Charge/Payment (CP) Section

BOX_00 (CP1000)

BOX_10 (CP1001)

BOX_20 (CP1005)

BOX_30 (CP1050)

BOX_40 (CP1051)

CP10 (CP1055)

BLAISE NAME: CPaySameLRnd

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

My records indicate that at the last interview, {you/{PERSON}} (or someone in the family) usually pay{s} a {$ AMT COPAY} copayment to {PROVIDER}. Is this still correct?

HELP: F1

Responses: YES, STILL PAY {$ AMT COPAY} 1 CP50 (CP1065)

NO 2 CP20 (CP1056)

REFUSED RF CP50 (CP1065)

DON'T KNOW DK CP50 (CP1065)

Programmer Instructions: If coded '1' (YES, STILL PAY {$ AMT COPAY}), 'RF' (REFUSED), OR 'DK' (DON'T KNOW), flag this person-provider as 'copayment situation' for the current round and set copayment amount from the previous round (Provider.PersonProvider[I].CpayAmt) as this person-provider pair's copayment amount for the current round.

Display Instructions: For '$ AMT COPAY' in the question text and response option '1' (YES, STILL PAY {$ AMT COPAY}), display the CP200 amount flagged as 'copayment situation' during the previous round (Provider.PersonProvider[I].CpayAmt) for this person-provider pair.

CP20 (CP1056)

BLAISE NAME: CPayChng

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

Has your copayment amount changed, or do you no longer have a copayment?

HELP: F1

Responses: PAY A DIFFERENT COPAYMENT AMOUNT 1 CP30 (CP1060)

NOT A COPAYMENT SITUATION ANYMORE 2 CP50 (CP1065)

REFUSED RF CP50 (CP1065)

DON'T KNOW DK CP50 (CP1065)

Programmer Instructions: If coded 2 'NOT A COPAYMENT SITUATION ANYMORE', DK 'DON'T KNOW', or RF 'REFUSED', do not flag this person-provider as 'copayment situation' for the current round.

Display Instructions:

CP30 (CP1060)

BLAISE NAME: CPayAmt

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

What is the correct copayment amount?

ENTER AMOUNT

HELP: F1

Responses: 1 CP50 (CP1065)

REFUSED RF CP50 (CP1065)

DON'T KNOW DK CP50 (CP1065)

Programmer Instructions: If amount entered, flag this person-provider as 'copayment situation' for the current round. Set dollar amount entered at CP30 as the new copayment amount for this person- provider pair for the current round.

If coded 'RF' (REFUSED), or 'DK' (DON'T KNOW), flag this person-provider pair as 'copayment situation' for the current round and set copayment amount from previous round (Provider.PersonProvider[I].CPayAmt) as copayment amount for the current round.

Soft check:

If amount entered is > or = $75, display the following message: "ENTER A DOLLAR AMOUNT < OR = $75, RF, OR DK."

Display Instructions:

CP40 (CP1061)

BLAISE NAME: ProvNoPay

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

My records indicate that at the last interview, {you/{PERSON}} (or someone in the family) do not usually have to make any payments for visits to {PROVIDER}. Is this still correct?

HELP: F1

Responses: YES 1 CP50 (CP1065)

NO 2 CP50 (CP1065)

REFUSED RF CP50 (CP1065)

DON'T KNOW DK CP50 (CP1065)

Programmer Instructions: If coded '1' (YES), DK 'DON'T KNOW', or RF 'REFUSED', flag this person-provider pair as 'copayment situation' for the current round and set copayment amount from the previous round (Provider.PersonProvider[I].CPayAmt) as the person's copayment amount for the current round ($0).

If coded '2' (NO), do not flag this person-provider as 'copayment situation' for the current round.

Display Instructions:

CP50 (CP1065)

BLAISE NAME: CPayIntro

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

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 {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 1 AND ENTER TO CONTINUE.

HELP: F1

Responses: CONTINUE 1

Programmer Instructions: If event type is ER, OP, MV, or DN and person-provider pair is flagged as 'COPAYMENT SITUATION' for the current round, go to CP60.

Otherwise, go to CP70.

Display Instructions: 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 '{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 this is an event for 'GLASSES OR CONTACT LENSES' (EE40='1' YES, EE50='1' YES, or OM10='1' YES).

Display 'ambulance services' if This is an OM event for 'AMBULANCE SERVICES' (OM30='1' YES)

Display 'disposable supplies' if this is an OM event for 'DISPOSABLE SUPPLIES' (OM40='1' YES)

Display 'long-term medical equipment' if this is an OM event for 'LONG-TERM MEDICAL EQUIPMENT' (OM50='1' YES).

CP60 (CP1075)

BLAISE NAME: CPayOnlyAmt

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVNDT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

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?

HELP: F1

Responses: YES 1 BOX_130 (CP1485)

NO 2 CP70 (CP1080)

REFUSED RF CP70 (CP1080)

DON'T KNOW DK CP70 (CP1080)

Programmer Instructions: 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), 'RF' (REFUSED), or 'DK' (DON'T KNOW), do NOT copy the copayment charge payment data for this person-provider pair to this event-provider pair.

Full charge payment data for this event-provider pair will be collected. The copayment flag remains unchanged for this person-provider pair, however, it is not applied to this particular event.

Display Instructions: Display 'only paid the {$ AMT COPAY} copayment' if this person-provider pair's copayment amount for the current round does not equal zero ($0).

For '$ AMT COPAY': Display the current copayment amount for this person-provider pair for this round (confirmed at CP10, updated at CP30, or amount entered at CP200 and set as current copayment amount per BOX_140).

Display 'paid nothing' if this person-provider pair's copayment amount for the current round equals zero ($0).

CP70 (CP1080)

BLAISE NAME: EvpvRcvBill

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REFDT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

{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 {OME ITEM GROUP NAME}/the services received at home}?

Responses: YES, AND DOCUMENTATION AVAILABLE 1 BOX_50 (CP1096)

YES, BUT DOCUMENTATION NOT AVAILABLE 2 BOX_50 (CP1096)

NO 3 CP80 (CP1085)

REFUSED RF CP80 (CP1085)

DON'T KNOW DK CP80 (CP1085)

Display Instructions: Display 'this hospital stay' if event type is HS.

Display 'this visit' if event type is ER, OP, MV, OR DN.

Display 'the {OME ITEM GROUP NAME}' if event type is OM.

Display 'the services received at home' if event type is HH.

For {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 this is an OM event for 'GLASSES OR CONTACT LENSES'(EE40='1' YES, EE50='1' YES, or OM10= '1' YES) .

Display 'ambulance services' if this is an OM event for 'AMBULANCE SERVICES' (OM30= '1' YES) .

Display 'disposable supplies' if this is an OM event for 'DISPOSABLE SUPPLIES' (OM40= '1' YES).

Display 'long-term medical equipment' if this is an OM event for 'LONG-TERM MEDICAL EQUIPMENT' (OM50= '1' YES).

CP80 (CP1085)

BLAISE NAME: EvpvYNoBill

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {OME ITEM GROUP NAME} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

& CP-1.

Please look at 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.}

HELP: F1

Responses: PAID AT TIME OF VISIT 1 BOX_50 (CP1096)

MADE A COPAYMENT 2 BOX_50 (CP1096)

BILL SENT DIRECTLY TO OTHER SOURCE 3 CP90 (CP1090)

BILL HAS NOT ARRIVED 4 BOX_50 (CP1096)

NO BILL SENT: HMO PLAN 5 BOX_50 (CP1096)

NO BILL SENT: VA (VETERANS ADMINISTRATION)/CHAMPVA 6 BOX_50 (CP1096)

NO BILL SENT: MILITARY FACILITY 7 BOX_50 (CP1096)

NO BILL SENT: PUBLIC ASSISTANCE/MEDICAID/SCHIP 8 BOX_50 (CP1096)

NO BILL SENT: INDIAN HEALTH SERVICE (IHS) 9 BOX_50 (CP1096)

NO BILL SENT: WORKER'S COMPENSATION 10 BOX_50 (CP1096)

NO BILL SENT: PRIVATE HEALTH CENTER/CLINIC 11 BOX_50 (CP1096)

NO BILL SENT: PUBLIC CLINIC/HEALTH CENTER OR PRIVATE CHARITY 12 BOX_50 (CP1096)

NO CHARGE: TELEPHONE CALL 13 BOX_130 (CP1485)

FREE FROM PROVIDER 14 BOX_130 (CP1485)

GOVERNMENT-FINANCED RESEARCH AND CLINICAL TRIALS 15 BOX_130 (CP1485)

{INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)} 95

REFUSED RF BOX_50 (CP1096)

DON'T KNOW DK BOX_50 (CP1096)

Programmer Instructions: If 'INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)' is selected, and event- provider pair does not represent a repeat visit group or this is not an OM event, ask the Flat Fee (FF) section immediately. Charge Payment information in the context of the single event is no longer needed.

Display Instructions: Display the interviewer instruction "SELECT 'INCLUDED WITH OTHER CHARGES' IF THIS IS A FLAT FEE SITUATION." if event-provider pair does not represent repeat visit stem or this is not an OM event. Otherwise, use a null display.

Display response option 95 ''INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)' if event provider pair does not represent a repeat visit stem or this is not an OM event. Otherwise, use a null display.

CP90 (CP1090)

BLAISE NAME: EvpvWhereBill

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV}{OME ITEM GROUP NAME} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

To whom was the bill sent?

RECORD VERBATIM.

Responses: 1 CP100 (CP1095)

REFUSED RF CP100 (CP1095)

DON'T KNOW DK CP100 (CP1095)

Display Instructions:

CP100 (CP1095)

BLAISE NAME: EvpvWhereBillTp

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {OME ITEM GROUP NAME} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

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

HELP: F1

Responses: HMO 1 BOX_50 (CP1096)

VA (VETERANS ADMINISTRATION)/CHAMPVA 2 BOX_50 (CP1096)

TRICARE 3 BOX_50 (CP1096)

OTHER MILITARY 4 BOX_50 (CP1096)

PUBLIC ASSISTANCE/MEDICAID/SCHIP 5 BOX_50 (CP1096)

WORKER'S COMPENSATION 6 BOX_50 (CP1096)

PRIVATE INSURANCE COMPANY 7 BOX_50 (CP1096)

INDIAN HEALTH SERVICE (IHS) 8 BOX_50 (CP1096)

OTHER 91 BOX_50 (CP1096)

REFUSED RF BOX_50 (CP1096)

DON'T KNOW DK BOX_50 (CP1096)

Display Instructions:

BOX_50 (CP1096)

CP110 (CP1097)

BLAISE NAME: FFeeSituation

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

Sometimes a person can be charged a 'lump sum' for orthodontia or dental restorative treatments that require a series of visits like braces, retainers, fillings, inlays, crowns, or caps. We call this "a flat fee situation." Is {your/{PERSON}'s} visit to {PROVIDER} on {VISIT DATE} part of a flat fee?

Responses: YES 1

NO 2 BOX_60 (CP1098)

REFUSED RF BOX_60 (CP1098)

DON'T KNOW DK BOX_60 (CP1098)

Programmer Instructions: If coded '1' YES, and event-provider pair does not represent a repeat visit group, ask the Flat Fee (FF) section immediately. Charge Payment information in the context of the single event is no longer needed.

Display Instructions:

BOX_60 (CP1098)

BOX_70 (CP1100)

CP120 (CP1105)

BLAISE NAME: EvpvKnowTotal

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

Do you know the total charge for {this hospital stay/this visit/the {OME ITEM GROUP NAME}/the services received at home}?

{ENTER 'INCLUDED WITH OTHER CHARGES' IF THIS IS A FLAT FEE SITUATION.}

HELP: F1

Responses: YES 1 BOX_80 (CP1106)

NO 2

{INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)} 95

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If:

Coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW)

And

(event type is OM or HH or HS, go to CP200.

If: coded '2' (NO), 'RF' (REFUSED), or 'DK' (DON'T KNOW)

And

event type is ER, OP, MV, or DN, go to CP170.

If coded 95 'INCLUDED WITH OTHER CHARGES' (E.G. FLAT FEE)' and the event- provider pair does not represent a repeat visit group or this is not an OM event, ask the Flat Fee (FF) section immediately. Charge Payment information in the context of the single event is no longer needed.

Display Instructions: Display 'this hospital stay' if event type is HS.

Display 'this visit' if event type is ER, OP, MV, or DN.

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 "ENTER 'INCLUDED WITH OTHER CHARGES' IF THIS IS A FLAT FEE SITUATION" if event-provider pair does not represent a repeat visit stem or this is not an OM event. 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 this is an OM event for 'GLASSES OR CONTACT LENSES'(EE40='1' YES, EE50='1' YES, or OM10= '1' YES) .

Display 'ambulance services' if this is an OM event for 'AMBULANCE SERVICES' (OM30= '1' YES) .

Display 'disposable supplies' if this is an OM event for 'DISPOSABLE SUPPLIES' (OM40= '1' YES).

Display 'long-term medical equipment' if this is an OM event for 'LONG-TERM MEDICAL EQUIPMENT' (OM50= '1' YES).

Display response option 95 ''INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)' if event provider pair does not represent a repeat visit stem or this is not an OM event.

Otherwise, use a null display.

BOX_80 (CP1106)

CP130 (CP1107)

BLAISE NAME: EvpvTotChrgRng

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {REF-DT}

Question Text:

&CP-2

Please look at card CP-2, and tell me how much the total charge was for all of the disposable supplies purchased {since {START DATE}/between {START DATE} and {END DATE}}? Include any amounts that may be paid by health insurance or other sources. Was it $0, $1 to $10, $11 to $30, $31 to $100, $101 or more?

HELP: F1

Responses: $0 1 BOX_130 (CP1485)

$1 TO $10 2 CP180 (CP1126)

$11 TO $30 3 CP180 (CP1126)

$31 TO $100 4 CP180 (CP1126)

$101 OR MORE 5 CP180 (CP1126)

REFUSED RF CP190 (CP1127)

DON'T KNOW DK CP190 (CP1127)

Display Instructions: Display 'Since {START DATE}' if not round 5. Display 'Between {START DATE} and {END DATE}', if round 5.

CP140 (CP1110)

BLAISE NAME: EvpvChrgTp

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {OME ITEM GROUP NAME} {EVN-DT/REF-DT} {REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

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.}

Responses: AMOUNT 1 CP150 (CP1115)

{INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)} 95

Programmer Instructions: If coded '95' 'INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)' and the event- provider-pair does not represent a repeat visit group or this is not an OM event, ask the Flat Fee (FF) section immediately. Charge Payment information in the context of the single event is no longer needed.

Display Instructions: Display 'Do not include any services 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 CP70 is coded '1' (YES, AND DOCUMENTATION AVAILABLE). 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, or HH. 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 repeat visit stem or this is not a OM event. Otherwise, use a null display.

Display response option 95 ''INCLUDED W/OTHER CHARGES (E.G. FLAT FEE)' if event provider pair does not represent a repeat visit stem or this is not an OM event.

Otherwise, use a null display.

CP150 (CP1115)

BLAISE NAME: EvpvTotChrg

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

[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.]

ENTER AMOUNT.

Responses: 1

REFUSED RF

DON'T KNOW DK

Programmer Instructions: If the amount is $0, go to BOX_130.

If: event type is ER, OP, MV, or DN and total charge is a non-zero whole number < or = $50.00 or CP150 is coded 'RF' (REFUSED) or 'DK' (DON'T KNOW), go to CP170.

If the amount is not $0, DK, or RF and the event type is HH, continue with CP160.

Otherwise, go to CP200.

Soft check: If amount entered is > or = $100,000, display the following message: display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Hard check:

Amount cannot be < 0.

Display Instructions: Display the question text "How much…other sources?" and "IF WORKING...DENIED CHARGES" in brackets and grayed-out text.

Display 'Do not include any services billed for separately such as physician charges or other services.' in brackets and grayed-out text, 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}." In brackets and grayed-out text, if CP70 is coded '1' (YES, AND DOCUMENTATION AVAILABLE). 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, or HH. Otherwise, use a null display.

CP160 (CP1120)

BLAISE NAME: EvpvMonthly

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

You said that the total charge for the services received at home was {$ AMOUNT}. Is that dollar amount a monthly amount or not?

Responses: YES, MONTHLY AMOUNT 1 CP200 (CP1130)

NO, NOT A MONTHLY AMOUNT 2

REFUSED RF CP200 (CP1130)

DON'T KNOW DK CP200 (CP1130)

Programmer Instructions: {$ AMOUNT}: Display amount entered at CP150.

Hard Check:

If coded '2' (NO), display the following message: "IF {$ AMOUNT} IS NOT THE MONTHLY AMOUNT CHARGED, CORRECT TOTAL CHARGE AT CP150 (EvpvTotChrg)." CAPI displays a selection CP150 as an option to return to. Code '2' (NO) is never allowed as a final response at CP160.

Display Instructions:

CP170 (CP1125)

BLAISE NAME: EvpvSetAmt

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

Is this the type of situation in which {you/he/she} always {make/makes} the same set dollar amount copayment regardless of what happens during the visit?

HELP: F1

Responses: YES 1 CP200 (CP1130)

NO 2 CP200 (CP1130)

USUALLY PAYS $0 (REGARDLESS OF SERVICE) 3 CP200 (CP1130)

REFUSED RF CP200 (CP1130)

DON'T KNOW DK CP200 (CP1130)

Display Instructions:

CP180 (CP1126)

BLAISE NAME: EvpvFamPaid

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {OME ITEM GROUP NAME}

{REF-DT}

Question Text:

How much of the total charge for the disposable supplies did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements? Was it all or almost all of the total charge, none of the total charge, or some of the total charge?

HELP: F1

Responses: ALL OR ALMOST ALL OF THE TOTAL CHARGE 1 BOX_90 (CP1145)

NONE OF THE TOTAL CHARGE 2 BOX_90 (CP1145)

OR SOME OF THE TOTAL CHARGE 3 CP190 (CP1127)

REFUSED RF CP190 (CP1127)

DON'T KNOW DK CP190 (CP1127)

Display Instructions:

CP190 (CP1127)

BLAISE NAME: EvpvAmtUPayRng

Question Text:

& CP-2

Please look at card CP-2, and tell me how much of the total charges for the disposable supplies did anyone in the family pay 'out-of-pocket,' that is, before any reimbursements? Was it $0, $1 to $10, $11 to $30, $31 to $100, $101 or more?

HELP: F1

Responses: $0 1 BOX_90 (CP1145)

$1 TO $10 2 BOX_90 (CP1145)

$11 TO $30 3 BOX_90 (CP1145)

$31 TO $100 4 BOX_90 (CP1145)

$101 OR MORE 5 BOX_90 (CP1145)

REFUSED RF BOX_90 (CP1145)

DON'T KNOW DK BOX_90 (CP1145)

Display Instructions:

CP200 (CP1130)

BLAISE NAME: EvpvAmtUPay

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {OME ITEM GROUP NAME} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

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, ENTER 0.

ENTER AMOUNT.

HELP:F1

Responses: 1 BOX_90 (CP1145)

REFUSED RF BOX_90 (CP1145)

DON'T KNOW DK BOX_90 (CP1145)

Programmer Instructions: Soft check: If amount entered is > or = $10,000, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Display Instructions: Display '{AMT TOT CH}' if an amount is given for the total charge at CP150. Display 'total charge' if CP120 is coded '2' (NO), 'RF' (REFUSED), 'DK' (DON'T KNOW), if CP120 =1 but CP150 = RF or DK, or is not asked.

For {AMT TOT CH} display the dollar amount entered at CP150.

BOX_90 (CP1145)

CP210 (CP1160)

BLAISE NAME: EvpvAnySrcPay

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

Question Text:

Has any private insurance company, HMO, Medicare, Medicaid, or any other source made any payments {to {PROVIDER}} for {this hospital stay/this visit/the {OME ITEM GROUP NAME}/the services received at home}?

HELP: F1

Responses: YES 1 CP220 (CP1165)

NO 2 BOX_100 (CP1295)

REFUSED RF BOX_100 (CP1295)

DON'T KNOW DK BOX_100 (CP1295)

Display Instructions: Display "to {PROVIDER}' if event type is not OM. 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 {OME ITEM GROUP NAME}' if event type is OM.

Display 'the services received at home' 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 this is an OM event for 'GLASSES OR CONTACT LENSES'(EE40='1' YES, EE50='1' YES, or OM10= '1' YES) .

Display 'ambulance services' if this is an OM event for 'AMBULANCE SERVICES' (OM30= '1' YES) .

Display 'disposable supplies' if this is an OM event for 'DISPOSABLE SUPPLIES' (OM40= '1' YES).

Display 'long-term medical equipment' if this is an OM event for 'LONG-TERM MEDICAL EQUIPMENT' (OM50= '1' YES).

CP220 (CP1165)

BLAISE NAME: EvpvSOPRoster

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {OME ITEM GROUP NAME} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

Who else paid?

PROBE: Anyone else?

TO ADD A NEW SOURCE OF PAYMENT, PRESS CTRL-A.

ENTER ALL THAT APPLY.

CTRL-A: ADD

CTRL-E: EDIT

CTRL-D: DELETE

Responses: {Name of Source of Payment} 1 1 CP230 (CP1170)

{Name of Source of Payment} 2 2 CP230 (CP1170)

{Name of Source of Payment} 3 3 CP230 (CP1170)

{Name of Source of Payment} 4 4 CP230 (CP1170)

{Name of Source of Payment} N 5 CP230 (CP1170)

Programmer Instructions: Roster behavior:

1. Multiple select allowed.
   
   
2. Multiple add allowed.
   
   
3. Pressing CTRL-A displays a pop-up with a text entry field and a selectable list of 15 common sources of payment. (See BOX_20 for a detailed list). The interviewer can type a new source or select one from the list. Upon return to CP220, the added source will appear on the roster as selected.
   
   
4. Limited delete allowed. If interviewer adds a source of payment, delete is possible for that source only, as long as the charge payment section for this person-provider pair has not been completed.
   
   
5. Write sources selected to the Event's-Sources-of- Payment-roster.

If at least one source is added or selected during the current round, the flag SOPFlag should be set to YES.

Display Instructions: Roster 3- add/edit/delete allowed.

Roster definition:

Display the RU-Sources-Of-Payment-roster for selection.

Display payment source name (SRCS.SRCNAME)

Roster filter:

Display all sources of payment except PERSON/FAMILY

CP230 (CP1170)

BLAISE NAME: PayMAmtPaid

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}}

Question Text:

How much did {SOURCE} pay?

ENTER AMOUNT.

TOTAL CHARGE: ${TOTAL CHARGE}

Responses: 1

REFUSED RF

DON'T KNOW DK

Programmer Instructions: Preloaded Grid Type 2

Soft check: If amount entered is > $10,000, display the following message: "VALUE IS HIGHER THAN USUAL. VERIFY AND CORRECT IF NEEDED."

Flag all sources and associated amounts as 'payment'.

Interviewer enters a dollar amount for each source displayed. Amounts can be changed as many times as necessary before the interviewer leaves the screen.

2. The PERSON/FAMILY amount paid cell is protected and prefilled with the family out- of- pocket payment amount entered at CP200; no changes are allowed to this amount.

Soft Check:

If any source coded '$0', display the following message: "IF {SOURCE} DID NOT PAY ANY PART OF THE TOTAL CHARGE, CORRECT THE SOURCES THAT MADE DIRECT PAYMENTS TO THIS PROVIDER AT CP210 (AnySrcPay) OR CP220 (SOPRoster). IF {SOURCE} IS THE ONLY SOURCE OF DIRECT PAYMENT, GO TO CP210 (AnySrcPay) AND CODE '2' (NO). IF THERE ARE OTHER SOURCES OF PAYMENT, GO TO CP220 (SOPRoster) AND DELETE {SOURCE} FROM THE LIST OF SOURCES OF DIRECT PAYMENT. IF RESPONDENT DOES NOT KNOW HOW MUCH {SOURCE} PAID, CODE "DK" AT CP230 (AmtPaid)."

Display Instructions: Roster 1- Report

Roster definition:

Display the Event's-Sources-of-Payment-roster for entry of payment amount in the form pane.

Display payment source name.

Roster Filter:

Display all sources selected at CP220 for this event-provider pair and the 'PERSON/FAMILY' record.

For TOTAL CHARGE, display amount entered at CP130, if event is OM event type '3' (DISPOSABLE SUPPLIES). Otherwise display amount entered at CP150.

BOX_100 (CP1295)

BOX_110 (CP1300)

BOX_120 (CP1305)

CP240 (CP1310)

BLAISE NAME: EvpvElsePay

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

Question Text:

Does anyone in the family or any other source expect to make additional payments for {this hospital stay/this visit/the {OME ITEM GROUP NAME}/the services received at home}?

Responses: YES 1 BOX_130 (CP1485)

NO 2 BOX_130 (CP1485)

REFUSED RF BOX_130 (CP1485)

DON'T KNOW DK BOX_130 (CP1485)

Display Instructions: Display 'this hospital stay' if event type is HS.

Display 'this visit' if event type is ER, OP, MV, OR DN.

Display 'the {OME ITEM GROUP NAME}' if event type is OM.

{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 this is an OM event for 'GLASSES OR CONTACT LENSES'(EE40='1' YES, EE50='1' YES, or OM10= '1' YES) .

Display 'ambulance services' if this is an OM event for 'AMBULANCE SERVICES' (OM30= '1' YES) .

Display 'long-term medical equipment' if this is an OM event for 'LONG-TERM MEDICAL EQUIPMENT' (OM50= '1' YES).

Display 'the services received at home' if event type is HH.

BOX_130 (CP1485)

BOX_140 (CP1490)

BOX_150 (CP1495)

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