OMB
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 3 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. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. 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 (OMB control number 0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email at REPORTSCLEARANCEOFFICER@ahrq.hhs.gov.
PRESS 1 TO CONTINUE
PRESS BREAKOFF TO DISCONTINUE
BILLING
Did you bill for the services provided in (PATIENT NAME)'s home during the calendar year 2024 by month, by 60-day period, or by week?
- BY MONTH = 1
- BY 60-DAY PERIOD = 2
- BY SOME OTHER PERIOD?
(USE THIS RESPONSE ONLY IF PROVIDER ABSOLUTELY CANNOT CALCULATE COSTS BY MONTH) = 3 - BY WEEK = 4
(IF SOME OTHER PERIOD: What was that?)
DK/REF — CONTINUE TO D1
VISIT DATE
D1. During calendar year 2024, what (was the (first/next) month/was the begin/was the end date) of the (first/next) 60-day period/(was the begin/was the end) date of the (first/next) OTHER PERIOD/(was the begin/was the end dateof the (first/next) weekly period) during which your records show that services were provided in (PATIENT NAME)'s home?
REFERENCE PERIOD — CALENDAR YEAR 2024
MONTH:
Month: (blank space for month)
Year: (blank space for year)
OR
BEGIN DATE:
END DATE:
DCS: ENTER A DATE IN FORMAT MM/DD/YYYY. INCLUDE LEADING 0's FOR SINGLE DIGIT MONTHS AND DAYS.
DK/REF — CONTINUE TO D2
SERVICES/CHARGES
D2. I need to know which type or types of persons provided services at (PATIENT NAME)'s home (during (MONTH)/from (BEGIN DATE) through (END DATE)) and either the number of hours or the number of visits for each type.
SELECT ONE; PROBE AS NEEDED.
EXPLAIN IF NECESSARY: By type of person I mean a housekeeper, therapist, nurse aide, yard worker, and so forth.
- HOME HEALTH AID
HOURS/MINUTES (blank space) OR VISITS (blank space) - HOMEMAKER
HOURS/MINUTES (blank space) OR VISITS (blank space) - I.V./INFUSION THERAPIST
HOURS/MINUTES (blank space) OR VISITS (blank space) - NURSE/ NURSE PRACTITIONER
HOURS/MINUTES (blank space) OR VISITS (blank space) - NURSE'S AIDE
HOURS/MINUTES (blank space) OR VISITS (blank space) - OCCUPATIONAL THERAPIST
HOURS/MINUTES (blank space) OR VISITS (blank space) - PERSONAL CARE ATTENDANT
HOURS/MINUTES (blank space) OR VISITS (blank space) - PHYSICAL THERAPIST
HOURS/MINUTES (blank space) OR VISITS (blank space) - RESPIRATORY THERAPIST
HOURS/MINUTES (blank space) OR VISITS (blank space) - SOCIAL WORKER
HOURS/MINUTES (blank space) OR VISITS (blank space) - SPEECH THERAPIST
HOURS/MINUTES (blank space) OR VISITS (blank space) - YARD WORKER
HOURS/MINUTES (blank space) OR VISITS (blank space) - DRIVER
HOURS/MINUTES (blank space) OR VISITS (blank space) - BABYSITTER
HOURS/MINUTES (blank space) OR VISITS (blank space) - Other (Specify):
HOURS/MINUTES (blank space) OR VISITS (blank space)
D3. I need a description of the services provided (during (MONTH)/from (BEGIN DATE) through (END DATE)).
- CLEANING OR YARD WORK
YES=1, NO=2 - TRANSPORTATION
YES=1, NO=2 - SHOPPING
YES=1, NO=2 - EMOTIONAL SUPPORT PERSON OR
ONE-ON-ONE BUDDY
YES=1, NO=2 - SUPPORT GROUPS
YES=1, NO=2 - CHILD CARE
YES=1, NO=2 - If other, please specify on the blank line.
YES=1, NO=2 - (IF OTHER WHAT WAS THAT?)
ANY MORE TYPES OF HOME CARE PERSONS PROVIDING SERVICES?
YES=1, NO=2
D2 — DK/REF — CONTINUE TO D3
D3 — DK/REF — CONTINUE TO C2
C2. What were the charges for the services provided to (PATIENT NAME) (during (MONTH)/from (BEGIN DATE) through (END DATE))?
VERIFY: Is this the total charge for (this/these) service(s)?
IF NOT, RECORD TOTAL CHARGE.
NOTE: WE NEVER ENTER $0 FOR A CHARGE
TOTAL CHARGES: $ (blank space for dollar amount)
C2 — DK/REF — CONTINUE TO C4a
SOURCES OF PAYMENT
C4a. From which of the following sources did your organization receive payment for the charges (for (MONTH)/from (BEGIN DATE) through (END DATE)) and how much was paid by each source? Please include all payments that have taken place between (MONTH/BEGIN DATE) and now for this care.
IF NONE, ENTER ZERO (0).
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.
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” HERE.
- Patient or Patient's Family (blank space for dollar amount)
- Medicare (blank space for dollar amount)
- Medicaid (blank space for dollar amount)
- Private Insurance (blank space for dollar amount)
- VA/ChampVA (blank space for dollar amount)
- Tricare (blank space for dollar amount)
- Worker's Comp; (blank space for dollar amount)
- Or something else? (blank space for dollar amount)
(IF SOMETHING ELSE: What was that? (blank space))C4a(h) — “Other Specify” menu:
Auto or Accident Insurance
Indian Health Service
State Public Mental Plan
State/County Local program
Other
C4a — DK/REF — CONTINUE TO C5
C5. I show the total of all payments received for (MONTH) / (BEGIN DATE) through (END DATE)) as [SYSTEM WILL COMPUTE AND DISPLAY TOTAL]. Is that correct?
IF NO, CORRECT ENTRIES ABOVE AS NEEDED.
- YES = 1
- NO = 2
C5 — IF RESPONSE = 2, DISPLAY HARD CHECK: "IF INCORRECT, CORRECT ENTRIES AS NEEDED."
VERIFICATION OF PAYMENT
C5a. 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 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 C4a.
- YES, FINAL PAYMENTS RECORDED IN C4a AND C5 = 1 (GO TO LUMP SUM PAYMENT QUESTION)
- NO = 2 (GO BACK TO C4a)
PAYMENTS LESS THAN CHARGES (UNDERPAYMENT)
PLC1. It appears that the total payments were less than the total charge. Is that because...
- There were adjustments or discounts YES=1 NO=2
- You are expecting additional payment YES=1 NO=2
- This was charity care or sliding scale YES=1 NO=2
- This was bad debt YES=1 NO=2
- Person is an eligible veteran YES=1 NO=2
DIFFERENCE BETWEEN PAYMENTS AND CHARGES
Are you expecting additional payment from:
IF THE ONLY PAYMENT FOR THIS EVENT WAS A LUMP SUM, ANSWER “NO” TO ALL OPTIONS
C6_additional
Expecting additional payment
- Patient or Patient's Family? YES=1 NO=2
- Medicare? YES=1 NO=2
- Medicaid? YES=1 NO=2
- Private Insurance? YES=1 NO=2
- VA/ChampVA? YES=1 NO=2
- Tricare? YES=1 NO=2
- Worker's Comp? YES=1 NO=2
- Something else YES=1 NO=2
(IF SOMETHING ELSE: What was that? (blank space))
ADJEXTRA
It appears that the total payment was more than the total charges. Is that correct?
- YES = 1
- NO = 2
DCS: IF THE ANSWER IS “NO” PLEASE GO BACK TO C5 (VERIFY TOTAL PAYMENTS) TO RECONFIRM CHARGES AND PAYMENTS AS NEEDED.
LUMP SUM PAYMENTS
LSPCHECK
WAS THIS EVENT COVERED BY A LUMP SUM?
- YES = 1
- NO = 2
DK/REF ALLOWABLE and SKIP TO END OF EVENT FORM
FINISH SCREEN
ENTER 1 TO FINALIZE CASE.