._section_ijp9x_1{border-radius:6px;padding:.5rem;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._physicianOrSupplierDivider_ijp9x_8{margin-top:1rem}._fullWidth_ijp9x_12{width:100%}._reservedForNuccField_ijp9x_16{height:44px}._error_ijp9x_20{position:absolute;top:5px;right:1rem;color:var(--error-color, #ff4d4f);padding-bottom:5px}._formRow_ijp9x_28{margin-block:8px}._emptyField_ijp9x_32{height:58px}._wrapper_h877i_1{position:relative;display:flex;flex-direction:column}._wrapper_h877i_1 ._error_h877i_6{position:absolute;right:12px;top:50%;transform:translateY(-50%);color:var(--error-color);z-index:3}._wrapper_h877i_1._errorWide_h877i_14 ._error_h877i_6{right:2rem}._wrapper_h877i_1 ._label_h877i_17{position:absolute;left:12px;top:50%;transform:translateY(-50%);color:var(--text-color-help, #6c757d);font-size:var(--font-size, 16px);pointer-events:none;transition:all .2s;z-index:2}._wrapper_h877i_1 ._label_h877i_17 ._asterisk_h877i_28{color:var(--primary-color);margin-inline-start:4px;font-size:var(--font-size);font-family:SimSun,sans-serif;line-height:1}._wrapper_h877i_1 input:not(:-moz-placeholder)+._label_h877i_17,._wrapper_h877i_1 textarea:not(:-moz-placeholder)+._label_h877i_17{top:-4px;left:8px;font-size:12px;background:var(--neutral-white-color, #fff);padding:0 4px;transform:none}._wrapper_h877i_1 input:focus+._label_h877i_17,._wrapper_h877i_1 input:not(:placeholder-shown)+._label_h877i_17,._wrapper_h877i_1 textarea:focus+._label_h877i_17,._wrapper_h877i_1 textarea:not(:placeholder-shown)+._label_h877i_17,._wrapper_h877i_1 select:focus+._label_h877i_17,._wrapper_h877i_1 select:not([value=""])+._label_h877i_17,._wrapper_h877i_1 ._ant-picker-focused_h877i_41+._label_h877i_17,._wrapper_h877i_1 ._ant-picker_h877i_41 ._ant-picker-input_h877i_42>input[value]:not([value=""])+._label_h877i_17,._wrapper_h877i_1 ._active_h877i_43{top:-4px;left:8px;font-size:12px;background:var(--neutral-white-color, #fff);padding:0 4px;transform:none}._wrapper_h877i_1 ._label_h877i_17._small_h877i_51._active_h877i_43{font-size:10px}._formRow_bul0f_1{margin-block:4px}._reservedForNuccField_bul0f_5{height:44px}._section_bul0f_9{border-radius:6px;padding:.5rem;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._title_16l21_1{color:var(--text-color-help, #6c757d);padding-bottom:5px;overflow:hidden;white-space:nowrap;text-overflow:ellipsis}._title_16l21_1 ._asterisk_16l21_8{color:var(--primary-color);margin-inline-start:4px;font-size:var(--font-size);font-family:SimSun,sans-serif;line-height:1}._section_4y0d8_1{border-radius:6px;padding:.5rem;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._fullWidth_4y0d8_8{width:100%}._provider_4y0d8_12 ._input_4y0d8_12 .ant-input{height:35px;line-height:35px;font-size:12px}._provider_4y0d8_12 ._npi_4y0d8_17,._provider_4y0d8_12 ._otherId_4y0d8_18{display:flex;flex-direction:row}._provider_4y0d8_12 ._npi_4y0d8_17{margin-top:4px}._provider_4y0d8_12 ._npi_4y0d8_17 ._field_4y0d8_25{width:100%}._provider_4y0d8_12 ._title_4y0d8_28{color:var(--text-color-help, #6c757d);margin-right:.5rem;display:flex;align-items:center}._section_kqbqi_1{border-radius:6px;padding:.5rem;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._fullWidth_kqbqi_8{width:100%}._diagnosis_kqbqi_12 ._icd_kqbqi_12{margin-left:auto}._diagnosis_kqbqi_12 ._icd_kqbqi_12 .ant-select{height:35px;line-height:35px}._diagnosis_kqbqi_12 ._icd_kqbqi_12 .ant-select .ant-select-selector{font-size:12px}._diagnosis_kqbqi_12 .ant-select{height:40px;line-height:40px}._diagnosis_kqbqi_12 ._list_kqbqi_26{margin-top:4px}._diagnosis_kqbqi_12 ._error_kqbqi_29{color:var(--error-color, #ff4d4f);padding-bottom:5px}._diagnose_kqbqi_34{display:flex;flex-direction:row;margin-bottom:4px}._diagnose_kqbqi_34 ._field_kqbqi_39{width:100%}._diagnose_kqbqi_34 ._pointer_kqbqi_42{color:var(--text-color-help, #6c757d);min-width:1rem;display:flex;align-items:center}._scrollContainer_1bv76_1{width:100%;overflow-x:auto}._table_1bv76_6{border-collapse:collapse;width:100%;color:var(--text-color-help, #6c757d)}._table_1bv76_6 th,._table_1bv76_6 td{font-weight:400;border:1px solid #bbb;padding:4px;text-align:center;vertical-align:middle}._smallInput_1bv76_20{width:3rem}._familyPlan_1bv76_24{width:7rem}._divider_1bv76_28{margin-block:4px}._npi_1bv76_32{height:30px}._qualifier_1bv76_36 .ant-select{height:30px;line-height:30px}._qualifier_1bv76_36 .ant-select .ant-select-selector{font-size:12px}._providerId_1bv76_44 .ant-input{height:30px;line-height:30px;font-size:12px}._addBtn_1bv76_50{margin-top:1rem}._minWidthInput_1bv76_54{min-width:10rem}._paymentDetailsRow_1bv76_58{background-color:var(--mod-coverage-service-payment-details-bg-color, #e9f3ff)}._paymentDetailsRow_1bv76_58 td{vertical-align:top}._paymentDetailsRow_1bv76_58 td>div:first-child{margin-bottom:8px}._fullWidth_1bv76_68{width:100%}._formRow_1bv76_72{margin-block:8px}._modInline_1bv76_76{display:grid;grid-template-columns:repeat(4,minmax(3rem,1fr));gap:4px}._adjustmentList_1bv76_82{display:grid;gap:8px}._adjustmentRow_1bv76_87{display:grid;grid-template-columns:repeat(4,minmax(90px,1fr)) auto;gap:8px;align-items:start}._adjustmentDeleteBtn_1bv76_94{place-self:center}._section_1u3nf_1{border-radius:6px;padding:.5rem;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._formRow_1u3nf_8{margin-block:4px}._reservedForNuccField_1u3nf_12{height:44px}._insuranceSelect_11lqv_1,._referenceCheckbox_11lqv_5{width:100%}._selectionRow_11lqv_9{width:100%;margin-top:.5em}._claimDetailsViewFormContent_20q40_1>*{margin-top:.75em;margin-bottom:.75em}._labeledValueWrapper_20q40_6{display:flex;flex-direction:column;gap:8px}._claimDetailsHeader_20q40_12{display:flex;align-items:baseline}._alignedHeader_20q40_17{margin-right:1em}._summary_20q40_21{font-weight:600}._erasList_20q40_25{max-height:450px;overflow-y:auto}._labeledValueWrapper_vzx96_1{display:flex;flex-direction:column;gap:8px}._fullWidth_vzx96_7{width:100%}._table_vzx96_11,._listItem_vzx96_12{margin-block:1rem}._tableWrap_ywft2_1{width:100%;overflow-x:auto}._table_ywft2_1{width:100%;border-collapse:separate;border-spacing:0}._thead_ywft2_12 th{text-align:left;padding:12px 16px;font-weight:600;border-bottom:1px solid var(--mod-coverage-table-border-color, #f0f0f0);white-space:nowrap}._tbody_ywft2_20 td{padding:12px 16px;border-bottom:1px solid var(--mod-coverage-table-border-color, #f0f0f0);vertical-align:middle}._row_ywft2_26:hover td{background:var(--mod-coverage-table-row-hover-color, #f4f2fa)}._row_ywft2_26{height:90px}._formCell_ywft2_34{position:relative}._formCell_ywft2_34 .ant-form-item{margin-bottom:0}._formCell_ywft2_34 .ant-form-item-explain{position:absolute}._table_ywft2_1 thead tr:first-child th:first-child{border-top-left-radius:8px}._table_ywft2_1 thead tr:first-child th:last-child{border-top-right-radius:8px}._tableWrap_ywft2_1 ._tbody_ywft2_20 tr:last-child td:first-child{border-bottom-left-radius:8px}._tableWrap_ywft2_1 ._tbody_ywft2_20 tr:last-child td:last-child{border-bottom-right-radius:8px}._amountInput_ywft2_58{width:150px}._writeOffInput_ywft2_62 .ant-input-number-group-wrapper,._writeOffInput_ywft2_62 .ant-input-number-affix-wrapper,._writeOffInput_ywft2_62 .ant-input-number{width:100px}._fullWidth_1rwwh_1{width:100%}._alignEnd_1rwwh_5{display:flex;justify-content:flex-end}._details_1rwwh_10{border-radius:6px;padding:1rem .5rem 0;background-color:var(--mod-coverage-details-bg-color, #fafafa);margin-bottom:1rem}._hint_1rwwh_17{margin-bottom:1rem}._warning_14rff_1{color:var(--color-warning)}._warning_14rff_1>._warningHeader_14rff_4{margin-right:2cqw}._error_14rff_8{color:var(--color-warning)}._error_14rff_8>._errorHeader_14rff_11{margin-right:2cqw}._response_14rff_15{border:1px;border-color:#000;background-color:#eeebeb;border-radius:15px;padding:1em;margin-top:.5em}._groupDescription_14rff_24{margin-bottom:.5rem}._planGroupNumber_14rff_28{margin-left:.25rem}