<!-- Step Progress -->
<div id="progress-bar" style="margin-bottom: 30px;">
  <div style="display: flex; justify-content: space-between; margin-bottom: 10px;">
    <div class="progress-step active" id="step1">1. Denial Info</div>
    <div class="progress-step" id="step2">2. Claim Details</div>
    <div class="progress-step" id="step3">3. Supporting Info</div>
    <div class="progress-step" id="step4">4. Generate Letter</div>
  </div>
  <div style="background: #e9ecef; height: 4px; border-radius: 2px;">
    <div id="progress-fill" style="background: #007bff; height: 100%; width: 25%; border-radius: 2px; transition: width 0.3s;"></div>
  </div>
</div>

<!-- Form Container -->
<div id="form-container">

  <!-- Step 1: Denial Information -->
  <div id="form-step-1" class="form-step active">
    <h3>Step 1: Denial Information</h3>

    <div class="form-group">
      <label for="denial-code">Denial Code:</label>
      <select id="denial-code" onchange="updateDenialDescription()">
        <option value="">Select denial code...</option>
        <option value="CO-16">CO-16 - Claim lacks information</option>
        <option value="CO-97">CO-97 - Timely filing</option>
        <option value="CO-11">CO-11 - Diagnosis inconsistent with procedure</option>
        <option value="CO-197">CO-197 - Missing prior authorization</option>
        <option value="CO-18">CO-18 - Duplicate claim</option>
        <option value="CO-29">CO-29 - Service date after death</option>
        <option value="CO-109">CO-109 - Claim not covered</option>
        <option value="CO-151">CO-151 - Payment denied</option>
        <option value="OTHER">Other - Custom reason</option>
      </select>
    </div>

    <div class="form-group">
      <label for="denial-description">Denial Description:</label>
      <textarea id="denial-description" rows="3" placeholder="Full denial reason as stated by insurance company..."></textarea>
    </div>

    <div class="form-group">
      <label for="denial-amount">Denial Amount:</label>
      <input type="text" id="denial-amount" placeholder="$0.00" />
    </div>

    <div class="form-group">
      <label for="denial-date">Denial Date:</label>
      <input type="date" id="denial-date" />
    </div>

    <button onclick="nextStep(2)" class="btn-primary">Next: Claim Details →</button>
  </div>

  <!-- Step 2: Claim Details -->
  <div id="form-step-2" class="form-step">
    <h3>Step 2: Claim Details</h3>

    <div class="form-group">
      <label for="claim-number">Claim Number:</label>
      <input type="text" id="claim-number" placeholder="Insurance claim number..." />
    </div>

    <div class="form-group">
      <label for="patient-name">Patient Name:</label>
      <input type="text" id="patient-name" placeholder="Patient full name..." />
    </div>

    <div class="form-group">
      <label for="patient-dob">Patient Date of Birth:</label>
      <input type="date" id="patient-dob" />
    </div>

    <div class="form-group">
      <label for="service-date">Service Date:</label>
      <input type="date" id="service-date" />
    </div>

    <div class="form-group">
      <label for="provider-name">Provider/Practice Name:</label>
      <input type="text" id="provider-name" placeholder="Dr. Smith / ABC Medical Practice" />
    </div>

    <div class="form-group">
      <label for="insurance-company">Insurance Company:</label>
      <input type="text" id="insurance-company" placeholder="Aetna, Blue Cross, etc." />
    </div>

    <div style="display: flex; gap: 10px;">
      <button onclick="previousStep(1)" class="btn-secondary">← Previous</button>
      <button onclick="nextStep(3)" class="btn-primary">Next: Supporting Info →</button>
    </div>
  </div>

  <!-- Step 3: Supporting Information -->
  <div id="form-step-3" class="form-step">
    <h3>Step 3: Supporting Information</h3>

    <div class="form-group">
      <label for="cpt-codes">CPT Codes:</label>
      <input type="text" id="cpt-codes" placeholder="99213, 36415, etc." />
    </div>

    <div class="form-group">
      <label for="icd-codes">ICD-10 Diagnosis Codes:</label>
      <input type="text" id="icd-codes" placeholder="Z00.00, M25.511, etc." />
    </div>

    <div class="form-group">
      <label for="medical-necessity">Medical Necessity Justification:</label>
      <textarea id="medical-necessity" rows="4" placeholder="Why was this service medically necessary? Include clinical details, symptoms, or conditions that justified the treatment..."></textarea>
    </div>

    <div class="form-group">
      <label for="supporting-docs">Supporting Documentation (list what you're including):</label>
      <textarea id="supporting-docs" rows="3" placeholder="• Medical records from [date]&#10;• Lab results showing...&#10;• Provider notes documenting..."></textarea>
    </div>

    <div class="form-group">
      <label for="additional-info">Additional Information:</label>
      <textarea id="additional-info" rows="3" placeholder="Any other relevant details, timeline issues, or special circumstances..."></textarea>
    </div>

    <div style="display: flex; gap: 10px;">
      <button onclick="previousStep(2)" class="btn-secondary">← Previous</button>
      <button onclick="nextStep(4)" class="btn-primary">Next: Generate Letter →</button>
    </div>
  </div>

  <!-- Step 4: Generated Letter -->
  <div id="form-step-4" class="form-step">
    <h3>Step 4: Your Professional Appeal Letter</h3>

    <div style="margin-bottom: 20px;">
      <div style="display: flex; gap: 10px; margin-bottom: 15px;">
        <button onclick="generateAppeal()" class="btn-primary">Generate Appeal Letter</button>
        <button onclick="copyAppealText()" class="btn-secondary">Copy to Clipboard</button>
        <button onclick="emailAppeal()" class="btn-secondary">Email Letter</button>
        <button onclick="printAppeal()" class="btn-secondary">Print Letter</button>
      </div>

      <div style="display: flex; gap: 10px; align-items: center;">
        <label>
          <input type="checkbox" id="include-urgency" onchange="generateAppeal()" />
          Include urgency language
        </label>
        <label>
          <input type="checkbox" id="include-legal" onchange="generateAppeal()" />
          Include contract references
        </label>
        <label>
          <input type="checkbox" id="formal-tone" checked onchange="generateAppeal()" />
          Formal business tone
        </label>
      </div>
    </div>

    <div id="appeal-letter-output" style="background: white; border: 1px solid #ddd; padding: 20px; min-height: 400px; font-family: 'Times New Roman', serif; line-height: 1.6;">
      <em>Click "Generate Appeal Letter" to create your custom appeal...</em>
    </div>

    <div style="margin-top: 20px; display: flex; gap: 10px;">
      <button onclick="previousStep(3)" class="btn-secondary">← Edit Information</button>
      <button onclick="resetForm()" class="btn-secondary">Start New Appeal</button>
    </div>
  </div>

</div>