Form Approved
OMB Number 0935-0118
Expiration Date 01/31/2013



MEDICAL EXPENDITURE PANEL SURVEY

MEDICAL PROVIDER COMPONENT

EVENT FORM

FOR

HOSPITAL PROVIDERS

COMBINED MEDICAL AND BILLING RECORDS

REFERENCE YEAR 2012


OMB STATEMENT

(Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.)



DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.

PRESS NEXT TO CONTINUE IN THIS EVENT FORM

PRESS BREAKOFF TO DISCONTINUE

MEDICAL RECORDS – LOCATION OF SERVICES


A1. The (first/next) time (PATIENT NAME) received services during calendar year 2012, were the services received:

CODE ONLY ONE

As an Inpatient............................................................. 1
In a Hospital Outpatient Department............................... 2
In a Hospital Emergency Room...................................... 3
In a Long Term Care unit such as skilled nursing facility... 5
Somewhere else?......................................................... 4
(IF SOMEWHERE ELSE: Where was that?)

IF INPATIENT: WHAT WAS THE INPATIENT VENUE?

Hospital
Institution
Rehab Center

[IF A1=1 or 5 GO TO A2a,
IF A1 =2 or 3 or 4 GO TO A2c]


MEDICAL RECORDS – EVENT DATE – INPATIENT/LTC (ADMIT/DISCHARGE DATES)


A2a. What were the admit and discharge dates of the inpatient stay?

REFERENCE PERIOD – CALENDAR YEAR 2012

ADMIT:

Month:_____
Day:________
Year:_______

DISCHARGE:

Month:_____
Day:________
Year:_______

NOT YET DISCHARGED....... 1

IF A2a = NOT YET DISCHARGED, CODE DISCHARGE AS 99/99/9999


A2b. Was (PATIENT NAME) admitted from the emergency room?

YES..... 1
NO...... 2

IF A2b = 2 go to A3, OTHERWISE CONTINUE TO A2c


MEDICAL RECORDS – EVENT DATE – OUTPATIENT/ER/OTHER (VISIT DATE)


A2c. What was the date of this visit?

REFERENCE PERIOD – CALENDAR YEAR 2012

Month:_____
Day:________
Year:_______

DK/REF/RETRIEVABLE – CONTINUE TO A3


MEDICAL RECORDS – SBD


A3. I need to record the name and specialty of each physician who provided services during the (TYPE OF EVENT) (DATE(S)) and whose charges might not be included in the hospital bill. We want to include such doctors as surgeons, attending physicians, radiologists, anesthesiologists, pathologists, and consulting specialists, but not residents, interns, or other doctors-in-training whose charges are included in the hospital bill.

THERE MAY BE MORE THAN ONE TYPE OF EACH DOCTOR, SO PROBE FOR MULTIPLE SURGEONS, RADIOLOGISTS, ANETHESIOLOGISTS, AND OTHER SEPARATELY BILLING MEDICAL PROFESSIONALS.

IF RESPONDENT IS NOT SURE WHETHER A PARTICULAR DOCTOR 'S CHARGES ARE INCLUDED IN THE HOSPITAL BILL, ANSWER YES HERE.

YES, SEPARATELY BILLING DOCTORS FOR THIS EVENT...... 1
NO SEPARATELY BILLING DOCTORS FOR THIS EVENT........ 2

[IF A3=NO, DK/REF/RETRIEVABLE – SKIP TO A4a
IF A3=YES, ASK EF1]


MEDICAL RECORDS – SBD SUBROUTINE


EF1. I need to collect information about the doctors whose services for this event might not be included in the charges on the hospital bill. I would like to record the group name, doctor name, and National Provider ID, if available

Group Name: ______________
Prefix: ________________
First Name: ____________
Middle Name:___________
Last Name:_____________
National Provider ID:_________

EF3. What is this physician 's specialty?

Specialty:______________
If other, please specify:_____________

EF2. Did this doctor provide any of the following services for this event: radiology, anesthesiology, pathology, or surgery?

  1. Radiology
  2. Anesthesiology
  3. Pathology
  4. Surgery
  5. None of the above
  6. DON 'T KNOW

EF5. How would you describe the role of this doctor for this medical event?

Active Physician/Providing Direct Care..... 1
Referring Physician.................................... 2
Copied Physician........................................ 3
Follow-up Physician................................... 4
Department Head........................................ 5
Primary Care Physician............................... 6
Some Other Physician................................. 7
None of the above....................................... 8
DON 'T KNOW.......................................... 9

If other, please describe:____________________

EF6. ENTER ANY COMMENTS ABOUT THIS SBD INCLUDING ADDITIONAL SERVICE(S) TO THE ONE SELECTED IN EF2


MEDICAL RECORDS – DIAGNOSES


A4a. I need the diagnoses for (this stay/this visit). I would prefer the ICD-9 codes, or the DSM-4 codes, if they are available.

IF CODES ARE NOT USED, RECORD DESCRIPTIONS. RECORD UP TO FIVE ICD-9 CODES OR DESCRIPTIONS.

ICD-9 CODE:_____________ DESCRIPTION:_________________

CHECK HERE IF THIS IS AN ICD-10 CODE

DK/REF/RETRIEVABLE – CONTINUE TO A4c


SBD REAL-TIME PROMPTING


SBDPR1:A diagnosis that you mentioned often involves a (FILL SPECIALTY). We did not record such persons in the earlier questions about separately billing doctors. Did you not mention them for this patient event because they were residents or interns?

IF SPECIALTY RECORDED IN COMMENTS, ANSWER “NO” HERE.

YES=1
NO=2

If SBDPR1=YES, SKIP TO A4c
If SBDPR1=NO, ASK SBDPR2

SBDPR2:Do your records indicate that a (FILL SPECIALTY) was associated with this patient event?

IF SPECIALTY RECORDED IN COMMENTS, ANSWER “NO” HERE.

YES=1
NO=2

If SBDPR2=YES, SYSTEM SKIP FOCUS BACK TO A3
If SBDPR2=NO, GO TO SBDPR3

SBDPR3:PROBE WHY THERE WAS NO SBD OF THE EXPECTED TYPES FOR THIS EVENT

IF SPECIALTY RECORDED IN COMMENTS, NOTE THAT HERE.



MEDICAL RECORDS – SUMMARY/CONCLUSION


A4c.
PRESS “BREAKOFF” TO CLOSE THIS MEDICAL RECORDS SECTION. CMS WILL ASK WHETHER YOUR MEDICAL RECORDS RESPONDENT HAS ADDITIONAL EVENTS FOR THIS PATIENT.

PRESS "NEXT" WHEN YOU ARE READY TO BEGIN PATIENT ACCOUNTS SECTION.


PATIENT ACCOUNTS – INTRODUCTION


PA_Intro I have information from Medical Records that (PATIENT NAME) received health care services (on (BEGIN_MONTH)/(BEGIN_DAY)/(BEGIN YEAR)/between BEGIN_MONTH/BEGIN_DAY/BEGIN_YEAR and END_MONTH/END_DAY/END_YEAR).

NOTE: IF THE ONLY EVENT OF THIS TYPE KNOWN BY PATIENT ACCOUNTS IS WITHIN A DAY OR TWO OF WHAT WAS REPORTED BY MEDICAL RECORDS, ANSWER YES BELOW.

YES, RECORDS FOUND FOR THIS EVENT=............ 1
NO, RECORDS NOT FOUND FOR THIS EVENT=....... 2
NO, OTHER RECORDS PROBLEM=........................ 3

[IF Intro = 1 AND A1 = 2, 3, or 4 CONTINUE WITH A5a.
IF Intro = 1 AND A1 = 1 or 5 GO TO A8.
IF Intro = 2 THEN GO TO EXIT EVENT FORM.]

PATIENT ACCOUNTS – GLOBAL FEE


A5a. Was the visit on (VISIT DATE) covered by a global fee, that is, was it included in a charge that covered services received on other dates as well?

EXPLAIN IF NECESSARY: An example would be a patient who received a series of treatments, such as chemotherapy, that was covered by a single charge.

YES........1, (GO TO A5b)
NO.........2 (GO TO A6a)
DK/REF/RETRIEVABLE (GO TO A6a)

A5b. Did the global fee for this date cover any services received while the patient was an inpatient?

YES........1, (GO TO A5c)
NO.........2 (GO TO A5d)
DK/REF/RETRIEVABLE (GO TO A5d)

A5c. What were the admit and discharge dates of that stay?

ADMIT:

Month:_____
Day:________
Year:_______

DISCHARGE:

Month:_____
Day:________
Year:_______

NOT YET DISCHARGED....... 1

DK/REF/RETRIEVABLE – CONTINUE TO A5d

A5c1. Were there any other dates on which services were covered by this global fee?

YES..... 1
NO...... 2

A5d. What were the other dates on which services covered by this global fee were provided? Please include dates before or after 2012 if they were included in the global fee.

Did (PATIENT NAME) receive services on this date in an:

Outpatient Department YES=1, NO=2
Emergency Room YES=1, NO=2
Somewhere else YES=1, NO=2

A5e. Do you expect (PATIENT NAME) will receive any future services that will be covered by this same global fee?

YES..... 1
NO...... 2

A5f. [ABS ONLY] You’ve described different dates of service covered by a global fee. Do you know if there were additional doctors providing services whose charges weren’t included in the hospital bill?

YES..... 1
NO...... 2

A5c1 – “NO” GO TO A5e
DK/REF/RETRIEVABLE NOT ALLOWED
A5d - [SYSTEM WILL SET UP AS A LOOP, SO NO LIMIT ON NUMBER OF DATES REQUIRED]
A5d - DK/REF/RETRIEVABLE – CONTINUE TO A5e
A5e - DK/REF/RETRIEVABLE – IF MODE=ABS THEN CONTINUE TO A5f. IF MODE=DCS GO TO C2a.
A5f –This question should only appear when mode=abs.
[IF A5f = 1, GO TO A3. IF A5f = 2, DK/RF/RETRIEVABLE GO TO A6A]

PATIENT ACCOUNTS – SERVICES/CHARGES – OUTPATIENT/ER/OTHER

SERVICES/CHARGES


A6a. I need to know what services were provided during (this visit/these visits). I would prefer the CPT-4 codes, if they are available.

IF CPT-4 CODES ARE NOT USED, DESCRIBE SERVICES AND PROCEDURES PROVIDED. ENTER UP TO 8 CHARACTERS.

IF CODE BEGINS WITH W, X, Y OR Z, ENTER A DESCRIPTION INSTEAD.

CPT-4 CODE:_______ DESCRIPTION:_____________
CPT-4 CODE:_______ DESCRIPTION:_____________
CPT-4 CODE:_______ DESCRIPTION:_____________
CPT-4 CODE:_______ DESCRIPTION:_____________

[If A6a is DK/REF/RETRIEVABLE – CONTINUE TO A6b.]


A6b. ASK FOR EACH CPT-4 CODE OR DESCRIPTION: What was the full established charge for this service, before any adjustments or discounts?

IF NO CHARGE: Some facilities that don’t charge for each individual service do associate dollar amounts with services for purposes of budgeting or cost analysis. This is sometimes called a “charge equivalent”. Could you give me the charge equivalent for this service?

NOTE: WE NEVER ENTER $0 FOR A CHARGE
IF SPECIFIC CHARGE WAS APPLIED TO ANOTHER SERVICE, ENTER -4
IF CHARGES ARE APPLIED TO ANOTHER LINKED EVENT, ENTER -5

$________.____
$________.____
$________.____
$________.____
$________.____
$________.____
$________.____

[If A6b is DK/REF/RETRIEVABLE – CONTINUE TO C2.]


C2. I show the total charges as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL] / I show the charge as undetermined. / I show the charge as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL], although one or more charges are missing. Is that correct?

IF INCORRECT, CORRECT ENTRIES SHOWN ABOVE AS NEEDED

CHARGES
Service Charge: CPT4 CODE:
Charges
Charge=$_____.___
Total Amount $____.___

YES...... 1 (IF A6b=-5, GO TO LC2; OTHERWISE, GO TO C3.]
NO......... 2 (GO BACK TO A6b)

LC2. You reported just now that the charges are linked to another event. What was the date of that other event where the charges appear?

Month:_____
Day:________
Year:_______

LC3. And what kind of event was that, was it...

Inpatient...................................................................... 1
Hospital Outpatient Department................................. 2
Hospital Emergency Room......................................... 3
Long term care unit such as skilled nursing facility... 4
Somewhere else?......................................................... 5

DK/REF/RETRIEVABLE, CONTINUE TO C3


PATIENT ACCOUNTS – SERVICES/CHARGES – INPATIENT/LTC


A8. According to Medical Records, (PATIENT NAME) was an inpatient during the period from [ADMIT DATE] to [DISCHARGE DATE]. What was the DRG for this stay?

DRG IS A CODE USED TO CLASSIFY INPATIENT STAYS AND IT IS USUALLY ONE TO THREE DIGITS LONG.

DRG:__________
DRG NOT RECORDED ...... 1

[If A8 is answered, GO TO C2a. If NODRG (A8=1) GO TO A9. DK/REF/RETRIEVABLE – CONTINUE TO A9.]


A9. Did the patient have any surgical procedures during this stay?

YES..... 1
NO....... 2

[If A9 = 2 GO TO C2a. If A9 is DK/REF/RETRIEVABLE – GO TO C2a]


A10a. What surgical procedures were performed during this stay? Please give me the procedure codes, that is the CPT-4 codes, if they are available.

IF CPT-4 CODES ARE NOT USED, DESCRIBE SERVICES AND PROCEDURES PROVIDED. ENTER UP TO 8 CHARACTERS.
IF CODE BEGINS WITH W, X, Y OR Z, ENTER A DESCRIPTION INSTEAD.

IT IS ACCEPTABLE TO ENTER ICD9-CM CODES WITH FORMAT # #. # OR # #. # # FOR THIS QUESTION.

CODE:_______ DESCRIPTION:_____________
CODE:_______ DESCRIPTION:_____________
CODE:_______ DESCRIPTION:_____________
CODE:_______ DESCRIPTION:_____________

C2a. What was the full established charge for this inpatient stay, before any adjustments or discounts?

Please do not include any emergency room charges.

EXPLAIN IF NECESSARY: The full established charge is the charge maintained in the hospital 's master fee schedule for billing insurance carriers and Medicare or Medicaid. It is the "list price" for the service, before consideration of any discounts or adjustments resulting from contractual arrangements or agreements with insurance plans.

IF NO CHARGE: Some facilities that don 't charge for each individual service do associate dollar amounts with services for purposes of budgeting or cost analysis. This is sometimes called a "charge equivalent". Could you give me the charge equivalent for this inpatient stay?

NOTE: WE NEVER ENTER $0 FOR A CHARGE

FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:

$________.____

C2b. [IF ADMITTED FROM ER, ASK FOLLOWING QUESTION] Were the emergency room charges included with the full established charge?

YES..... 1
NO....... 2

C2c. [IF LONG TERM CARE, ASK FOLLOWING QUESTION] Were the ancillary charges included with the full established charge?

YES..... 1
NO....... 2

PATIENT ACCOUNTS – REIMBURSEMENT TYPE


C3. Was the facility reimbursed for (this visit/these visits/this stay) on a fee-for-service basis or capitated basis?

EXPLAIN IF NECESSARY:
Fee-for-service means that the practice was reimbursed on the basis of the services provided. Capitated basis means that the patient was enrolled in a prepaid managed care plan where reimbursement is not tied to specific visits, this is also called Per Member Per Month.

IF IN DOUBT, CODE FEE-FOR-SERVICE

FEE-FOR-SERVICE BASIS........ 1
CAPITATED BASIS.................... 2 (go to C7a)

PATIENT ACCOUNTS – SOURCES OF PAYMENT


C4. From which of the following sources has the facility received payment for (this visit/these visits/this stay) and how much was paid by each source? Please include all payments that have taken place between (VISIT DATE) and now for this (visit/these visits).

RECORD PAYMENTS FROM ALL THAT APPLY

[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?

[DCS ONLY] IF PROVIDER VOLUNTEERS THAT PATIENT PAYS A MONTHLY PREMIUM, VERIFY: So, you receive a monthly payment rather than payment for the specific service? IF YES: GO BACK TO C3 AND CODE AS CAPITATED BASIS.

IF ANY OF THE PAYMENTS IS A LUMP SUM THAT IS NOT YET ALLOCATED, ENTER F8 IN THE APPROPRIATE FIELD(S).

  1. Patient or Patient 's Family; .....$__________.____
  2. Medicare; ................................ $__________.____
  3. Medicaid; ................................ $__________.____
  4. Private Insurance; ................... $__________.____
  5. VA/Champva; ......................... $__________.____
  6. Tricare; .................................... $__________.____
  7. Worker 's Comp; ...................... $__________.____
  8. Something else?....................... $__________.____
    (IF SOMETHING ELSE: What was that? _____________)

[If C4 is DK/REF/RETRIEVABLE – CONTINUE TO C5]


C5. [I show the total payment as TOTPAYM / I show the payment as undetermined. / I show the payment as TOTPAYM, although one or more payments are missing ] Is that correct?

TOTAL PAYMENTS $
YES..... 1
NO....... 2

IF NO, CORRECT ENTRIES ABOVE AS NEEDED.

[If C5 is DK/REF/RETRIEVABLE – CONTINUE TO BOX 2.]


BOX 2


DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?

YES, AND ALL PAID BY PATIENT OR PATIENT ’S FAMILY..... – 1 (GO TO LSPCHECK)
YES, OTHER PAYERS............................................................ - 2 (GO TO C5a)
NO, PAYMENTS < CHARGES .............................................. - 3 (GO TO PLC1)
NO, PAYMENTS > CHARGES .............................................. - 3 (GO TO Q6_EXCEEDED)


PATIENT ACCOUNTS – VERIFICATION OF PAYMENT


C5a: I recorded that the payment(s) you received equal the charge(s). I would like to make sure that I have this recorded correctly. I recorded that the total payment is [SYSTEM WILL DISPLAY TOTAL PAYMENT FROM C5]. Does this total payment include any other amounts such as adjustments or discounts, or is this the final payment?

IF NECESSARY, READ BACK AMOUNT(S) RECORDED IN C4.

YES, FINAL PAYMENTS RECORDED IN C4 AND C5... =1
NO.......................................................................................... =2

[IF C5a=1 and A1=2,3, OR 4 GO TO BOX 3.
IF C5a =1 and A1=1 OR 5 GO TO FINISH SCREEN.
IF C5a =2 GO BACK TO C4]


PAYMENTS LESS THAN CHARGES


PLC1: It appears that the total payments were less than the total charge. Is that because...

IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS.

  1. There were adjustments or discounts ..... YES=1 NO=2
  2. You are expecting additional payment ... YES=1 NO=2
  3. This was charity care or sliding scale ..... YES=1 NO=2
  4. This was bad debt .................................... YES=1 NO=2

[If [a=1 and b=1] or [a=2 and b=2 and c=2 and d=2] then show both C6_adjustments and C6_additional.
If both c=1 and d=1 with no other selection, show neither C6_adjustments or C6_additional.
If both c=1 or d=1 with no other selection, show neither C6_adjustments or C6_additional.]


PATIENT ACCOUNTS – DIFFERENCE BETWEEN PAYMENTS AND CHARGES


C6: It appears that the total payments were (less than/more than) the total charges. What is the reason for that difference? Please include all adjustment activity that has taken place between (VISIT DATE) and now for (this visit/these visits). Was it a:

IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS.

C6_adjustments
PAYMENTS LESS THAN CHARGES:
Adjustment or discount

  1. Medicare limit or adjustment? ................ YES=1 NO=2
  2. Medicaid limit or adjustment? ................ YES=1 NO=2
  3. Contractual arrangement with insurer or managed care organization? ............... YES=1 NO=2
  4. Courtesy discount? .................................. YES=1 NO=2
  5. Insurance write-off? ................................ YES=1 NO=2
  6. Worker 's Comp limit or adjustment? ..... YES=1 NO=2
  7. Eligible veteran? ..................................... YES=1 NO=2
  8. Something else? ...................................... YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

C6_additional
Are you expecting additional payment from:

Expecting additional payment

  1. Patient or Patient 's Family? .................YES=1 NO=2
  2. Medicare? ........................................... YES=1 NO=2
  3. Medicaid? ............................................ YES=1 NO=2
  4. Private Insurance? ............................... YES=1 NO=2
  5. VA/Champva? ..................................... YES=1 NO=2
  6. Tricare? ............................................... YES=1 NO=2
  7. Worker 's Comp? ................................. YES=1 NO=2
  8. Something else .................................... YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

Q6_exceeded
Do the charges exceed payments because of

  1. Charity care or sliding scale?........... YES=1 NO=2
  2. Bad debt?......................................... YES=1 NO=2

Q6_extra
It appears that the total payments were more than the total charges. What is the reason for that difference? Please include all adjustment activity that has taken place between (DATE) and today. Was it (a)

PAYMENTS MORE THAN CHARGES:

  1. Medicare adjustment?...................... YES=1 NO=2
  2. Medicaid adjustment?...................... YES=1 NO=2
  3. Private insurance adjustment?.......... YES=1 NO=2
  4. Something else?................................ YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

LUMP SUM PAYMENTS


LSPCHECK

WAS ANY LUMP SUM ASSOCIATED WITH THE SOURCES OF PAYMENT?

YES ..... 1
NO ....... 2

[GO TO FINISH]


PATIENT ACCOUNTS – CAPITATED BASIS


C7a. What kind of insurance plan covered the patient for (this visit/these visits/this stay)? Was it:

[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?

  1. Medicare? ................................... YES=1 NO=2
  2. Medicaid? ................................... YES=1 NO=2
  3. Private Insurance? ...................... YES=1 NO=2
  4. VA/Champva? ............................ YES=1 NO=2
  5. Tricare? ...................................... YES=1 NO=2
  6. Worker 's Comp? ......................... YES=1 NO=2
  7. Something else ............................ YES=1 NO=2
    (IF SOMETHING ELSE: What was that? _______________)

[If C7a is DK/REF/RETRIEVABLE – CONTINUE TO C7b]


C7b. Was there a co-payment for (this visit/these visits/this stay)?

YES ................... 1
NO ..................... 2 (GO TO C7e)

[If C7b is DK/REF/RETRIEVABLE – GO TO C7e.]


C7c. How much was the co-payment?

$___________._____

C7d. Who paid the co-payment? Was it:

[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?

  1. Patient or Patient ’s Family? .... YES=1, NO=2
  2. Medicare? ............................... YES=1, NO=2
  3. Medicaid? ................................ YES=1, NO=2
  4. Private Insurance? ................... YES=1, NO=2
  5. Something else? ...................... YES=1, NO=2
    (IF SOMETHING ELSE: What was that?)

If C7c is DK/REF/RETRIEVABLE – CONTINUE TO C7d.
If C7d is DK/REF/RETRIEVABLE – CONTINUE TO C7e.]


C7e. Do your records show any other payments for (this visit/these visits/this stay)?

YES ..... 1
NO ....... 2

[IF DK/REF/RETRIEVABLE and If A1 = 2, 3, or 4 GO TO BOX 3.
If DK/REF/RETRIEVABLE and A1 = 1 or 5 GO TO FINISH SCREEN.]
IF C7e=2 and If A1 = 2, 3, or 4 GO TO BOX 3.
If C7e=2 and If A1 = 1 or 5 GO TO FINISH SCREEN.]


C7f. From which of the following other sources has the practice received payment for (this visit/these visits/ this stay) and how much was paid by each source? Please include all adjustment activity that has taken place between (VISIT DATE) and now for (this visit/these visits).

RECORD PAYMENTS FROM APPLICABLE PAYERS.

[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO, PROBE: And is that Medicare, Medicaid, or private insurance?

  1. Patient or Patient ’s Family; .... $__________.____
  2. Medicare; ................................ $__________.____
  3. Medicaid; ................................ $__________.____
  4. Private Insurance; ................... $__________.____
  5. VA/Champva; ......................... $__________.____
  6. Tricare; .................................... $__________.____
  7. Worker ’s Comp; ...................... $__________.____
  8. Something else?....................... $__________.____
    (IF SOMETHING ELSE: What was that? _____________)

[If A1 = 2, 3, or 4 GO TO BOX 3. If A1 = 1 or 5 GO TO FINISH SCREEN.]
If DK/REF/RETRIEVABLE – CONTINUE TO BOX 2.]


BOX 3


GLOBAL FEE SITUATION (A5a=YES)................................. 1 (GO TO FINISH SCREEN)
RECORDED 5 OR FEWER EVENTS........................................2 (GO TO FINISH SCREEN)
RECORDED 6 OR MORE EVENTS...........................................3 (GO TO FINISH SCREEN)

FINISH SCREEN

PRESS VALIDATE TO COMPLETE THIS EVENT FORM.