Charge Payment (CP) Section

BOX_00A

CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PROV.PROVNAME, EVPV.EVNTTYPE,
EVPV.EVNTBEGM, EVPV.EVNTBEGD, EVPV.EVNTBEGY,
EVPV.EVNTENDM, EVPV.EVNTENDD, EVPV.EVNTENDY,
PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY,
PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY,
EVPV.RVNAME, FFEE.FFEENAME

DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE
CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’
(PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL
EXPENSES). OTHERWISE, USE NULL VALUE.

DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT
TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’
(OTHER MEDICAL EXPENSES).

DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT
TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER
MEDICAL EXPENSES).

DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT
GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A
REPEAT VISIT STEM.

DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT
GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A
FLAT FEE STEM.

FOR ‘{EVN - DT}’, DISPLAYED IN THE CONTEXT HEADER,
DISPLAY THE START DATE OF THE CURRENT ROUND FOR OM
EVENTS THAT ARE ‘REGULAR’ GROUP TYPE (EV02A=1 OR
NOT ASKED) AND DISPLAY ‘JAN 01 {YEAR}’ FOR OM
EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).

FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT
HEADER, DISPLAY THE START DATE OF THE CURRENT
ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE
(EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01 {YEAR}’
FOR OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).

(FOR SPECIFICATION PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): ‘YEAR’ IN CONTEXT HEADER IS FIRST
CALENDAR YEAR OF PANEL IF ROUND 3. ‘YEAR’ IS
SECOND CALENDAR YEAR OF PANEL IF ROUND 5.

BOX_00

THROUGHOUT THE CHARGE/PAYMENT (CP) SECTION,
ENTRY OF ALL DOLLAR AMOUNTS WILL INCLUDE ONLY
WHOLE DOLLARS. ENTRY OF CENTS WILL BE DISALLOWED.

SOME ITEMS (CP01B, CP12A, CP14A, AND CP20) IN
THIS SECTION ALLOW THE ADDITION OF A SOURCE OF
PAYMENT FOR THE RU. WHEN THE INTERVIEWER SELECTS
THE "ADD" LINK, CAPI DISPLAYS A POP-UP WITH A
BLANK ENTRY FIELD AND A SELECTABLE PICK LIST OF
SOME COMMON SOURCES AS FOLLOWS:

GOVERNMENT SOURCES
- ‘MEDICARE’
- ‘MEDICAID/{STATE NAME FOR MEDICAID}’
- ‘SCHIP/{STATE NAME FOR CHIP}’
- ‘VA/(VETERAN’S ADMINISTRATION)/CHAMPVA’
- ‘TRICARE’
- ‘MILITARY FACILITY’
- ‘INDIAN HEALTH SERVICE’
- ‘WORKER’S COMPENSATION’
PRIVATE SOURCES
- ‘AARP’
- ‘AETNA’
- ‘BLUE CROSS/BLUE SHIELD’
- ‘CIGNA’
- ‘DELTA DENTAL’
- ‘KAISER/KAISER PERMANENTE’
- ‘UNITED HEALTHCARE’

THE PICK LIST EXPEDITES THE ENTRY OF ONE OF THESE
COMMON SOURCES. ONCE THE INTERVIEWER SELECTS FROM
THE PICK LIST (OR TYPES AN ENTRY) AND RETURNS TO
THE MAIN SCREEN, THE ADDED SOURCE OF PAYMENT
APPEARS IN THE ROSTER AS SELECTED.

BEGINNING IN PANEL 13, ROUND 1, THE SOURCE OF
PAYMENT PICK LIST GROUPS VA AND CHAMPVA TOGETHER
RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS
HAVE DONE.

THE SOP PICK LIST FOR ALL ROUNDS OF PANEL 12
READS:

‘VA/VETERAN’S ADMINISTRATION’
‘TRICARE/CHAMPVA’

THE PICK LIST FOR ALL ROUNDS OF PANEL 13 AND ALL
SUBSEQUENT PANELS READS:

‘VA (VETERAN’S ADMINISTRATION)/CHAMPVA’
‘TRICARE’

IF EVENT TYPE IS HH
AND
HH PROVIDER ASSOCIATED WITH THE EVENT BEING ASKED
ABOUT IS FLAGGED AS ‘AGENCY’ OR ‘INFORMAL’,
GO TO BOX_26

IF EVENT TYPE IS MV AND MV01 IS CODED ‘2’
(TELEPHONE CALL)
OR
IF EVENT TYPE IS OP AND OP02 IS CODED ‘2’
(TELEPHONE CALL),
GO TO BOX_26

OTHERWISE, CONTINUE WITH BOX_01

BOX_01

IF EVENT TYPE IS PM AND IS OM TYPE 2 OR 3, GO
TO CP03

IF EVENT TYPE IS PM AND IS NOT OM TYPE 2 OR 3,
CONTINUE WITH BOX_02

OTHERWISE, GO TO BOX_03

BOX_02

IF PERSON ALREADY FLAGGED AS ‘NO CP INFORMATION
FOR PM EVENTS NECESSARY’ FOR THE CURRENT ROUND, GO
TO BOX_26

IF PERSON ALREADY FLAGGED AS ‘CP INFORMATION FOR
PM EVENTS NECESSARY’ FOR THE CURRENT ROUND, GO TO
CP03

OTHERWISE, CONTINUE WITH CP01A

CP01A

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

Now I’d like to ask you about the charges for {your/{PERSON}’s}
prescription medicine(s).

Has {your/{PERSON}’s} health insurance or another source of coverage
helped pay for any of {your/his/her} prescription medications since
{START DATE}?

SELECT ‘NO’ IF PERSON REPORTS NO HEALTH INSURANCE OR ANOTHER SOURCE
OF COVERAGE.

YES .................................... 1 {CP01B}
NO ..................................... 2 {CP01C}
REF ................................... -7 {CP01C}
DK .................................... -8 {CP01C}

HELP AVAILABLE FOR DEFINITION OF HEALTH INSURANCE OR ANOTHER SOURCE OF COVERAGE.

QUESTIONS CP01A THROUGH CP01C WERE REVISED IN
PANEL 12 ROUND 3. STARTING IN PANEL 13, THESE
ITEMS WILL BE INCORPORATED IN ALL ROUNDS.

CP01B

{PERSON'S FIRST MIDDLE AND LAST NAME} {EV}
{EVN-DT}

Who usually helps pay?

[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]

HELP AVAILABLE FOR DEFINITION OF SOURCE OF PAYMENT.

[Code One]

WRITE SOURCES SELECTED TO THE SOURCES-OF-PAYMENT
ROSTER.

CONTINUE WITH CP01C

ROSTER DETAILS:
TITLE: RU_SOP_2

COL # 1 HEADER: SELECT PAYMENT SOURCE
INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME
(SRCS.SRCNAME)

ROSTER DEFINITION:
DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE ADD AND MULTIPLE SELECT ALLOWED.

2. ADD ALLOWED. THE SCREEN DISPLAYS A LINK "ADD A
SOURCE OF PAYMENT" THAT THE INTERVIEWER CAN
SELECT. SELECTING THE LINK DISPLAYS A POP-UP WITH
A TEXT ENTRY FIELD AND A SELECTABLE LIST OF 15
COMMON SOURCES OF PAYMENT. (SEE BOX_00 FOR A
DETAILED LIST). THE INTERVIEWER CAN TYPE A NEW
SOURCE OR SELECT ONE FROM THE LIST. UPON RETURN TO
CP01B, THE ADDED SOURCE WILL APPEAR ON THE ROSTER
AS SELECTED.

3. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE
SOURCE OF PAYMENT.

4. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A
SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT
SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT
LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS
NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR
MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST
ENTERED.’

5. LIMITED EDIT ALLOWED. IF INTERVIEWER ADDS A
SOURCE OF PAYMENT, EDITING IS POSSIBLE FOR THAT
SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT
LEFT THE SCREEN. IF EDIT IS ATTEMPTED WHEN IT IS
NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR
MESSAGE: ‘EDIT ALLOWED ONLY WHEN SOURCE FIRST
ENTERED.’

6. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN,
DISPLAY THE STANDARD WVS INSTRUCTION: "EITHER THE
ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP
ANY CHOICES."

ROSTER FILTER:
DISPLAY ALL SOURCES OF PAYMENT THAT ARE NOT
PERSON/FAMILY.

CP01C

{PERSON'S FIRST MIDDLE AND LAST NAME}

How much did {you/{PERSON}} pay out-of-pocket for {your/his/her}
last prescription?

IF AMOUNT PAID IS NOTHING, ENTER 0.

IF AMOUNT PAID VARIES DEPENDING ON TYPE OF MEDICATION, ENTER
THE OUT-OF-POCKET COST FOR THE LAST PRESCRIPTION FILLED DURING THE
REFERENCE PERIOD.

IF MORE THAN ONE PRESCRIPTION WAS FILLED AT THE SAME TIME, ENTER THE
AMOUNT FOR THE LAST PRESCRIPTION ON RECEIPT.

[Enter $ Amount] ....................... {CP01}
REF ................................... -7 {CP01}
DK .................................... -8 {CP01}

HARD RANGE CHECK: $0 - $999,999

CP01COV2

OMITTED.

BEGINNING IN PANEL 13 ROUND 2 AND PANEL 12 ROUND
4, CP01C IS ASKED OF ALL PERSONS ASKED CP01A.
PERCENT WAS REMOVED FROM CP01 AT THE SAME TIME.

CP01

{PERSON'S FIRST MIDDLE AND LAST NAME} {EV}
{EVN-DT}

{Do/Does} {you/{PERSON}} (or someone in the family) send in a claim
form to the insurance company for {your/his/her} prescription
medicines or does the pharmacy automatically file the claim
forms?

FAMILY SENDS IN CLAIM FORMS ............ 1 {CP03}
PHARMACY AUTOMATICALLY FILES CLAIM ..... 2 {BOX_26}
NOT EITHER TYPE OF SITUATION ........... 3 {BOX_26}
REF ................................... -7 {CP03}
DK .................................... -8 {CP03}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

[Code One]

IF CODED ‘2’ (PHARMACY AUTOMATICALLY FILES CLAIM),
OR ‘3’ (NOT EITHER TYPE OF SITUATION), FLAG THIS
PERSON AS ‘NO CP INFORMATION FOR PM EVENTS
NECESSARY’ FOR THE CURRENT ROUND.

IF CODED ‘1’ (FAMILY SENDS IN CLAIM FORMS), ‘-7’
(REFUSED), OR ‘-8’ (DON’T KNOW), FLAG THIS PERSON
AS ‘CP INFORMATION FOR PM EVENTS NECESSARY’ FOR
THE CURRENT ROUND.

BOX_03

IF FIRST TIME THROUGH CHARGE PAYMENT FOR THIS
PERSON-PROVIDER PAIR AND PAIR WAS FLAGGED AS
‘COPAYMENT SITUATION’ DURING THE PREVIOUS ROUND,
CONTINUE WITH CP02

OTHERWISE, GO TO CP03

CP02

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Before we talk about the charges for {your/{PERSON}’s} visit to
{PROVIDER} on {VISIT DATE}, let me take a moment to verify some
information.

Last time we recorded that {you/he/she} (or someone in the family)
{usually pay(s) a {$ AMT COPAY} copayment/usually pay(s) nothing for
visits} to {PROVIDER}. Is this still correct?

YES .................................... 1 {CP03}
NO {- PAYS A COPAYMENT AMOUNT NOW} ..... 2 {CP02OV}
NOT {A COPAYMENT/THE SAME} SITUATION
ANYMORE ............................. 99 {CP03}
REF ................................... -7 {CP03}
DK .................................... -8 {CP03}

[Code One]

HELP AVAILABLE FOR DEFINITION OF COPAYMENT.

DISPLAY ‘usually pay(s) {$ AMT COPAY} copayment’
AND ‘A COPAYMENT’ IN RESPONSE CATEGORY 99 IF THE
CP11OV1 AMOUNT FLAGGED AS ‘COPAYMENT SITUATION’
DOES NOT EQUAL ZERO. DISPLAY ‘usually pay(s)
nothing for visits’, ‘PAYS A COPAYMENT AMOUNT NOW’
IN RESPONSE CATEGORY 2, AND ‘THE SAME’ IN RESPONSE
CATEGORY 99 IF THE CP11OV1 AMOUNT FLAGGED AS
‘COPAYMENT SITUATION’ EQUALS ZERO.

FOR ‘$ AMT COPAY’, DISPLAY THE CP11OV1 AMOUNT
FLAGGED AS ‘COPAYMENT SITUATION’ DURING THE
PREVIOUS ROUND FOR THIS PERSON-PROVIDER PAIR.

IF CODED ‘99’ (NOT {A COPAYMENT/THE SAME}
SITUATION ANYMORE), FLAG THIS PERSON-PROVIDER AND
THIS PERSON AS ‘NOT A COPAYMENT SITUATION’ FOR
THE CURRENT ROUND.

IF CODED ‘1’ (YES), ‘-7’ (REFUSED), OR ‘-8’
(DON’T KNOW), FLAG THIS PERSON-PROVIDER PAIR AND
THIS PERSON AS ‘COPAYMENT SITUATION’ FOR THE
CURRENT ROUND AND SET COPAYMENT AMOUNT FROM THE
PREVIOUS ROUND AS THE PERSON’S COPAYMENT AMOUNT
FOR THE CURRENT ROUND.

CP02OV

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

What is the correct copayment amount?

[Enter $ Amount] ...................... {CP03}
NOT A COPAYMENT SITUATION ANYMORE ..... 99 {CP03}
REF ................................... -7 {CP03}
DK .................................... -8 {CP03}

HELP AVAILABLE FOR DEFINITION OF COPAYMENT.

SET DOLLAR AMOUNT ENTERED AT CP02OV AS THE NEW
COPAYMENT AMOUNT FOR THIS PERSON-PROVIDER PAIR
FOR THE CURRENT ROUND. USE THIS AMOUNT IN CP04.

IF CODED ‘99’ (NOT A COPAYMENT SITUATION ANYMORE),
DO NOT FLAG THIS PERSON-PROVIDER AS ‘COPAYMENT
SITUATION’ FOR THE CURRENT ROUND.

IF CODED ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW),
FLAG THIS PERSON-PROVIDER PAIR AS ‘COPAYMENT
SITUATION’ FOR THE CURRENT ROUND AND SET COPAYMENT
AMOUNT FROM PREVIOUS ROUND AS COPAYMENT AMOUNT FOR
THE CURRENT ROUND.

HARD CHECK:
$0 - $50.

HARD CHECK MESSAGE:
"ENTER A DOLLAR AMOUNT < OR = $50, DK, RF OR
CHECK ‘NOT A COPAYMENT SITUATION ANYMORE.’"

CP03

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Now I'd like to ask you about the charges for {your/{PERSON}'s} stay
at {HOSPITAL} that began on {ADMIT DATE}/{your/{PERSON}'s} visit to
{PROVIDER} on {VISIT DATE}/the last purchase of {NAME OF
PRESCRIBED MEDICINE} for {you/{PERSON}}/the services for {FLAT FEE
GROUP} for {you/{PERSON}}/the {OME ITEM GROUP NAME} used by
{you/{PERSON}} since {START DATE}/services received at home from
{PROVIDER} during {MONTH} for {you/{PERSON}}.

{Let's begin with the charges from the hospital itself, not
including any separate physician services or lab tests.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR DEFINITION OF CHARGE.

DISPLAY ‘{your/{PERSON}'s} stay at {HOSPITAL}
that began on {ADMIT DATE}’ IF EVENT TYPE IS HS.

DISPLAY ‘{your/{PERSON}'s} visit to {PROVIDER} on
{VISIT DATE}’ IF EVENT TYPE IS ER, OP, MV, OR DN.

DISPLAY ‘the last purchase of {NAME OF PRESCRIBED
MEDICINE} for {you/{PERSON}}’ IF EVENT TYPE IS PM.

FOR ‘{NAME OF PRESCRIBED MEDICINE}’, DISPLAY THE
NAME OF THE PRESCRIPTION MEDICINE BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘the services for {FLAT FEE GROUP} for
{you/{PERSON}}’ IF EVENT-PROVIDER PAIR REPRESENTS
A FLAT FEE GROUP.

FOR ‘{FLAT FEE GROUP}’ DISPLAY THE NAME OF THE
FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT
FF03.

DISPLAY ‘the {OME ITEM GROUP NAME} used by {you/
{PERSON}} since {START DATE}’ IF EVENT TYPE IS OM.

DISPLAY ‘services received at home from {PROVIDER}
during {MONTH} for {you/{PERSON}}’ IF EVENT TYPE
IS HH.

DISPLAY ‘{Let's begin with the charges from the
hospital itself, not including any separate
physician services or lab tests.}’ IF EVENT TYPE
IS HS.

FOR {OME ITEM GROUP NAME}, DISPLAY THE NAME OF
THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT, AS FOLLOWS:

DISPLAY ‘glasses or contact lenses’ IF THE OM
ITEM GROUP IS ‘1’ (GLASSES OR CONTACT LENSES).

DISPLAY ‘ambulance services’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘disposable supplies’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘alterations or modifications’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY
FIELD FOR THE OM EVENT BEING ASKED ABOUT.

IF PERSON-PROVIDER PAIR FLAGGED AS ‘COPAYMENT
SITUATION’ FOR THE CURRENT ROUND, AND THIS EVENT-
PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP,
GO TO CP04

IF ROUND 3 OR 5 AND IF EVENT TYPE IS OM AND OM
GROUP TYPE IS ‘ADDITIONAL’ (EV02A=2), CONTINUE
WITH CP03A. (NOTE THAT ADDITIONAL OM EVENTS CAN
BE ENTERED IN ROUNDS 3 AND 5 ONLY.

OTHERWISE, GO TO CP05

CP03A

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Did {you/{PERSON}} (or anyone in the family) purchase or rent the
{OME ITEM GROUP NAME} used by {you/him/her}?

PURCHASED .............................. 1 {CP05}
RENTED ................................. 2 {CP05}
NO CHARGE: BORROWED, FREE FROM
CHARITY/ORGANIZATION, ETC. .......... 95 {BOX_26}
REF ................................... -7 {CP05}
DK .................................... -8 {CP05}

[Code One]

{OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE
OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘ambulance services’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘disposable supplies’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘alterations or modifications’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY

CP04

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Is this the type of situation where {you/{PERSON}} (or someone in
the family) {only paid the {$ AMT COPAY} copayment/paid nothing}
for this visit and {you/he/she} {do/does} not know the total charge?

YES .................................... 1 {CP37}
NO ..................................... 2 {CP05}
REF ................................... -7 {CP05}
DK .................................... -8 {CP05}

HELP AVAILABLE FOR DEFINITION OF COPAYMENT AND TOTAL CHARGE.

DISPLAY ‘only paid the {$ AMT COPAY} copayment’
IF THE CP11OV1 AMOUNT FLAGGED AS ‘COPAYMENT
SITUATION’ DOES NOT EQUAL ZERO ($0).

FOR ‘$ AMT COPAY’ DISPLAY THE CP02OV OR CP11OV1
AMOUNT FLAGGED AS ‘COPAYMENT SITUATION’ FOR THE
CURRENT ROUND FOR THIS PERSON-PROVIDER PAIR.

DISPLAY ‘paid nothing’ IF THE CP11OV1 AMOUNT
FLAGGED AS ‘COPAYMENT SITUATION’ EQUALS ZERO ($0).

IF CODED ‘1’ (YES), COPY ALL PREVIOUS COPAYMENT
CHARGE PAYMENT DATA FOR THE PERSON-PROVIDER PAIR
TO THIS EVENT-PROVIDER-PAIR.

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), IGNORE ‘COPAYMENT SITUATION’ FLAG FOR THIS
PERSON-PROVIDER PAIR FOR THIS EVENT (THAT IS,
COLLECT CHARGE/PAYMENT INFORMATION FOR THIS EVENT-
PROVIDER PAIR).

IF CODED ‘1’ (YES), GO TO CP37

IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T
KNOW), CONTINUE WITH CP05

CP05

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{Have/Has} {you/{PERSON}} (or anyone in the family) received
anything in writing, such as a bill, receipt, or statement,
for {this hospital stay/this visit/the last purchase of {NAME OF
PRESCRIBED MEDICINE}/the services for {FLAT FEE GROUP}/the {OME
ITEM GROUP NAME}/the services received at home}?

YES, AND DOCUMENTATION AVAILABLE ....... 1 {CP08}
YES, BUT DOCUMENTATION NOT AVAILABLE ... 2 {CP08}
NO ..................................... 3 {CP06}
NO, FREE SAMPLE ........................ 4 {CP37}
REF ................................... -7 {CP06}
DK .................................... -8 {CP06}

[Code One]

HELP AVAILABLE FOR DEFINITION OF ANYTHING IN WRITING.

this hospital stay: DISPLAY IF EVENT TYPE IS HS.

this visit: DISPLAY IF EVENT TYPE IS ER, OP, MV,
OR DN.

the last purchase of {NAME OF PRESCRIBED
MEDICINE}: DISPLAY IF EVENT TYPE IS PM.

{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME
OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT
FOR THIS EVENT.

the services for {FLAT FEE GROUP}: DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR {FLAT FEE GROUP}, DISPLAY THE NAME OF THE
FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT
FF03.

the {OME ITEM GROUP NAME}: DISPLAY IF EVENT TYPE
IS OM.

the services received at home: DISPLAY IF EVENT
TYPE IS HH.

{OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE
OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘glasses or contact lenses’ IF EVENT
TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES
OR CONTACT LENSES).

DISPLAY ‘ambulance services’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘disposable supplies’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘alterations or modifications’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY
FIELD FOR OM EVENTS.

‘NO, FREE SAMPLE’ IS A RADIO BUTTON BELOW THE
ENTRY FIELD.

DISPLAY NO, FREE SAMPLE RESPONSE CATEGORY AND THE
CORRESPONDING RADIO BUTTON ONLY IF THE EVENT TYPE
OF THE EVENT-PROVIDER PAIR IS PM.

CP06

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

SHOW CARD CP-1.

Why {have/has} {you/{PERSON}} (or anyone in the family) not
received anything in writing?

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE
SITUATION.}

PAID AT TIME OF VISIT ................... 1 {CP08}
MADE A COPAYMENT ........................ 2 {CP08}
BILL SENT DIRECTLY TO OTHER SOURCE ...... 3 {CP07}
BILL HAS NOT ARRIVED .................... 4 {CP08}
NO BILL SENT:
HMO PLAN .............................. 5 {BOX_04}
VA (VETERANS ADMINISTRATION)/CHAMPVA... 6 {BOX_04}
MILITARY FACILITY ..................... 7 {BOX_04}
PUBLIC ASSISTANCE/MEDICAID/SCHIP ...... 8 {BOX_04}
INDIAN HEALTH SERVICE (IHS) .......... 15 {BOX_04}
WORKER’S COMPENSATION ................. 9 {BOX_04}
PRIVATE HEALTH CENTER/CLINIC .......... 10 {BOX_04}
PUBLIC CLINIC/HEALTH CENTER OR PRIVATE
CHARITY ............................ 11 {BOX_04}
NO CHARGE: TELEPHONE CALL ............. 12 {CP37}
FREE FROM PROVIDER ..................... 13 {CP37}
GOVERNMENT-FINANCED RESEARCH AND
CLINICAL TRIALS ........................ 14 {CP37}
INCLUDED WITH OTHER CHARGES ............ 95
REF .................................... -7 {CP08}
DK ..................................... -8 {CP08}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES AND FLAT FEE.

BEGINNING IN PANEL 13, ROUND 1, RESPONSE CATEGORY
6 AT CP06 GROUPS VA AND CHAMPVA TOGETHER.

CATEGORY 6 AT CP06 FOR ALL ROUNDS OF PANEL 12
READS:

‘VA (VETERANS ADMINISTRATION)’

CATEGORY 6 AT CP06 FOR ALL ROUNDS OF PANEL
13 AND BEYOND READS:

‘VA (VETERANS ADMINISTRATION)/CHAMPVA’

{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME
OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT
FOR THIS EVENT.

{OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE
OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘GLASSES OR CONTACT LENSES’ IF EVENT
TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES
OR CONTACT LENSES).

DISPLAY ‘AMBULANCE SERVICES’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘ORTHOPEDIC ITEMS’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘HEARING DEVICES’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘PROSTHESES’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘BATHROOM AIDS’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘MEDICAL EQUIPMENT’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘DISPOSABLE SUPPLIES’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘ALTERATIONS OR MODIFICATIONS’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY
FIELD FOR OM EVENTS.

DISPLAY THE INTERVIEWER INSTRUCTION ‘SELECT
"INCLUDED WITH OTHER CHARGES" IF THIS IS A FLAT
FEE SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT
REPRESENT A FLAT FEE. OTHERWISE, USE A NULL
DISPLAY.

NOTE: SHOW CARD FOR CODE ‘10’ WILL READ: ‘SCHOOL,
EMPLOYER, OR OTHER PRIVATE HEALTH CENTER/CLINIC’.
THE SHOW CARD FOR CODE ‘11’ WILL INCLUDE THE
FOLLOWING: ‘(INCLUDE COMMUNITY AND MIGRANT HEALTH
CENTER, FEDERALLY QUALIFIED HEALTH CENTER, INDIAN
HEALTH SERVICE)’. THE SHOW CARD FOR CODE ‘13’
WILL INCLUDE THE FOLLOWING: ‘(PROFESSIONAL
COURTESY/FREE SAMPLE)’. THESE CODES HAVE BEEN
ABBREVIATED TO CONSERVE SPACE ON THE SCREEN.

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM,
DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT
AVAILABLE FOR A PM EVENT.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT
STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE
GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A FLAT FEE GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED, AND
THE EVENT TYPE IS NOT PM AND EVENT-PROVIDER
PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A
REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.

INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN
PANEL 12 ROUND 3. STARTING IN PANEL 13, IT
WILL BE AVAILABLE IN ALL ROUNDS.

CP07

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

To whom was the bill sent?

RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT
NEXT PAGE.

[Enter Text] ........................... {CP07OV1}

CP07OV1

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL
WAS SENT:

HMO .................................... 1 {BOX_04}
VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 {BOX_04}
TRICARE ................................ 3 {CP08}
Other Military ......................... 4 {BOX_04}
PUBLIC ASSISTANCE/Medicaid/SCHIP ....... 5 {BOX_04}
INDIAN HEALTH SERVICE (IHS) ............ 8 {box_04}
Worker’s Compensation .................. 6 {BOX_04}
Private Insurance Company .............. 7 {BOX_04}
OTHER ................................. 91 {CP08}
REF ................................... -7 {CP08}
DK .................................... -8 {CP08}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN
PANEL 12 ROUND 3. STARTING IN PANEL 13, IT
WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED
ON THE PICK LIST BETWEEN PUBLIC ASSISTANCE AND
WORKER’S COMPENSATION.

BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE
CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA
TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST
ROUNDS HAVE DONE.

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF
PANEL 12 READ:

‘VA (VETERANS ADMINISTRATION)’
‘TRICARE/CHAMPVA’

CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF
PANEL 13 AND BEYOND READ:

‘VA (VETERANS ADMINISTRATION)/CHAMPVA’
‘TRICARE’

BOX_04

IF:
- EVENT TYPE IS OM, HH, OR PM
OR
- EVENT TYPE IS HS
OR
- THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT
FEE GROUP,
GO TO CP11

OTHERWISE, GO TO CP10

CP08

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Do you know the total charge for {this hospital stay/this visit/the
last purchase of {NAME OF PRESCRIBED MEDICINE}/the services for
{FLAT FEE GROUP}/the {OME ITEM GROUP NAME}/the services received
at home}?

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE
SITUATION.}

YES .................................... 1 {CP09}
NO ..................................... 2
INCLUDED WITH OTHER CHARGES ........... 95
REF ................................... -7
DK .................................... -8

HELP AVAILABLE FOR DEFINITIONS OF TOTAL CHARGE AND FLAT FEE.

DISPLAY ‘this hospital stay’ IF EVENT TYPE IS HS.

DISPLAY ‘this visit’ IF EVENT TYPE IS ER, OP, MV,
OR DN.

DISPLAY ‘the last purchase of {NAME OF PRESCRIBED
MEDICINE}’ IF EVENT TYPE IS PM.

FOR ‘{NAME OF PRESCRIBED MEDICINE}’, DISPLAY THE
NAME OF THE PRESCRIPTION MEDICINE BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘the services for {FLAT FEE GROUP}’
IF EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE
GROUP.

FOR {FLAT FEE GROUP}, DISPLAY THE NAME OF THE
FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT
FF03.

DISPLAY ‘the {OME ITEM GROUP NAME}’ IF EVENT TYPE
IS OM.

DISPLAY ‘the services received at home’ IF EVENT
TYPE IS HH.

DISPLAY THE INTERVIEWER INSTRUCTION ‘SELECT
"INCLUDED WITH OTHER CHARGES" IF THIS IS A FLAT
FEE SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT
REPRESENT A FLAT FEE. OTHERWISE, USE A NULL
DISPLAY.

FOR {OME ITEM GROUP NAME}, DISPLAY THE NAME OF
THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT AS FOLLOWS:

DISPLAY ‘glasses or contact lenses’ IF EVENT
TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES
OR CONTACT LENSES).

DISPLAY ‘ambulance services’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘disposable supplies’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘alterations or modifications’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY
FIELD FOR THE OM EVENT BEING ASKED ABOUT.

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM,
DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT
AVAILABLE FOR A PM EVENT.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE
GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A FLAT FEE GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT
STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER
PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A
REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.

IF:
CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T
KNOW)
AND
(EVENT TYPE IS OM, HH, OR PM
OR
EVENT TYPE IS HS
OR
THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE
GROUP),
GO TO CP11

IF:
CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T
KNOW)
AND
EVENT TYPE IS ER, OP, MV, OR DN
GO TO CP10

CP09

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much was the total charge, including any amounts that may be
paid by health insurance or other sources?

{Do not include any services billed for separately such as
physician charges or other services.} {Include charges for
procedures such as x-rays, lab tests, or diagnostic procedures
that are listed separately on the {hospital} bill {or statement}.}

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT
DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE
SITUATION.}

AMOUNT ................................. 1 {CP09OV}
INCLUDED WITH OTHER CHARGES ........... 95

[Code One]

HELP AVAILABLE FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE
AND FLAT FEE.

DISPLAY ‘Do not include any services billed for
billed for separately such as physician charges
or other services.’ IF EVENT TYPE IS HS, ER, OR
OP. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘Include charges for procedures such as
x-rays, lab tests, or diagnostic procedures that
are listed separately on the {hospital} bill {or
statement}’. IF CP05 IS CODED ‘1’ (YES, AND
DOCUMENTATION AVAILABLE) AND EVENT TYPE IS NOT
PM. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘hospital’ IF EVENT TYPE IS HS, ER, OR OP.
OTHERWISE, USE A NULL DISPLAY. DISPLAY ‘or
statement’ IF EVENT TYPE IS MV, DN, OM, HH OR
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
OTHERWISE, USE A NULL DISPLAY.

DISPLAY INTERVIEWER INSTRUCTION ‘SELECT "INCLUDED
WITH OTHER CHARGES" IF THIS IS A FLAT FEE
SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT
REPRESENT A FLAT FEE GROUP. OTHERWISE, USE A NULL
DISPLAY.

{OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE
OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘GLASSES OR CONTACT LENSES’ IF EVENT
TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES
OR CONTACT LENSES).

DISPLAY ‘AMBULANCE SERVICES’ IF THE OM ITEM
GROUP IS ‘4’ (AMBULANCE SERVICES).

DISPLAY ‘ORTHOPEDIC ITEMS’ IF THE OM ITEM GROUP
IS ‘5’ (ORTHOPEDIC ITEMS).

DISPLAY ‘HEARING DEVICES’ IF THE OM ITEM GROUP
IS ‘6’ (HEARING DEVICES).

DISPLAY ‘PROSTHESES’ IF THE OM ITEM GROUP IS ‘7’
(PROSTHESES).

DISPLAY ‘BATHROOM AIDS’ IF THE OM ITEM GROUP IS
‘8’ (BATHROOM AIDS).

DISPLAY ‘MEDICAL EQUIPMENT’ IF THE OM ITEM GROUP
IS ‘9’ (MEDICAL EQUIPMENT).

DISPLAY ‘DISPOSABLE SUPPLIES’ IF THE OM ITEM
GROUP IS ‘10’ (DISPOSABLE SUPPLIES).

DISPLAY ‘ALTERATIONS OR MODIFICATIONS’ IF THE OM
ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS).

DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM
GROUP IS ‘91’ (OTHER).

FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE
TEXT CATEGORY ENTERED IN THE OTHER SPECIFY
FIELD FOR OM EVENTS.

IF ‘INCLUDED WITH OTHER CHARGES’ DISPLAY THE
FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE
FOR A PM EVENT.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE
GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A FLAT FEE GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT
STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE
IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.'

IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND
THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER
PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A
REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.

CP09OV

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

$ AMOUNT:

[Enter $ Amount] .......................
REF ................................... -7
DK .................................... -8

IF THE AMOUNT IS $0, GO TO CP37

IF:
EVENT TYPE IS ER, OP, MV, OR DN
AND
TOTAL CHARGE IS A NON-ZERO WHOLE NUMBER < OR =
$50.00 OR CP090V IS CODED '-7' (REFUSED) OR '-8'
(DON’T KNOW),
GO TO CP10

IF THE AMOUNT IS NOT $0, DK, OR REF AND THE EVENT
TYPE IS HH, CONTINUE WITH CP09A

OTHERWISE, GO TO CP11

SOFT CHECK:
SOFT RANGE CHECK: $0 - $100,000

HARD CHECK:
AMOUNT CANNOT BE < 0

CP09A

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Let me be sure I recorded this correctly. The total charge for
the services received at home during {MONTH} was {$ AMOUNT}.

Is that correct?

YES .................................... 1 {CP11}
NO ..................................... 2
REF ................................... -7 {CP11}
DK .................................... -8 {CP11}

{$ AMOUNT}: DISPLAY AMOUNT ENTERED AT CP09OV.

IF CODED ‘2’ (NO), DISPLAY THE FOLLOWING MESSAGE:
‘USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS
MONTH.’

CP10

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Is this a situation in which {you/{PERSON}} {are/is} required to
pay a certain set amount each time {you/he/she} {visit/visits}
{PROVIDER} regardless of what happens during the visit?

PROBE: For example, is this the type of situation in which
{you/he/she} always {make/makes} the same set dollar amount copayment?

YES .................................... 1 {CP11}
NO ..................................... 2 {CP11}
USUALLY PAYS $0 (REGARDLESS OF SERVICE). 3 {CP11}
REF ................................... -7 {CP11}
DK .................................... -8 {CP11}

HELP AVAILABLE FOR DEFINITION OF SET AMOUNT AND COPAYMENT.

CP11

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much of the {{AMT TOT CH}/total charge} did anyone in the
family pay ‘out-of-pocket,’ that is, before any reimbursements?

IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT ‘DOLLARS’, THEN
ENTER 0, DK, OR RF.

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP11OV1}
PERCENT ................................ 2 {CP11OV2}

[Code One]

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

{{AMT TOT CH}/total charge}: DISPLAY ‘{AMT TOT
CH}’ IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT
CP09OV. DISPLAY ‘total charge’ IF CP08 IS CODED
‘2’ (NO), ‘-7’ (REFUSED), ‘-8’ (DON’T KNOW), OR IS
NOT ASKED.

{AMT TOT CH}: DISPLAY THE DOLLAR AMOUNT ENTERED AT
CP09OV.

CP11OV1

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

$

[Enter $ Amount] ....................... {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF-
PAYMENT-ROSTER.

WRITE 'PERSON/FAMILY' TO THE EVENT’S-SOURCES-OF-
PAYMENT-ROSTER.

HARD RANGE CHECK:
$0 - $999,999

CP11OV2

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

%

[Enter Percent %] ...................... {BOX_05}

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL
CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT
PAID BY THE FAMILY AT CP11.

IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T
KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE
CALCULATED. RECORD DOLLAR AMOUNT PAID BY
PERSON/FAMILY AS 'DK' OR ‘REF’ AS APPROPRIATE.

WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF-
PAYMENT-ROSTER.

WRITE 'PERSON/FAMILY' TO THE EVENT’S-SOURCES-OF-
PAYMENT-ROSTER.

SOFT CHECK: 1% - 100%.

HARD CHECK:
IF 0, DK OR RF IS ENTERED, DISPLAY THE FOLLOWING
MESSAGE: 0, DK, RF ARE NOT ALLOWED ON THIS
SCREEN. SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.

BOX_05

IF:
CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED) OR '-8'
(DON'T KNOW)
AND
CP08 IS CODED '2' (NO), '-7' (REFUSED), OR '-8'
(DON'T KNOW)
AND
CP10 IS CODED '2' (NO), '-7' (REFUSED), OR '-8'
(DON'T KNOW),
DISPLAY THE FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT
RESOLUTION WILL BE NEEDED FOR THIS CASE.
CONTINUE.' THEN GO TO CP37

OTHERWISE, CONTINUE WITH CP12

LOOP_01

OMITTED.

BOX_LP01

OMITTED.

CP12

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Has any {other} source already paid for any of the charges for
{this hospital stay/this visit/the last purchase of {NAME OF
PRESCRIBED MEDICINE}/the services for {FLAT FEE GROUP}/the {OME
ITEM GROUP NAME}/the services received at home}?

By other source, we mean a private insurance company, an HMO,
Medicare, Medicaid, or any other public program that may have paid.

YES .................................... 1 {CP12A}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}

HELP AVAILABLE FOR A DEFINITION OF SOURCE AND ‘ALREADY PAID’.

DISPLAY ‘OTHER’ IN THE QUESTION TEXT IF AN AMOUNT
WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT > $0
OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE
USE A NULL DISPLAY.

DISPLAY ‘this hospital stay’ IF EVENT TYPE IS HS.

DISPLAY ‘this visit’ IF EVENT TYPE IS ER, OP, MV,
OR DN.

DISPLAY ‘the last purchase of {NAME OF PRESCRIBED
MEDICINE}’ IF EVENT TYPE IS PM.

{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE
NAME OF THE PRESCRIPTION MEDICINE BEING ASKED
ABOUT FOR THIS EVENT.

DISPLAY ‘the services for {FLAT FEE GROUP}’ IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.

FOR {FLAT FEE GROUP}, DISPLAY THE NAME OF THE
FLAT FEE GROUP SELECTED AT FF02 OR ENTERED AT
FF03.

DISPLAY ‘the {OME ITEM GROUP NAME}’ IF EVENT TYPE
IS OM.

DISPLAY ‘the services received at home’ IF EVENT
TYPE IS HH.

CP12A

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who else paid? PROBE: Anyone else?

[1. Name of Source of Direct Payment-35]
[2. Name of Source of Direct Payment-35]
[3. Name of Source of Direct Payment-35]

WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-
PAYMENTS-ROSTER.

CONTINUE WITH CP13

ROSTER DETAILS:
TITLE: RU_SOP_2

COL # 1 HEADER: SELECT PAYMENT SOURCE
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME
(SRCS.SRCNAME)

ROSTER DEFINITION:
DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. MULTIPLE ADD ALLOWED. THE SCREEN DISPLAYS A
LINK "ADD A SOURCE OF PAYMENT" THAT THE
INTERVIEWER CAN SELECT. SELECTING THE LINK
DISPLAYS A POP-UP WITH A TEXT ENTRY FIELD AND A
SELECTABLE LIST OF 15 COMMON SOURCES OF PAYMENT.
(SEE BOX_00 FOR A DETAILED LIST). THE INTERVIEWER
CAN TYPE A NEW SOURCE OR SELECT ONE FROM THE
LIST. UPON RETURN TO CP12A, THE ADDED SOURCE WILL
APPEAR ON THE ROSTER AS SELECTED.

3. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A
SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT
SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT
LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS
NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR
MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST
ENTERED.’

4. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN,
DISPLAY THE STANDARD WVS INSTRUCTION: "EITHER THE
ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP
ANY CHOICES."

5. PERSON/FAMILY IS FOR DISPLAY ONLY. THIS SOURCE
IS AUTOMATICALLY SELECTED.

ROSTER FILTER:
DISPLAY ALL SOURCES OF PAYMENT.

CP13

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much did (SOURCE) pay?

ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.

IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN
ENTER PERCENT.

TOTAL CHARGE: {$XXXXXXXXX}

ROSTER. SOURCE OF PAYMENT	CP13_02. DOLLAR AMOUNT PAID	CP13_03. PERCENT AMOUNT PAID
PERSON/Family	[Display $ Amount]	[Display % Amount]
[Display Source of Payment]	[Enter $ Amount]	[Enter % Amount]
[Display Source of Payment]	[Enter $ Amount]	[Enter % Amount]

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.

DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF
PAYMENT.

DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT
PAID' OR ‘PERCENT AMOUNT PAID’ COLUMN FOR
PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11
IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE
‘DOLLAR AMOUNT PAID’ COLUMN. IF THE RESPONSE TO
CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE
AMOUNT IN THE ‘PERCENT AMOUNT PAID’ COLUMN. IF
THE DOLLAR AMOUNT AT CP11 IS CODED ‘-8’
(DON’T KNOW), DISPLAY ‘DK’ FOR THE AMOUNT IN BOTH
COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED ‘-7’
(REFUSED), DISPLAY ‘REF’ FOR THE AMOUNT IN BOTH
COLUMNS.

FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS
‘DIRECT PAYMENT’.

FEATURES OF THE SOURCE OF PAYMENT MATRIX:

1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO
MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT
COLUMN ASSOCIATED WITH THAT SOURCE.
INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO
MOVE BETWEEN SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT
ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED
TO SOURCES AT THIS SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A
PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.
AMOUNTS CAN BE CHANGED AS MANY TIMES AS
NECESSARY BEFORE THE INTERVIEWER LEAVES THE
SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE
CHANGED OR CORRECTED. NOTE THAT THE SCREEN
WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN
THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS
DOLLAR AMOUNT MAY BE ENTERED BY THE
INTERVIEWER OR CALCULATED BY CAPI BASED ON %
OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN.
5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR
PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE
IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL
BE DISPLAYED. FOR EXAMPLE, IF THE
INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR
AMOUNT WILL BE CALCULATED USING THE TOTAL
CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE
DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN
(NEXT TO THE PERCENT AMOUNT PAID COLUMN).
6. IF A SOURCE IS ENTERED IN ERROR, THE
INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.
7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER
DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS
SCREEN.

SOFT CHECK:
$0 - $10,000

CONTINUE WITH BOX_06

ROSTER DETAILS:
TITLE: EVNT_SOP_1

COL # 1 HEADER: SOURCE OF PAYMENT
INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME
(PAYM.REIMNAM/PAYF.REIMNAM)

COL # 2 HEADER: DOLLAR AMOUNT PAID
INSTRUCTIONS: ENTER $ AMOUNT PAID
(PAYM.AMTPAID/PAYF.AMTPAID)

COL # 3 HEADER: PERCENT AMOUNT PAID
INSTRUCTIONS: ENTER % AMOUNT PAID
(PAYM.PCTPAID/PAYF.PCTPAID)

ROSTER DEFINITION:
DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR
ENTRY.

ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED TO SOURCES AT THIS SCREEN.

2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR
CORRECTED.

3. THE INTERVIEWER CAN ENTER A DOLLAR OR A
PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY
TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES
THE SCREEN.

5. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN
ENTERED AND THERE IS A TOTAL CHARGE, THE
RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,
IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR
AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE.

6. IF A SOURCE IS ENTERED IN ERROR, THE
INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.

ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS
EVENT-PROVIDER PAIR AND THE ‘PERSON/FAMILY’
RECORD.

CP13OV

OMITTED.

END_LP01

OMITTED.

BOX_06

IF 'AMOUNT PAID' BY PERSON/FAMILY > $0, CONTINUE
WITH CP14

OTHERWISE, GO TO BOX_09

LOOP_02

OMITTED.

BOX_LP02

OMITTED.

CP14

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT} {NAME OF PMED}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Has any source paid back any of the {$/% FAMILY PAID} paid
‘out-of-pocket’?

YES .................................... 1 {CP14A}
NO ..................................... 2 {BOX_09}
REF ................................... -7 {BOX_09}
DK .................................... -8 {BOX_09}

HELP AVAILABLE FOR DEFINITION OF SOURCE AND REIMBURSEMENT.

{$/% FAMILY PAID}: DISPLAY THE FAMILY DOLLAR
AMOUNT PAID IF CP11 IS CODED ‘1’ (DOLLARS).
DISPLAY THE FAMILY PERCENT AMOUNT PAID IF CP11 IS
CODED ‘2’ (PERCENT).

CP14A

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who paid the family back?

PROBE: Anyone else?

[1. Name of Source of Reimbursement-35]
[2. Name of Source of Reimbursement-35]
[3. Name of Source of Reimbursement-35]

WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-
PAYMENTS-ROSTER.

NOTE: SOURCES OF PAYMENTS AND SOURCES OF
REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL
ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.

CONTINUE WITH CP15

ROSTER DETAILS:
TITLE: RU_SOP_2

COL # 1 HEADER: SELECT REIMBURSEMENT SOURCE
INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME
(SRCS.SRCNAME)

ROSTER DEFINITION:
DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE ADD AND MULTIPLE SELECT ALLOWED.

2. ADD ALLOWED. THE SCREEN DISPLAYS A LINK "ADD A
SOURCE OF PAYMENT" THAT THE INTERVIEWER CAN
SELECT. SELECTING THE LINK DISPLAYS A POP-UP WITH
A TEXT ENTRY FIELD AND A SELECTABLE LIST OF 15
COMMON SOURCES OF PAYMENT. (SEE BOX_00 FOR A
DETAILED LIST). THE INTERVIEWER CAN TYPE A NEW
SOURCE OR SELECT ONE FROM THE LIST. UPON RETURN TO
CP14A, THE ADDED SOURCE WILL APPEAR ON THE ROSTER
AS SELECTED.

3. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE
SOURCE OF PAYMENT.

4. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A
SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT
SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT
LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS
NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR
MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST
ENTERED.’

5. LIMITED EDIT ALLOWED. IF INTERVIEWER ADDS A
SOURCE OF PAYMENT, EDITING IS POSSIBLE FOR THAT
SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT
LEFT THE SCREEN. IF EDIT IS ATTEMPTED WHEN IT IS
NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR
MESSAGE: ‘EDIT ALLOWED ONLY WHEN SOURCE FIRST
ENTERED.’

6. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN,
DISPLAY THE STANDARD WVS INSTRUCTION: "EITHER THE
ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP
ANY CHOICES."

ROSTER FILTER:
DISPLAY ALL SOURCES OF PAYMENT ON THE ROSTER
EXCEPT PERSON/FAMILY.

CP15

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much did (SOURCE) pay the family back?

ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.

IF ONLY PERCENT KNOWN, ENTER F5 FOR DOLLAR AMOUNT PAID AND THEN
ENTER PERCENT.

PERSON/FAMILY PAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

ROSTER. SOURCE OF REIMBURSEMENT	CP15_02. DOLLAR AMOUNT REIMBURSED	CP15_03. PERCENT AMOUNT REIMBURSED
[Display Source of Reimbursement]	[Enter $ Amount]	[Enter % Amount]
[Display Source of Reimbursement]	[Enter $ Amount]	[Enter % Amount]

HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.

TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.

PERSON/FAMILY PAYMENT: {$XXXXXXXXX}: DISPLAY THE
DOLLAR AMOUNT ENTERED AT CP11OV1 IF CP11 IS CODED
‘1’ (DOLLARS). DISPLAY THE PERCENT AMOUNT ENTERED
AT CP11OV2 IF CP11 IS CODED ‘2’ (PERCENT).

TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT
ENTERED AT CP09OV. IF CP08 IS CODED ‘2’ (NO), ‘-8’
(DON’T KNOW), OR IF CP09 IS CODED ‘-8’ (DON’T
KNOW), DISPLAY ‘UNKNOWN’ FOR {$XXXXXXXXX}. IF CP08
IS CODED ‘-7’ (REFUSED) OR IF CP09 IS CODED ‘-7’
(REFUSED), DISPLAY ‘REFUSED’ FOR {$XXXXXXXXX}.

FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS
‘REIMBURSEMENT’.

SOFT CHECK:
0 – 999999

ROSTER DEFINITION:
DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED TO SOURCES AT THIS SCREEN.

2. THE INTERVIEWER CAN ENTER A DOLLAR OR A
PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

3. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY
TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES
THE SCREEN.

4. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN
ENTERED AND THERE IS A TOTAL CHARGE, THE
RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,
IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR
AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE.

5. IF A SOURCE IS ENTERED IN ERROR, THE
INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. IF THE
TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE
AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS
THE MESSAGE ‘IF THE VALUE IS OK, CLICK ACCEPT. IF
YOU WANT TO CHANGE THE VALUE, CLICK CHANGE.’

6. INTERVIEWERS WILL BE INSTRUCTED TO ENTER ONLY
REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN.

7. THE SAME SOURCE CAN BE FLAGGED AS BOTH A
REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE
AMOUNT OF THE DIRECT PAYMENT WILL PLAY INTO THE
RESOLUTION PROCESS.

8. POST DATA COLLECTION EDITING WILL BE NECESSARY
TO DETERMINE THE NET PAYMENTS OF SOURCES.

ROSTER FILTER:
DISPLAY ALL SOURCES SELECTED AT CP14A FOR THIS
EVENT-PROVIDER PAIR.

CONTINUE WITH BOX_09

CP15OV

OMITTED.

END_LP02

OMITTED.

BOX_07

OMITTED.

BOX_08

OMITTED.

CP16

OMITTED.

CP17

OMITTED.

CP17OV1

OMITTED.

CP17OV2

OMITTED.

BOX_11

OMITTED.

BOX_10

OMITTED.

CP18

OMITTED.

CP19

OMITTED.

CP19OV1

OMITTED.

CP19OV2

OMITTED.

CP20

OMITTED.

BOX_09

DETERMINE IF THERE IS AN OVERPAYMENT OR
UNDERPAYMENT: SUBTRACT THE TOTAL PAYMENT FROM
THE TOTAL CHARGE AT CP09. IF THE ABSOLUTE VALUE
OF THE REMAINDER IS > 3% OR $5 (WHICHEVER IS
HIGHER) OF THE TOTAL CHARGE, CONTINUE WITH BOX_12

OTHERWISE, DISPLAY THE FOLLOWING MESSAGE: 'NO
CHARGE-PAYMENT RESOLUTION NEEDED FOR THIS CASE.
PRESS ENTER TO CONTINUE.' THEN GO TO CP37

BOX_12

IF CP09OV (TOTAL CHARGE) OR 'AMOUNT PAID' BY ANY
SOURCE OF DIRECT PAYMENT (INCLUDING PERSON/FAMILY,
BUT EXCLUDING REIMBURSEMENTS) IS CODED '-7'
(REFUSED) OR '-8' (DON'T KNOW), DISPLAY THE
FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT RESOLUTION
NEEDED FOR THIS CASE. PRESS ENTER TO CONTINUE.'
THEN GO TO CP37

OTHERWISE, CONTINUE WITH BOX_13

BOX_13

IF THE UNDERPAYMENT IS > 3% OR $5 (WHICHEVER IS
HIGHER) OF THE TOTAL CHARGE, CONTINUE WITH CP21

IF THE OVERPAYMENT IS > 3% OR $5 (WHICHEVER IS
HIGHER) OF THE TOTAL CHARGE, GO TO CP26

CP21

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Does anyone in the family or any other source expect to make
additional payments for {this hospital stay/this visit/the last
purchase of {NAME OF PRESCRIBED MEDICINE}/the services for {FLAT
FEE GROUP}/the {OME ITEM GROUP NAME}/the services received at home}?

YES .................................... 1 {CP22}
NO ..................................... 2 {CP24}
REF ................................... -7 {CP24}
DK .................................... -8 {CP24}

CP22

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

How much more does anyone in the family or any other source
expect to pay?

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP22OV1}
PERCENT ................................ 2 {CP22OV2}

[Code One]

CP22OV1

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

$

[Enter $ Amount] ....................... {BOX_14}
REF ................................... -7 {BOX_14}
DK .................................... -8 {BOX_14}

HARD RANGE CHECK:
$0 - $999,9999

CP22OV2

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

%

[Enter % Amount] ....................... {BOX_14}
REF ................................... -7 {BOX_14}
DK .................................... -8 {BOX_14}

HARD RANGE: 1% - 100%.

HARD CHECK:
IF 0, DK OR RF IS ENTERED, DISPLAY THE FOLLOWING
MESSAGE: "0, DK, RF NOT ALLOWED ON THIS
SCREEN. SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF."

BOX_14

IF AN AMOUNT IS ENTERED AT CP22OV1 OR AT CP22OV2
OR IF CP22OV1 OR CP22OV2 ARE CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY THE
FOLLOWING MESSAGE: ‘NO CHARGE-PAYMENT
RESOLUTION NEEDED FOR THIS CASE. CONTINUE.’ THEN
GO TO CP37

LOOP_03

OMITTED.

BOX_LP03

OMITTED.

CP23

OMITTED.

CP24

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

At the moment, it appears that {AMOUNT REMAINING} of the total
charge is still unpaid. Let me be sure I have entered everything
correctly.

REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH
RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.

IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.

TO ADD ANOTHER PAYMENT SOURCE, BACK UP TO CP12A.

UNDERPAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

ROSTER. SOURCE OF PAYMENT	CP24_02. DOLLAR AMOUNT PAID	CP24_03. PERCENT AMOUNT PAID
PERSON/Family	[Display $ Amount]	[Display % Amount]
[Display Source of Payment]	[Display $ Amount]	[Display % Amount]
[Display Source of Payment]	[Enter $ Amount]	[Enter % Amount]

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF
PAYMENT.

IF THE AMOUNT PAID BY PERSON/FAMILY WAS ADJUSTED
AT CP13, DISPLAY ADJUSTED AMOUNT. IF AMOUNT PAID
BY PERSON/FAMILY WAS NOT ADJUSTED, DISPLAY
THE RESPONSE TO CP11 IN THE 'AMOUNT PAID'
COLUMN FOR PERSON/FAMILY. THAT IS, IF THE
RESPONSE TO CP11 IS A DOLLAR AMOUNT, DISPLAY THE
DOLLAR AMOUNT IN THE ‘DOLLAR AMOUNT PAID’ COLUMN.
IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY
THE PERCENTAGE AMOUNT IN THE ‘PERCENT AMOUNT PAID’
COLUMN. IF THE DOLLAR AMOUNT OR PERCENT AT CP11 IS
CODED ‘-8’ (DON’T KNOW), DISPLAY ‘DK’ FOR THE
AMOUNT IN BOTH COLUMNS. IF THE DOLLAR AMOUNT OR
PERCENT IS CODED ‘-7’ (REFUSED), DISPLAY ‘REF’
FOR THE AMOUNT IN BOTH COLUMNS.

UNDERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT
OF THE CALCULATED UNDERPAYMENT.

TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT
ENTERED AT CP09OV.

{AMOUNT REMAINING}: DISPLAY THE AMOUNT OF THE
CALCULATED UNDERPAYMENT.

FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS
‘DIRECT PAYMENTS’.

SOFT CHECK:
WHOLE DOLLAR AMOUNT (INTEGER): 0 - $100,000

ROSTER DEFINITION:
DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR
ENTRY.

ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED TO SOURCES AT THIS SCREEN.

2. THE INTERVIEWER CAN ENTER A DOLLAR OR A
PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

3. NO CORRECTIONS OR UPDATES MAY BE MADE TO SOURCE
NAMES OR AMOUNTS OF REIMBURSEMENT.

4. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN
ENTERED AND THERE IS A TOTAL CHARGE, THE
RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,
IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR
AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE.

5. IF A SOURCE IS ENTERED IN ERROR, THE
INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.

6. ONLY NEW SOURCES OF DIRECT PAYMENTS MAY BE
ADDED.

ROSTER FILTER:
DISPLAY ALL SOURCES FLAGGED AS ‘DIRECT PAYMENT’
FOR THIS EVENT.

GO TO CP37

CP24OV

OMITTED.

END_LP03

OMITTED.

LOOP_04

OMITTED.

BOX_LP04

OMITTED.

CP25

OMITTED.

CP26

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

The payments you reported exceed the charge I have recorded by
{$ DISCREPANCY}. Let me be sure I have all the information
recorded correctly.

REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH
RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.

IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.

TO ADD ANOTHER PAYMENT SOURCE, BACK UP TO CP12A.

OVERPAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

ROSTER. SOURCE OF PAYMENT	CP26_02. DOLLAR AMOUNT PAID	CP26_03. PERCENT AMOUNT PAID
PERSON/Family	[Display $ Amount]	[Display % Amount]
[Display Source of Payment]	[Display $ Amount]	[Display % Amount]
[Display Source of Payment]	[Enter $ Amount]	[Enter % Amount]

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

{$ DISCREPANCY}: DISPLAY THE AMOUNT OF THE
CALCULATED OVERPAYMENT.

OVERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT
OF THE CALCULATED OVERPAYMENT.

TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT
ENTERED AT CP09OV.

FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS
‘DIRECT PAYMENTS’.

SOFT CHECK:
WHOLE DOLLAR AMOUNT (INTEGER): 0 - $100,000

ROSTER DEFINITION:
DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR
ENTRY.

ROSTER BEHAVIOR:
1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED TO SOURCES AT THIS SCREEN.

2. THE INTERVIEWER CAN ENTER A DOLLAR OR A
PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED.

3. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN
ENTERED AND THERE IS A TOTAL CHARGE, THE
RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,
IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR
AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE.

4. IF A SOURCE IS ENTERED IN ERROR, THE
INTERVIEWER WILL ZERO OUT THE AMOUNT PAID.

ROSTER FILTER:
DISPLAY ALL SOURCES FLAGGED AS ‘DIRECT PAYMENT’.

CONTINUE WITH CP37

CP26OV

OMITTED.

END_LP04

OMITTED.

BOX_15

OMITTED.

BOX_16

OMITTED.

CP27

OMITTED.

CP28

OMITTED.

CP28OV1

OMITTED.

CP28OV2

OMITTED.

BOX_17

OMITTED.

BOX_18

OMITTED.

CP29

OMITTED.

CP30

OMITTED.

CP30OV1

OMITTED.

CP30OV2

OMITTED.

BOX_19

OMITTED.

BOX_20

OMITTED.

CP31

OMITTED.

CP32

OMITTED.

CP32OV1

OMITTED.

CP32OV2

OMITTED.

BOX_21

OMITTED.

CP33

OMITTED.

CP34

OMITTED.

CP34OV1

OMITTED.

CP34OV2

OMITTED.

BOX_22

OMITTED.

CP35

OMITTED.

CP36

OMITTED.

CP37

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: WHAT RECORDS WERE USED IN COMPLETING THE
CHARGE/PAYMENT INFORMATION FOR {THIS EVENT/THIS FLAT FEE GROUP/
THE LAST PURCHASE OF {NAME OF PRESCRIBED MEDICINE}/the {OME ITEM
GROUP NAME}}?

CHECK ALL THAT APPLY.

RESPONDENT’S/FAMILY MEMBER’S MEMORY ....... 1
RESPONDENT’S/FAMILY MEMBER’S CHECK BOOK ... 2
STATEMENT, BILL OR RECEIPT FROM
PROVIDER’S OFFICE ......................... 3
EXPLANATION OF BENEFITS FROM MEDICARE ..... 4
EXPLANATION OF BENEFITS FROM PRIVATE
INSURANCE CARRIER ....................... 5
CALENDAR .................................. 6
PRESCRIBED MEDICINE BOTTLE, BAG, OR
CONTAINER ............................... 7
ELECTRONIC RECORDS ........................ 8
PHARMACY PATIENT PROFILE .................. 9
OTHER .................................... 91 {CP37OV}

[Code All That Apply]

THIS EVENT: DISPLAY IF EVENT TYPE IS HS, OP, ER,
MV, DN, OR HH.

THIS FLAT FEE GROUP: DISPLAY IF EVENT-PROVIDER
PAIR REPRESENTS A FLAT FEE GROUP.

THE LAST PURCHASE OF {NAME OF PRESCRIBED
MEDICINE}: DISPLAY IF EVENT TYPE IS PM.

{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME
OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT
FOR THIS EVENT.

THE {OME ITEM GROUP NAME}: DISPLAY IF EVENT TYPE
IS OM.

IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION
WITH OTHER CODES, CONTINUE WITH CP37OV

OTHERWISE, GO TO BOX_23

CP37OV

SPECIFY:

[Enter Other Specify] .................. {BOX_23}

BOX_23

IF CP37 IS CODED '3' (PROVIDER'S OFFICE), '4'
(EXPLANATION OF BENEFITS FROM MEDICARE), OR '5'
(EXPLANATION OF BENEFITS FROM PRIVATE INSURANCE
CARRIER)
AND
EVENT TYPE IS NOT PM OR OM,
CONTINUE WITH CP38

OTHERWISE, GO TO BOX_24

CP38

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: DOES THE PAPERWORK SHOW THAT {PROVIDER} HAS
ANOTHER NAME?

YES .................................... 1 {CP39}
NO ..................................... 2 {BOX_24}

HELP AVAILABLE FOR DEFINITION OF PROVIDER NAME.

CP39

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE
GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: ENTER OTHER NAME FOR {PROVIDER}.

[Enter Medical-Provider-65] .............. {BOX_24}

BOX_24

IF:
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP,
OR
EVENT TYPE IS PM, HS, OM, OR HH,
OR
PERSON-PROVIDER PAIR ALREADY FLAGGED AS ‘COPAYMENT
SITUATION’,
GO TO BOX_26

OTHERWISE, CONTINUE WITH BOX_25

BOX_25

IF [CP08 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR
‘-8’ (DON’T KNOW)] OR [THE AMOUNT IN CP09 IS SET
TO THE COPAYMENT AMOUNT] OR [CP08 AND CP09 WERE
NOT ASKED AND CP06 IS CODED ‘5’ (NO BILL SENT:
HMO PLAN), ‘6’ (NO BILL SENT: VA), ‘8’ (NO BILL
SENT: PUBLIC ASSISTANCE/MEDICAID/SCHIP) OR ‘15’
(NO BILL SENT: INDIAN HEALTH SERVICE)]
AND
CP10 IS CODED ‘1’ (YES) OR ‘3’ (USUALLY PAYS $0)
AND
CP11 IS CODED ‘1’ (DOLLARS) AND A WHOLE DOLLAR
AMOUNT GREATER THAN OR EQUAL TO (=>) $0 AND LESS
THAN OR EQUAL (<=) TO $50 IS ENTERED IN CP11OV1,
FLAG THIS PERSON-PROVIDER PAIR AS A ‘COPAYMENT
SITUATION’, THEN CONTINUE WITH BOX_26

OTHERWISE, DO NOT SET ANY FLAGS AND THEN CONTINUE
WITH BOX_26

BOX_26

FLAG CP STATUS OF EVENT-PROVIDER PAIR AS
‘PROCESSED’.

END OF CHARGE PAYMENT (CP) SECTION.

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