MEDICAL EXPENDITURE PANEL SURVEY
MEDICAL PROVIDER COMPONENT
MEDICAL EVENT FORM FOR INSTITUTIONAL PROVIDERS
(NON-HOSPITAL FACILITIES)
FOR
REFERENCE YEAR 2009
INSTITUTIONAL EVENT FORM
[COMPLETE ONE FORM FOR EACH STAY]
QUESTIONS 1 THROUGH 3: TO BE COMPLETED WITH MEDICAL RECORDS.
READ ONLY FOR FIRST STAY FOR THIS PATIENT: Someone in (PATIENT)'s family reported that (he/she) was a patient
in this facility during 2009.
1 CONFIRM PATIENT RECEIVED SERVICES (GO TO Q1)
2 FACILITY KNOWS PATIENT BUT NO EVENTS RECORDED FOR 2009 (GO TO NEXT PATIENT, PAIR IS FINAL)
3 FACILITY DOES NOT KNOW PATIENT (GO TO NEXT PATIENT, REVIEW TO SEE IF DISAVOWAL IS ELIGIBLE FOR
CONVERSION)
MEDICAL RECORDS
1. What were the admit and discharge dates of the (first/next) stay?
ADMIT: MONTH ___ DAY ___ YEAR ___
DISCHARGE: MONTH ___ DAY ___ YEAR ___
NOT YET DISCHARGED ____1
2a. I need the diagnoses for this stay. I would prefer the ICD-9 codes (or DSM-IV codes), if they are available.
IF CODES ARE NOT USED, RECORD DESCRIPTIONS.
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 5 ICD-9 CODES TO BE COLLECTED]
CODE: ___ DESCRIPTION: ___
3. Please give me the name, specialty, and telephone number of each physician who provided services during the stay starting on (ADMIT DATE) and whose charges might not be included in the facility bill. We are interested in physicians with whom your facility has contractual arrangements, not the patient's private physician.
RECORD NAMES ON SEPARATELY BILLING DOCTOR FORM. IF RESPONDENT IS NOT SURE WHETHER A PARTICULAR DOCTOR'S CHARGES ARE INCLUDED IN THE FACILITY BILL, RECORD INFORMATION FOR THAT DOCTOR ON SEPARATELY BILLING DOCTOR FORM.
DOES NOT HAVE THIS INFORMATION ....0 COLLECT CONTACT INFORMATION FOR PERSON WITHRECORDS
SEPARATELY BILLING DOCTORS FOR THIS EVENT ...1
NO SEPARATELY BILLING DOCTORS FOR THIS STAY ...2
4a. Have we covered all of this patient's stays during the calendar year 2009?
YES, ALL STAYS COVERED ...1 (GO TO Q4b)
NO, NEED TO COVER ADDITIONAL STAYS ...2 (GO TO Q1-NEXT EVENT FORM)
4b. IF ALL STAYS ARE RECORDED FOR THIS PATIENT, REVIEW NUMBER OF STAYS REPORTED BY HOUSEHOLD.
NO DIFFERENCE OR FACILITY REPORTED MORE STAYS THAN HOUSEHOLD ...1 (GO TO ENDING FOR MEDICAL RECORDS)
FACILITY RECORDED FEWER STAYS ...2
[DCS ONLY] PROBE: (PATIENT NAME) reported (NUMBER) stays at (FACILITY) during 2009, but I have only recorded (NUMBER) stays. Do you have any information in your records that would explain this discrepancy?
DON’T KNOW ...1
UNACCESSIBLE ARCHIVED RECORDS ...2
ACCESSIBLE ARCHIVED RECORDS ...3 COLLECT CONTACT INFORMATION FOR PERSON WITH RECORDS
OTHER (SPECIFY):_______ 4
(GO TO ENDING FOR MEDICAL RECORDS)
ENDING FOR MEDICAL RECORDS:
GO TO NEXT PATIENT. IF NO MORE PATIENTS, THANK RESPONDENT AND END. THEN ATTEMPT CONTACT WITH PATIENT ACCOUNTS OR ADMINISTRATIVE OFFICE.
QUESTIONS 5 THROUGH END: TO BE COMPLETED WITH PATIENT ACCOUNTS.
According to Medical Records, (PATIENT NAME) was a patient in your facility during the period from (ADMIT DATE) to (DISCHARGE DATE/END OF 2009).
1 CONFIRM PATIENT RECEIVED SERVICES (GO TO Q5)
2 FACILITY KNOWS PATIENT BUT NO EVENTS RECORDED FOR 2009 (GO TO NEXT PATIENT, PAIR IS FINAL)
3 FACILITY DOES NOT KNOW PATIENT (GO TO NEXT PATIENT, REVIEW TO SEE IF DISAVOWAL IS ELIGIBLE FOR
CONVERSION)
5. Was the facility reimbursed for this stay on a fee-for-service basis or a capitated basis?
EXPLAIN IF NECESSARY:
Fee-for-service means that the facility was reimbursed on the basis of the services provided.
Capitated basis means that the patient was enrolled in a prepaid managed care plan, such as an HMO, and reimbursement to the facility
was not based on the services provided.
IF IN DOUBT, CODE FEE-FOR-SERVICE.
FEE-FOR-SERVICE BASIS ...1
CAPITATED BASIS ...2 (GO TO Q21a)
BASIC CHARGES
6. What was the full established charge for room, board, and basic care for this stay, before any adjustments or discounts, between (ADMIT DATE) and (DISCHARGE DATE/END OF 2009)?
EXPLAIN IF NECESSARY: The full established charge is the charge maintained in the facility's master fee schedule for billing private pay
patients. 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 in their records for
purposes of budgeting or cost analysis. This kind of information is sometimes call a "charge equivalent." Could you give me the charge equivalent for this stay?
VERIFY: Is this the total full established charge or “list price” for these services? IF NOT, RECORD FULL ESTABLISHED CHARGE.
FULL ESTABLISHED CHARGE OR CHARGE EQUIVALENT:
$_______________ . ________ (GO TO Q7)
CAN'T GIVE TOTAL CHARGE ...991 (GO TO Q10)
NO CHARGE ...992 (GO TO Q6a)
6a. Why is there no charge for room, board, and basic care for this stay?
FACILITY ASSUMES COST 1
PREPAID TO CONTINUING CARE 2
STATE-FUNDED INDIGENT CARE
(NOT MEDICAID) 3
RELIGIOUS ORGANIZATION
ASSUMES COST 4
VA FACILITY 5
OTHER (SPECIFY) 6
(GO TO Q14)
7. From which of the following sources has the facility received payment for this charge and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 20 SOURCES OF PAYMENT TO BE COLLECTED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS CAPITATED BASIS
a. Patient or Patient’s Family: $___.__,
b. Medicare: $___.__,
c. Medicaid: $___.__,
d. Private Insurance: $___.__,
e. VA/Champva: $___.__,
f. Tricare: $___.__,;
g. Worker’s Comp: $___.__,
h. or something else? (IF SOMETHING ELSE: What was that? ___ ) : $___.__,
8. I show the total payment as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS $__________.____
BOX 1
DO TOTAL PAYMENTS EQUAL TOTAL CHARGE?
YES, AND ALL PAID BY PATIENT OR PATIENT’S FAMILY ...1 (GO TO Q14)
YES, OTHER PAYERS ...2 (GO TO Q8a)
NO ...3 (GO TO Q9)
IF, AFTER VERIFICATION, PAYMENTS DO NOT EQUAL CHARGE COMPLETE Q9 AND GO TO Q14
8a. I recorded that the payment(s) you received equal the charge. 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 Q8]. 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 Q7.
YES, FINAL PAYMENTS RECORDED IN Q7 AND Q8 1 (GO TO Q14)
NO 2 (GO BACK TO Q7)
9. It appears that the total payments were (less than/more than) the total charge. What is the reason for this
difference?
CODE 1 (YES) FOR ALL REASONS MENTIONED.
PAYMENTS LESS THAN CHARGE:
Adjustment or discount
a. Medicare limit or adjustment; YES=1/NO=2
b. Medicaid limit or adjustment; YES=1/NO=2
c. Contractual arrangement with insurer or managed care organization; YES=1/NO=2
d. Courtesy discount; YES=1/NO=2
e. Insurance write-off; YES=1/NO=2
f. Worker’s Comp limit or adjustment; YES=1/NO=2
g. Eligible veteran; or YES=1/NO=2
h. Something else? YES=1/NO=2
(IF SOMETHING ELSE: What was that?)
Expecting additional payment
i. Patient or Patient’s Family; YES=1/NO=2
j. Medicare; YES=1/NO=2
k. Medicaid; YES=1/NO=2
l. Private Insurance; YES=1/NO=2
m. VA/Champva; YES=1/NO=2
n. Tricare; YES=1/NO=2
o. Worker’s Comp; or YES=1/NO=2
p. Something else? YES=1/NO=2
(IF SOMETHING ELSE: What was that?)
q. Charity care or sliding scale; YES=1/NO=2
r. Bad debt; YES=1/NO=2
PAYMENTS MORE THAN CHARGE:
s. Medicare adjustment; YES=1/NO=2
t. Medicaid adjustment; YES=1/NO=2
u. Private insurance adjustment; or YES=1/NO=2
v. Something else? …………………………. YES=1/NO=2
(IF SOMETHING ELSE: What was that?)
(GO TO Q14)
10. Can you tell me what the facility's full established daily rate for room and board and basic care was during this stay?
$_______________ . ________ (GO TO Q11)
RATE CHANGED DURING STAY 991 (GO TO Q12)
NO CHARGE 992 (GO TO Q10a)
10a. Why was there no charge for room, board, and basic care for this stay?
FACILITY ASSUMES COST 1
PREPAID TO CONTINUING CARE 2
STATE-FUNDED INDIGENT CARE (NOT MEDICAID) 3
RELIGIOUS ORGANIZATION ASSUMES COST 4
VA FACILITY 5
OTHER (SPECIFY) 6
(GO TO Q14)
11. For how many days was the patient charged during this stay? (Please give only the days during 2009.)
__________________ DAYS
IF RESPONDENT CAN'T PROVIDE TOTAL DAYS, GO TO Q12.
OTHERWISE, CONTINUE.
11a. From which of the following sources has the facility received payment for these charges and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 20 SOURCES OF PAYMENT TO BE COLLECTED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS CAPITATED BASIS
a. Patient or Patient’s Family: $__________.____ ,
b. Medicare: $__________.____ ,
c. Medicaid: $__________.____ ,
d. Private Insurance: $__________.____ ,
e. VA/Champva: $__________.____ ,
f. Tricare: $__________.____ ,
g. Worker’s Comp: $__________.____ ,
h. Or something else? (IF SOMETHING ELSE: What was that? ___) : $__________.____ ,
11b. I show the total payment as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS $__________.____
(GO TO Q14)
12. Perhaps it would be easier if you gave me the information billing period by billing period.
BILLING PERIOD NUMBER-1
BILLING PERIOD NUMBER ___
BILLING START DATE: MONTH ___ DAY ___ YEAR ___
BILLING END DATE: MONTH ___ DAY ___ YEAR ___
Number of DAYS IN BILLING PERIOD: _________
12-1. Between (BP DATES), how many days was the patient charged for room and board and basic care? BILLED DAYS ___
IF # BILLED DAYS IS LESS THAN # DAYS IN BP, Please explain why the number of days the patient was charged for room and board and basic care is less than the number of days in the billing period:
12-2. Between (BP DATES), what was the private pay rate for room and board and basic care (PERSON) received? If the rate changed, please give me the first one. $__________.____
12-3. How many days would that rate have applied during this billing period? ___DAYS
(GO TO Q12-6)
12-6. LOOK AT Q12-1. ARE ALL BILLED DAYS ACCOUNTED FOR?
Yes 1 [RATE WILL BE RECORDED IN Q12-8]
No 2 (GO TO Q12-2A)
12-2A. Between (BP DATES), what other private pay rate applied to the basic care that (PERSON) received? $__________.____
12-3A. On what date did this rate begin?
MONTH ___ DAY ___ YEAR ___
DK -8
12-4A. During this billing period, how many days would that rate have applied? ___DAYS
12-5A. Why did the rate change?
CODE ONLY ONE.
LEVEL OF CARE 1
PATIENT DISCHARGED:
TO HOSPITAL 2
TO COMMUNITY 3
TO OTHER FACILITY 4
RATE INCREASE 5
ROOM CHANGE 6
OTHER, SPECIFY 7
12-6A. LOOK AT Q12-1. ARE ALL BILLED DAYS ACCOUNTED FOR?
Yes 1 (GO TO Q12-7)
No 2 (GO TO Q12-2B)
12-2B. Between (BP DATES), what other private pay rate applied to the basic care that (PERSON) received? $__________.____
12-3B. On what date did this rate begin?
MONTH ___ DAY ___ YEAR ___
DK -8
12-4B. During this billing period, how many days would that rate have applied? # DAYS
12-5B. Why did the rate change?
CODE ONLY ONE.
LEVEL OF CARE 1
PATIENT DISCHARGED:
TO HOSPITAL 2
TO COMMUNITY 3
TO OTHER FACILITY 4
RATE INCREASE 5
ROOM CHANGE 6
OTHER, SPECIFY 7
12-6B. LOOK AT Q12-1. ARE ALL BILLED DAYS ACCOUNTED FOR?
Yes 1 (GO TO Q12-7)
No 2 [SYSTEM WILL REGENERATE 12-2B AS NECESSARY]
12-7 Is (RATE IN 12-2A/12-2B/ETC.) the private pay rate that applied at the end of the billing period?
YES 1 [RATE WILL BE RECORDED IN Q12-8]
NO 2 (GO TO Q12-8)
12-8. What was the private pay rate that applied at the end of the billing period? $______________._____
13. From which of the following sources did the facility receive payments for this billing period and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 20 SOURCES OF PAYMENT TO BE COLLECTED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
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 Q5 AND CODE AS
CAPITATED BASIS
a. Patient or Patient’s Family: $__________.____ ,
b. Medicare: $__________.____ ,
c. Medicaid: $__________.____ ,
d. Private Insurance: $__________.____ ,
e. VA/Champva: $__________.____ ,
f. Tricare: $__________.____ ,
g. Worker’s Comp: $__________.____ ,
h. Or something else? (IF SOMETHING ELSE: What was that? ____) : $__________.____ ,
13a. I show the total payment for this billing period as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS $__________.____
INDICATE WHETHER INFORMATION NEEDS TO BE COLLECTED FOR ANOTHER BILLING PERIOD
NEXT BILLING PERIOD [SYSTEM WILL REGENERATE Q12, Q13, AND Q13A FOR THE NEXT BILLING PERIOD]
NO MORE BILLING PERIODS (GO TO Q14)
ANCILLARY CHARGES
14. Did (PATIENT) have any health-related ancillary charges for this stay? (That is, were there charges for additional services not included in the basic rate?)
YES 1
NO 2 (GO TO Q22)
15. What was the total of full established charges for health-related ancillary care during this stay? Please exclude charges for non-health related services such as television, beautician services, etc.
EXPLAIN IF NECESSARY: Ancillaries are facility charges that are not included in the basic charge. Ancillary charges may include laboratory,
radiology, drugs and therapy (physical, speech, occupational).
TOTAL CHARGES: $__________.___ (GO TO Q16)
VERIFY: Is this the total of full established charges or “list price” for these service(s)? IF NOT, RECORD FULL ESTABLISHED CHARGES.
__ CHECK HERE IF RESPONDENT CAN'T SEPARATE HEALTH AND NON-HEALTH RELATED ANCILLARY CHARGES (GO TO Q16).
__ CHECK HERE IF RESPONDENT CAN'T GIVE TOTAL ANCILLARY CHARGES (GO TO Q19).
16. From which of the following sources has the facility received payment for these charges and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
[SYSTEM WILL ALLOW FOR A MAXIMUM OF 20 SOURCES OF PAYMENT TO BE COLLECTED]
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
a. Patient or Patient’s Family: $__________.____ ,
b. Medicare: $__________.____ ,
c. Medicaid: $__________.____ ,
d. Private Insurance: $__________.____ ,
e. VA/Champva: $__________.____ ,
f. Tricare: $__________.____ ,
g. Worker’s Comp: $__________.____ ,
h. Or something else? (IF SOMETHING ELSE: What was that? ___) : $__________.____ ,
17. I show the total payment as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
TOTAL PAYMENTS $__________.____
BOX 2
DO TOTAL PAYMENTS EQUAL TOTAL CHARGES?
YES, AND ALL PAID BY PATIENT OR PATIENT’S FAMILY 1 (GO TO Q22)
YES, OTHER PAYERS 2 (GO TO Q17a)
NO 3 (GO TO Q18)
IF, AFTER VERIFICATION, PAYMENTS DO NOT EQUAL CHARGES COMPLETE Q18 AND GO TO Q22
17a. I recorded that the payment(s) you received equal the charges. 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 Q17]. 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 Q16.
YES, FINAL PAYMENTS RECORDED IN Q16 AND Q17 1 (GO TO Q22)
NO 2 (GO BACK TO Q16)
18. It appears that the total payments were (less than/more than) the total charges. What is the reason for this difference?
CODE 1 (YES) FOR ALL REASONS MENTIONED.
PAYMENTS LESS THAN CHARGES:
Adjustment or discount
a. Medicare limit or adjustment; YES=1/NO=2
b. Medicaid limit or adjustment; YES=1/NO=2
c. Contractual arrangement with insurer
or managed care organization; YES=1/NO=2
d. Courtesy discount; YES=1/NO=2
e. Insurance write-off; YES=1/NO=2
f. Worker’s Comp limit or adjustment; YES=1/NO=2
g. Eligible veteran: YES=1/NO=2
h Or something else?(IF SOMETHING ELSE: What was that? ___) YES=1/NO=2
Expecting additional payment
i. Patient or Patient’s Family; YES=1/NO=2
j. Medicare; YES=1/NO=2
k. Medicaid; YES=1/NO=2
l. Private Insurance; YES=1/NO=2
m. VA/Champva; YES=1/NO=2
n. Tricare; YES=1/NO=2
o. Worker’s Comp YES=1/NO=2
p. Or something else? (IF SOMETHING ELSE: What was that? ____) YES=1/NO=2
q. Charity care or sliding scale; YES=1/NO=2
r. Bad debt; YES=1/NO=2
PAYMENTS MORE THAN CHARGES:
s. Medicare adjustment; YES=1/NO=2
t. Medicaid adjustment; YES=1/NO=2
u. Private insurance adjustment; or YES=1/NO=2
v. Something else? YES=1/NO=2
(IF SOMETHING ELSE: What was that?)
(GO TO Q22)
19. Perhaps it would be easier if you gave me the information billing period by billing period.
a. First, what was the start date of the first billing period (BP) in which (PATIENT) was a patient? ENTER MONTH ONLY IF BILLING PERIOD IS MONTHLY.
BP1 MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
BP2 MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
BP3 MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
BP4 MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
BP5 MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
LAST BP MONTH: ___ (GO TO Q19c) or START DATE MONTH: ___ DAY: ___ YEAR: ___
b. And what was the end date?
BP1 END DATE MONTH: ___ DAY: ___ YEAR: ___
BP2 END DATE MONTH: ___ DAY: ___ YEAR: ___
BP3 END DATE MONTH: ___ DAY: ___ YEAR: ___
BP4 END DATE MONTH: ___ DAY: ___ YEAR: ___
BP5 END DATE MONTH: ___ DAY: ___ YEAR: ___
LAST BP END DATE MONTH: ___ DAY: ___ YEAR: ___
c. What was the total of full established charges for health-related ancillary care during this billing period? Please exclude charges for non-health related services such as television, beautician services, etc.
BP1 $__________.____ (GO TO NEXT BP)
BP2 $__________.____ (GO TO NEXT BP)
BP3 $__________.____ (GO TO NEXT BP)
BP4 $__________.____ (GO TO NEXT BP)
BP5 $__________.____ (GO TO NEXT BP)
LAST BP $__________.____
20. From which of the following sources did the facility receive payments for ancillary charges for this billing period and how much was paid by each source? SELECT ALL THAT APPLY
BP1
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO NEXT BP)
BP2
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO NEXT BP)
BP3
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO NEXT BP)
BP4
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO NEXT BP)
BP5
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO NEXT BP)
LAST BP
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva;$__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or$__________.____
h. Something else? $__________.____
(IF SOMETHING ELSE: What was that?) _________________
(GO TO Q22)
20a. [SYSTEM WILL GENERATE AFTER Q20 FOR EACH BILLING PERIOD IN Q19]
I show the total payment as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
CAPITATED BASIS
21a. What kind of insurance plan covered the patient for this stay? Was it:
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
a. Medicare; YES=1/NO=2
b. Medicaid; YES=1/NO=2
c. Private Insurance; YES=1/NO=2
d. VA/Champva; YES=1/NO=2
e. Tricare; YES=1/NO=2
f. Worker’s Comp; YES=1/NO=2
g. Or something else? (IF SOMETHING ELSE: What was that?___) YES=1/NO=2
21b. What was the monthly payment from that plan? $___________.__
21c. Was there a co-payment for any part of this stay?
YES 1
NO 2 (GO TO Q21g)
21d. How much was the co-payment?
[DCS ONLY] PROBE TO DETERMINE IF FOR DAY, WEEK, ETC.
$___________.__
per DAY 1
WEEK 2
MONTH 3
OTHER 4
SPECIFY:
DON'T KNOW 8
21e. For how many (days/weeks/months/other) was the co-payment paid? _______________#
DON'T KNOW 98
21f. Who paid the co-payment? Was it:
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR HMO,
PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
a. Patient or Patient’s Family; YES=1/NO=2
b. Medicare; YES=1/NO=2
c. Medicaid; YES=1/NO=2
d. Private Insurance; or YES=1/NO=2
e. Something else? YES=1/NO=2
(IF SOMETHING ELSE: What was that?)
21g. Do your records show any other payments for this stay?
YES ...1
NO ...2 (GO TO Q22)
21h. From which of the following other sources has the facility received payment for this stay and how much was paid by each source?
SELECT ALL THAT APPLY
[DCS ONLY] IF NAME OF INSURER, PUBLIC, OR
HMO, PROBE: And is that Medicare, Medicaid, or private insurance?
OTHER SPECIFY: PROBE FOR SOURCE OF FUNDS AND TYPE OF PLAN.
a. Patient or Patient’s Family;$__________.____
b. Medicare;$__________.____
c. Medicaid;$__________.____
d. Private Insurance;$__________.____
e. VA/Champva; $__________.____
f. Tricare;$__________.____
g. Worker’s Comp; or $__________.____
h. Something else? (IF SOMETHING ELSE: What was that? ___) $__________.____
22. ARE THERE ANY ADDITIONAL STAYS FOR THIS PATIENT TO BE ACCOUNTED FOR?
YES ...1 (GO TO PATIENT ACCOUNTS SECTION (Q5) OF NEXT EVENT FORM.)
NO ... 2 (GO TO NEXT PATIENT. IF NO MORE PATIENTS, THANK RESPONDENT AND END.)