Charge Payment (CP) SectionBOX_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, AND CP14A) 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 (INCLUDING 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} {EV} CP01B {PERSON’S FIRST MIDDLE AND LAST NAME} {EV}
WRITE SOURCES SELECTED TO THE SOURCES-OF-PAYMENT ROSTER.
CONTINUE WITH CP01
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 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: “THE SOURCES ROSTER IS EMPTY.”
ROSTER FILTER: DISPLAY ALL SOURCES OF PAYMENT THAT ARE NOT PERSON/FAMILY. CP01 {PERSON’S FIRST MIDDLE AND LAST NAME} {EV}
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
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
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.’ IF COPAYMENT IS ACTUALLY > $50, ENTER ‘DK’ FOR AMOUNT AND ENTER THE ACTUAL COPAYMENT AMOUNT IN A COMMENT.” CP03 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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
{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
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
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
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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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(E.G. FLAT FEE)’ 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
{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. CP07OV1 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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
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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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
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.
{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.
IF ‘INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)’ DISPLAY THE FOLLOWING MESSAGE: ‘THIS CODE IS NOT AVAILABLE FOR A PM EVENT.’
IF ‘INCLUDED WITH OTHER CHARGES (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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 (E.G. FLAT FEE)’ 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
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 - $100,000 HARD CHECK: AMOUNT CANNOT BE < 0 CP09A {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
{$ 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 CP11 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
{{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.
{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. CP11OV1 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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
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), GO TO CP37
OTHERWISE, CONTINUE WITH CP12 CP12 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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.
{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. CP12A {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
{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.
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: “THE SOURCES ROSTER IS EMPTY.” 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
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.
{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.
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. BOX_06
IF ‘AMOUNT PAID’ BY PERSON/FAMILY > $0, CONTINUE WITH CP14
OTHERWISE, GO TO BOX_09 CP14 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT FOR THIS EVENT. {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED ABOUT FOR THIS EVENT. DISPLAY ‘GLASSES OR CONTACT LENSES’ IF EVENT TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES OR CONTACT LENSES). DISPLAY ‘AMBULANCE SERVICES’ IF THE OM ITEM GROUP IS ‘4’ (AMBULANCE SERVICES). DISPLAY ‘ORTHOPEDIC ITEMS’ IF THE OM ITEM GROUP IS ‘5’ (ORTHOPEDIC ITEMS). DISPLAY ‘HEARING DEVICES’ IF THE OM ITEM GROUP IS ‘6’ (HEARING DEVICES). DISPLAY ‘PROSTHESES’ IF THE OM ITEM GROUP IS ‘7’ (PROSTHESES). DISPLAY ‘BATHROOM AIDS’ IF THE OM ITEM GROUP IS ‘8’ (BATHROOM AIDS). DISPLAY ‘MEDICAL EQUIPMENT’ IF THE OM ITEM GROUP IS ‘9’ (MEDICAL EQUIPMENT). DISPLAY ‘DISPOSABLE SUPPLIES’ IF THE OM ITEM GROUP IS ‘10’ (DISPOSABLE SUPPLIES). DISPLAY ‘ALTERATIONS OR MODIFICATIONS’ IF THE OM ITEM GROUP IS ‘11’ (ALTERATIONS/ MODIFICATIONS). DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM GROUP IS ‘91’ (OTHER). FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE TEXT CATEGORY ENTERED IN THE OTHER SPECIFY FIELD FOR OM EVENTS.
{$/% 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
{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.
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. 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. 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.’ 5. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, DISPLAY THE STANDARD WVS INSTRUCTION: “THE SOURCES ROSTER IS EMPTY.”
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
HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
{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.
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 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 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 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, 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), 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
OTHERWISE, GO TO CP37 CP21 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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. CP22 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE CP22OV1 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
HARD RANGE CHECK: $0 - $999,9999 CP22OV2 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
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.” CP37 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE
RESPONDENT’S/FAMILY MEMBER’S MEMORY ....... 1 [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.
{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 CODED ‘91’ (OTHER), ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH CP37OV
OTHERWISE, GO TO BOX_23 CP37OV SPECIFY: 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 CP39 {PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL
CARE 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. |