i class="ml-8 icon ri-edit-2-line"></i></button>
</td>
</tr>
<tr class="description">
<td class="bg-warn" colspan="24">Lorem ipsum dolor sit amet consectetur adipisicing elit. Rerum, iure facilis saepe, at fugiat unde ab recusandae animi, blanditiis voluptas quod pariatur eos provident exercitationem tempora odit dolor libero laudantium.</td>
</tr>
<tr class="editform" style="display: none">
<td colspan="24">
<div class="grid">
<div class="column grid p-0">
<label class="column w-12 control">
<span class="label inline-block mb-2">D.O.T</span>
<input class="input col" type="date" />
</label>
<label class="column w-12 control">
<span class="label inline-block mb-2">Medical Service</span>
<input class="input col" type="text" />
</label>
<label class="column w-12 control">
<span class="label inline-block mb-2">Gross</span>
<input class="input col" min="0" type="number" />
</label>
<label class="column w-12 control">
<span class="label inline-block mb-2">Rejected</span>
<input class="input col" min="0" type="number" />
</label>
</div>
<label class="column w-8 control flex is-y">
<span class="label inline-block mb-2">Rejected Reason</span>
<textarea rows="4" class="input col"></textarea>
</label>
</div>
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<div class="create-filter-block">
<a class="create-filter" href="#">
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<path d="M4.66667 7.22C4.66695 6.86464 4.52536 6.52386 4.27333 6.27333L0.393334 2.39333C0.141308 2.1428 -0.000281165 1.80203 4.19197e-07 1.44667V0.666667C4.19197e-07 0.298477 0.298477 0 0.666667 0H11.3333C11.7015 0 12 0.298477 12 0.666667V1.44667C12.0003 1.80203 11.8587 2.1428 11.6067 2.39333L7.72667 6.27333C7.47464 6.52386 7.33305 6.86464 7.33333 7.22V9.66667C7.33333 10.0863 7.13574 10.4815 6.8 10.7333L5.2 11.9333C5.099 12.0091 4.96386 12.0213 4.85093 11.9648C4.738 11.9083 4.66667 11.7929 4.66667 11.6667V7.22Z" />
</svg>
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<div class="create-filter_text">Create Filter</div>
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<form>
<table>
<tr>
<th>
<div class="table_checkbox">
<input id="table_checkbox_1" name="table_checkbox_1" type="checkbox" />
<label for="table_checkbox_1"></label>
</div>
</th>
<th>
<span class="table_filter">Ind Number</span>
</th>
<th>
<span class="table_filter">Family Number</span>
</th>
<th>
<span class="table_filter">First Name</span>
</th>
<th>
<span class="table_filter">Last Name</span>
</th>
<th>
<span class="table_filter">Father’s Name</span>
</th>
<th>
<span class="table_filter">Mother’s Name</span>
</th>
<th>Actions</th>
</tr>
<tr>
<td>19194132HJJ</td>
<td>19194132HJJ</td>
<td>George</td>
<td>Malone</td>
<td>Abdul</td>
<td>Hanna</td>
</tr>
<tr>
<td>19194132HJJ</td>
<td>19194132HJJ</td>
<td>George</td>
<td>Malone</td>
<td>Abdul</td>
<td>Giana</td>
</tr>
<tr>
<td>19194132HJJ</td>
<td>19194132HJJ</td>
<td>George</td>
<td>Malone</td>
<td>Abdul</td>
<td>Skylar</td>
</tr>
</table>
<div class="create-filter-block">
<a class="create-filter" href="#">
<div class="create-filter_svg">
<svg viewBox="0 0 12 12" xmlns="http://www.w3.org/2000/svg">
<path d="M4.66667 7.22C4.66695 6.86464 4.52536 6.52386 4.27333 6.27333L0.393334 2.39333C0.141308 2.1428 -0.000281165 1.80203 4.19197e-07 1.44667V0.666667C4.19197e-07 0.298477 0.298477 0 0.666667 0H11.3333C11.7015 0 12 0.298477 12 0.666667V1.44667C12.0003 1.80203 11.8587 2.1428 11.6067 2.39333L7.72667 6.27333C7.47464 6.52386 7.33305 6.86464 7.33333 7.22V9.66667C7.33333 10.0863 7.13574 10.4815 6.8 10.7333L5.2 11.9333C5.099 12.0091 4.96386 12.0213 4.85093 11.9648C4.738 11.9083 4.66667 11.7929 4.66667 11.6667V7.22Z" />
</svg>
</div>
<div class="create-filter_text">Create Filter</div>
</a>
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</form>
</div>
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<option>Test 6</option>
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</optgroup>
</select>
<span class="label w-8">Provider :</span>
</label>
</div>
<div class="column w-12">
<label class="control grid align-middle has-gap-0">
<select class="order-1 input w-auto flex-grow">
<option>Please Select</option>
<optgroup label="tesing">
<option>Test 1</option>
<option>Test 2</option>
<option>Test 3</option>
<option>Test 4</option>
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</optgroup>
<optgroup label="tesing">
<option>Test 6</option>
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<option>Test 10</option>
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</optgroup>
</select>
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</label>
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<label class="control grid align-middle has-gap-0"><input class="order-1 input w-auto flex-grow" type="text" /> <span class="label column w-8">Cur Name :</span> </label>
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<label class="control grid align-middle has-gap-0"><input class="order-1 input w-auto flex-grow" type="text" /> <span class="label column w-8">Cur :</span> </label>
</div>
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<label class="control grid"><textarea class="order-1 input w-auto flex-grow" rows="3"></textarea> <span class="label column w-8">Note :</span> </label>
</div>
</div>
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<button class="inline-flex align-middle btn is-sld is-primary" type="button">Create Batch</button>
<button class="inline-flex align-middle btn is-sld is-valid" type="button">Create & go to batch</button>
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