DCS: IF YOU HAVE ALREADY READ THESE ITEMS TO THE POC DURING THIS CALL, CLICK CONTINUE WITHOUT READING THEM AGAIN.
A1. Have I reached [[PROVIDER] OR [POC_NAME]]?
PHONE NUMBER: [[PROVIDER TELEPHONE NUMBER] OR [POC TELEPHONE NUMBER]]
[IF A1 = 1 GO TO A2,
IF A1 = 2 GO TO CONTACT BLOCK,
IF A1 = 3 GO TO Need_Sup_Review]
[Need_Sup_Review] Let me confer with my supervisor, and if necessary, we will call you back. Thank you for your time.
DCS: PLEASE CHECK WITH YOUR SUPERVISOR AS TO HOW TO HANDLE THIS SITUATION. PLEASE RETURN TO THE POC GRID NOW.
A2. [FILL_A2].
DCS: [FILL_A2] THE PROGRAMED RESPONSE WILL VARY BY PROVIDER TYPE
[IF A2= 1 GO TO B1,
IF A2=2 GO TO CONTACT BLOCK,
IF A2=3 GO TO Need_Sup_Review]
[Need_Sup_Review] Let me confer with my supervisor, and if necessary, we will call you back. Thank you for your time.
DCS: PLEASE CHECK WITH YOUR SUPERVISOR AS TO HOW TO HANDLE THIS SITUATION. PLEASE RETURN TO THE POC GRID NOW.
B1. My name is [YOUR NAME]. I am calling on behalf of the U.S. Department of Health and Human Services. We are conducting MEPS which is a study about how people in the United States use and pay for healthcare. For quality assurance and training purposes, this call may be monitored.
POC: [POC NAME]
[FILL B1]
DCS: [FILL_B1] THE PROGRAMED RESPONSE WILL VARY BY PROVIDER TYPE
DCS: IF THIS PERSON CANNOT HELP, COLLECT NEW POC PHONE NUMBER IN THE CONTACT BLOCK.
B2. Thank you. First, can you confirm that this is [FILL_B2]?
DCS: [FILL_B2] THE PROGRAMED RESPONSE WILL VARY BY PROVIDER TYPE
[For HOSP provider type, IF B2=2 GO TO B4; IF B2 NE 2 GO TO hosp_b3a.
For INST provider type, IF B2=4 GO TO B4; IF B2 NE 4 GO TO inst_B3a.
For OBD provider type, IF B2=1 or 5 GO TO OBD_B3; IF B2=2 GO TO B4; IF B2=3
OR 4 GO TO Potentially_Ineligible.
For HH (or HNH) provider type, IF B2=3 GO TO B4; IF B2 NE 3 GO TO HC_B2a.]
hosp_B3a. How would you describe this facility? Is this:
[IF hosp_B3a NE 6 GO TO B4;
IF hosp_B3a=6 Specify text field allows up to 250 characters.
THEN GO TO B4.]
inst_B3a. How would you describe this facility? Is this:
[IF inst_B3a NE 6 GO TO B4;
IF inst_B3a=6 Specify text field allows up to 250 characters.
THEN GO TO B4.]
OBD_B3. And is there at least one physician in the practice
who is a Medical Doctor or a Doctor of Osteopathy?
ALL SPECIALTIES ARE CONSIDERED MD/DO EXCEPT FOR: DENTISTS, OPTOMETRISTS,
CHIROPRACTORS AND PODIATRISTS.
[IF OBD_B3=1 or 3 GO TO B4;
IF OBD_B3=2 GO TO OBD_B3_1]
OBD_B3_1. Is this office under the supervision of an MD or a DO?
[IF OBD_B3_1=1 GO TO B4;
IF OBD_B3_1=2 GO TO OBD_B3a]
OBD_B3a. WHAT KIND OF OFFICE IS THIS PROVIDER?
I'm sorry. The information I was hoping to collect today is specific to doctor's offices. Because this is not a doctor's office one of my colleagues will be calling back to collect the necessary information.
[IF OBD_B3a=9, ENTER IN SPECIFY FIELD.]
[OTHER (SPECIFY) field allows up to 250 characters.]
HC_B2a. Does your organization include a home care unit or department?
[IF HC_B2a=1 GO TO B4;
IF HC_B2a=2 GO TO HC_B2b]
HC_B2b. Does your organization ever make arrangements for other organizations or individuals to provide some kind of assistance to people in their homes?
[IF HC_B2b=1 GO TO B4;
IF HC_B2b=2 GO TO HC_B3]
HC_B3. Does your organization provide any kind of assistance to people in their homes?
[IF HC_B3=1 GO TO HC_B3a;
IF HC_B3=2 GO TO Potentially_Ineligible]
HC_B3a. Are your services provided to persons who need in-home assistance for health reasons?
EXPLAIN IF NECESSARY: Health reasons can include either physical or mental health conditions.
[IF HC_B3A = 1, GO TO B4;
IF HC_B3A = 2, GO TO HC_B3b]
NOTE: IF HC_B3a=1, THEN THE CASE SHOULD BE LABELED AS A HOME CARE HEALTH FOR
EVENT FORM DATA COLLECTION.
IF HC_B3a=2, THE CASE SHOULD BE HOME CARE NON-HEALTH.
HC_B3b. What kind of services does your organization provide to people in their homes?
[IF HC_B3b NE 7 GO TO B4;
IF HC_B3b=7 GO TO Potentially_Ineligible]
[IF HC_B3b=7, ENTER IN OTHER-RECORD FIELD.]
Item is select-all-that-apply.
B4. [FILL_B4]
DCS [FILL_B4] THE PROGRAMED RESPONSE WILL VARY BY PROVIDER TYPE
[IF B4 = 1 GO TO Contact Block Section,
IF B4 = 2 GO TO B4_1]
B4_1. Are you the person who deals with the [FILL_MED_BILL_SVC]?
[IF YES, GO TO Contact Block Section;
IF NO, GO TO B4_2]
B4_2. I’ll need to collect the name and telephone number for the person in your office who deals with the [FILL_MED_BILL_SVC].
Continue BUTTON TAKES USER TO THE CONTACT BLOCK
GROUP/PRACTICE NAME
*ONLY FILL THIS OUT IF WORKING WITH INTERNAL CONTACT FOR EXTERNAL SERVICE
MEDICAL RECORDS/BILLING SERVICE NAME
TITLE
POC FIRST NAME
POC LAST NAME
TIME ZONE
PHONE
PHONE EXT
FAX
VERIFY FAX
Primary POC for this role?
POC_Role.
How do you want the AFs sent to you?
VERIFY E-MAIL
DEPARTMENT
ADDRESS
ADDRESS (LINE 2)
CITY
STATE
ZIP
Individual packets? ARE INDIVIDUALIZED PACKETS NEEDED. (COMMONLY USED FOR VA CASES.)
Is this a Military Provider? (For Pharmacy Provider Types only)
CB2.
[DCS: An entry is required in POC FIRST NAME, POC LAST NAME, or both
fields in order to save the POC.
Some fields require numbers only. Phone and Fax require 10 digits.
CB2 choices are restricted for certain provider types:
CB2 [FILL_CB2]:
SECTION NOTE: THIS SECTION IS SKIPPED FOR PHAR PROVIDER TYPE.
DCS: POC_ROLE AND CB2 FILL WITH ANSWERS FROM PREVIOUS QUESTIONS. CHANGE ANSWERS ONLY IF POC VOLUNTEERS UPDATED ANSWERS; OTHERWISE, ASK ITEM CB2b OR CB2c NEXT.
POC_Role.
(CHECK ALL THAT APPLY.)
This item pre-fills in the POC Categorization section based on the answer(s)
to this item from the Contact Block. The responses can be edited in the POC
Categorization section, if necessary.
POC_Role option 5 (ADMINISTRATIVE OFFICE) appears only for HOSP and INST
provider types.
CB2.
PROVIDER LEVEL GATEKEEPER = 1
HANDLES RELEASE OF IN-HOUSE RECORDS (PA) = 2
DEALS WITH [[FILL_CB2]] = 3
[[FILL_CB2]] GATEKEEPER = 4
HANDLES RELEASE OF RECS FOR [[FILL_CB2]] = 5
ON SITE - HANDLES RELEASE OF RECS FOR [[FILL_CB2]] = 16
DEALS WITH IN-HOUSE RECORDS FOR MR = 9
DEALS WITH MEDICAL RECORDS SERVICE = 10
MEDICAL RECORDS SERVICE GATEKEEPER = 11
HANDLES RELEASE FOR MEDICAL RECORDS SERVICE = 12
ON SITE - HANDLES RELEASE FOR MEDICAL RECORDS SERVICE = 17HANDLES RELEASE OF IN-HOUSE/AO POC = 14
POC FOR REMAINING PROVIDERS (SBDs) = 15
ADMINISTRATIVE OFFICE POC = 13
COURTESY PACKET RECIPIENT = 6
PERMISSION PACKET RECIPIENT = 7
NEW/UPDATED NAME FOR PROVIDER = 8
CB2 choices are restricted for certain provider types:
CB2 [FILL_CB2]:
[IF PHAR, FILL_CB2 = “OTHER DEPARTMENT/CORPORATE OFFICE”;
IF HOSP, INST, OBD, HH (or HNH), SBD, FILL_CB2 = “EXTERNAL BILLING SERVICE&”]
[IF POC_Role = 2, 3, AND/OR 4, GO TO CB2b;
IF POC_Role NE 2, 3, AND/OR 4, BUT POC_Role = 1, GO TO CB2c]
CB2b. Does this office handle records for... (CHECK ALL THAT APPLY)
Item not asked for HH, HHN.
[IF POC_Role=1 IN ADDITION TO 2, 3, AND/OR 4, GO TO CB2c;
ELSE, GO TO PROVIDER VERIFICATION SECTION]
IF HOSP OR INST AND THEY HANDLE MEDICAL RECORDS, ASK THIS QUESTION.
IF FOR THE CURRENT POC WE DON’T HAVE THIS INFO AND THE POC HANDLES
MEDICAL RECORDS, THEN ASK CB2c:
CB2c. Does this office handle medical records for... (CHECK ALL THAT APPLY)
DCS: Item asked only for HOSP and INST.
PROVIDER VERIFICATION.
Before we send you the form(s) I’ll need to determine that you can provide [FILL_MED_BILL] records for all of the providers or locations I have listed as associated with this provider in [FILL_YR]. I’m going to read you a list of providers or locations; please tell me if you can provide [FILL_YR] [FILL_MED_BILL] records for each.
IF A PROVIDER IS NOT ASSOCIATED WITH THIS PRACTICE IN 2021, CHECK THE BOX NEXT TO THEIR NAME(S) AND CLICK "Remove selected provider(s)". IF NO PROVIDERS ARE TO BE REMOVED FROM THE LIST, CLICK "Continue".
List of providers associated with this grid
ABOVE HEADER BOX, DISPLAY: These questions are posed if POC has not confirmed the providers yet.
DCS NOTE: Checkboxes below have been disabled. You can't disavow the only provider in the group.
[FILL_MED_BILL]:
IF PROVIDER TYPE = HOSP OR INST, USE FILL_MED_BILL INSTRUCTIONS IMMEDIATELY ABOVE. IF PROVIDER TYPE = OBD OR HOME HEALTH, ALWAYS FILL WITH “billing and payment”. IF PROVIDER TYPE = PHAR, ALWAYS FILL WITH “prescription”.
GO TO B4.
B4.
[REFER TO ELIGIBILITY SECTION FOR SPECS ON ITEM B4.]
CONFIRM INFORMATION IF QUESTION BACKGROUND IS SHADED GRAY.
[IF B4 = 1 GO TO B4b;
IF B4 = 2 GO TO B4_1]
B4_1. Are you the person who deals with the [[FILL_MED_BILL_SVC]]?
[IF YES, GO TO B4b;
IF NO, GO TO B4a.]
B4a. I’ll need to collect the name and telephone number for the person in your office who deals with the [[FILL_MED_BILL_SVC]]. Do you know that person?
[IF B4a = 1 (YES), GO TO CONTACT BLOCK;
IF B4a = 2 (NO), RETURN TO POC GRID, MAKE THIS POC NOT PRIMARY, AND MAKE THEM
INACTIVE. DISPLAY: “My supervisor or someone else may call back in the
future to try to gather additional information. Thank you for your
time.” ALSO DISPLAY: “PLEASE RETURN TO POC GRID NOW.”]
B4b. I would like to send the authorization form to you, along with additional information explaining the study. I need to be sure I have the correct information for the packet. Should I direct it to you?
READ IF THE PERSON ON THE PHONE WOULD LIKE TO PROVIDE THE DATA PRIOR TO RECEIVING AUTHORIZATION FORMS: In order to remain HIPAA compliant, I need to send you the authorization form first. Once you have received the form, then we can arrange for the collection of the data.
(IF THEY SAY NO, GO TO THE CONTACT BLOCK.)
IF B4b = 1, GO TO B4b_1;
IF B4b = 2, NO FURTHER ITEMS ARE DISPLAYED. DCS IS INSTRUCTIONED (VIA
ONSCREEN INSTRUCTION) TO GO TO CONTACT BLOCK.
B4b_1. Do you want me to send them to you by fax, mail, or send them electronically?
DCS NOTE: PROGRAMMING COMPARES SELECTION AGAINST CONTACT BLOCK ENTRY
GO TO F1
F1. [FILL_F1]
[FILL_F1_MR]
[FILL_F1_PA]
NOTE: [FILL_F1] VARIES BY PROVIDER TYPE
DCS: AS NEEDED, PROBE: (Once you have received the authorization form packet, is there a delay before you’re able to view it? IF YES: How long is that?)
PROVIDER WILL RESPOND:
NOTE: [FILL_F1] VARIES BY PROVIDER TYPE
NOTE: [FILL_MED_BILL] VARIES BY PROVIDER TYPE AND BY CONTRACT GROUP SIZE FOR OBD AND SBD:
Within the next [FILL_FAXMAILTIME] we will [FILL_FAXMAIL] the authorization forms and include instructions for providing the information we need. I will call you back to confirm receipt, and collect the information over the phone. If you have any questions about the information we need, please call our toll-free number on the instruction sheet. We may call again if other patients identify identify your practice as a source of medical services.
F2. [FILL_FAXMAILTIME]:
[FILL_FAXMAIL]:
[FILL_MED_BILL]:
If POC_Role=1 (but not 2, 3, or 4), fill “medical”;
If POC_Role-2, 3, and/or 4 (but not 1), fill “billing and payment”;
If POC_Role = 1 and POC_Role = 2, 3, and/or 4, fill “billing and payment/medical”.
FILL_F1_MR and FILL_F1_PA are populated for only HOSP and INST provider types. Otherwise, they are blank.
IF POC_Role = 1, [FILL_F1_MR]: “For each date of service in [[FILL_YR]], we are requesting information about the diagnoses and services, and the names of the physicians who treated each patient in [[FILL_YR]].”
IF POC_Role NE 1, [FILL_F1_MR]: “ “
IF POC_Role = 2, 3, and/or 4, [FILL_F1_PA]: “For each date of service in [[FILL_YR]], we are collecting the amounts charged for services before any adjustments or discounts, and the sources and amounts of payment.”
IF POC_Role NE 2, 3, and/or 4, [FILL_F1_PA]: “ “
If POC_Role includes both 1 as well as 2, 3, and/or 4, populate both [FILL_F1_MR] and [FILL_F1_PA].
IF B4b_1 = 4 (BY ELECTRONIC PORTAL) GO TO F3. ELSE, ALLOW ONLY NAVIGATION THREE BUTTON OPTIONS: “Send AF event”, “Return to POC Grid”, AND “Go to Contact Block”.
F3.
When the authorization form packet is ready, you will receive an email from noreplyMEPS@rti.org with your unique username to access the electronic portal. The username is a randomized set of numbers and is connected to your email account. You can use the login over the course of the project.
Your password is [FILL_EMAIL1234], all in lower case. Your password is created from part of your email address before the @ sign and followed by the number 1234. You will be prompted to change your password after you first log in. We recommended you change the password to something you will remember. Once logged in, please go to the Download Authorization Form Packets page.
To protect confidentiality, each authorization form packet will be encrypted with a different password. Your password for the packet is [FILL_EMAILGRP]. This password is also in lower case.
You will have 7 calendar days to download the authorization form packet from the electronic portal. The authorization form packet link will disappear after 7 days. It is very important that you download the packet to a different place so you can access it at a later time. It will no longer be available after 7 calendar days from the date it is posted.
G1. DCS: CONFIRM YOU ARE SPEAKNG WITH [POC_NAME].
Hello, my name is [YOUR NAME]. I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.
Did you receive the authorization form[s] we sent to you?
IF POC DID NOT RECEIVE AFs: CLICK NO, AND GO TO THE CONTACT BLOCK TO VERIFY/UPDATE POC CONTACT INFORMATION.
IF G1=2, DCS IS TO FOLLOW ONSCREEN INSTRUCTION AND USE “Go to Contact Block” BUTTON TO UPDATE POC INFORMATION.
IF G1=1: [IF F1=1, GO TO G4_PH; ELSE, GO TO G4]
G4_PH. If it is convenient for you, we can just go ahead and complete the data forms together over the phone right now. I’d be happy to hold on while you get the information you need from your records.
[IF 1, DCS WILL USE Confirm AF event BUTTON THEN “Go To CMS”
BUTTON;
IF 2, GO TO G4_PH_B;
IF 3, DCS WILL USE Confirm AF event BUTTON]
NOTE: Once a full answer to either G4 or G4_PH is entered, the “Confirm AF event” button becomes active and the DCS can move forward with assigning an event code.
G4_PH_B. I understand. What would be the best date and time to call you back to complete the data forms?
[DISPLAY CALENDAR TO COLLECT DATE AND TIME]
A “Save Appointment” BUTTON SAVES THE APPOINTMENT INFORMATION.
GO TO G4_PH_C.
G4_PH_C. Thank you for your time. I will call you back on [FILL_APPT_DATE_TIME]
G4. Our records indicate that you will [FILL_FAX_MAIL_UPLOAD] the records to us.
[FILL_G4]
[FILL_G4_MR]
[FILL_G4_PA]
IF THE POC MENTIONS UB04 OR CMS 1500, SAY: We need a final itemized statement that includes payments and adjustments so that we do not have to call back to obtain this information, but we can use UB04/CMS 1500 forms to accompany these final itemized statements.
IF POC MENTIONS A SUMMARY REPORT, SAY: We need something like a tax statement that includes patient payment and third-party payment, and type.
When will you send us these records?
[DISPLAY CALENDAR]: DATE IS CAPTURED VIA AN ONSCREEN CALENDAR. THE DATE SELECTED POPULATES IN A FILL FOR G4_1.
GO TO G4_1
G4_1. Thank you. We will call you back if we do not receive the records by [FILL G4 DAY, DATE].
G4_2. DCS: PLEASE CONFIRM YOU ARE SPEAKING WITH [POC_NAME]. POC INDICATED THEY WILL [FILL_FAX_MAIL_UPLOAD] RECORDS.
Hello, my name is [YOUR NAME]. I am calling on behalf of the U.S. Department of Health and Human Services. For quality assurance and training purposes, this call may be monitored. We previously spoke about the MEPS study.
We were anticipating receiving [FILL_MED_BILL] records from you by [FILL G4 DATE], but my records show we have not received them. Have you sent the records to us?
IF G4_2 = 1, GO TO G4_3;
IF G4_2 = 2 GO TO G4_5]
G4_3. How did you send the records? Did you fax, mail hardcopies via express or regular mail, mail CDs via express or regular mail, or use a record service’s portal?
IF POC IS SENDING CD: Was the password provided or did you send it separately?
Can you tell me the password used to encrypt the file please?
G4_4. What date did you send them?
[DISPLAY CALENDAR]
Thank you for sending them. The records are received in a separate department and it can take a few days to upload the documents into our system. We will investigate and call you back if we have further questions. We apologize for any inconvenience.
[DISPLAY CALENDAR]: DATE IS CAPTURED VIA AN ONSCREEN CALENDAR.
G4_5. We need to obtain these records for the study as soon as possible. Is there something that can be done to speed up (or expedite) the process?
INTERVIEWER: LISTEN TO POC TO DETERMINE IF THERE IS ANYTHING WE CAN DO TO HELP FACILITATE THEM SENDING IN RECORDS. OFFER:
GO TO G4_5_1
G4_5_1. When will you send us these records?
[DISPLAY CALENDAR]
[DISPLAY CALENDAR]: DATE IS CAPTURED VIA AN ONSCREEN CALENDAR. THE DATE SELECTED POPULATES IN [FILL G4_6 DAY, DATE] FILL FOR G4_6.
GO TO G4_6
G4_6. Thank you. We will call you back if we do not receive the records by [FILL G4_6 DAY, DATE].
AO_A2.
IF AO POC WAS PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:
May I please speak to [POC NAME]?
IF NO AO POC PROVIDED BY MEDICAL RECORDS OR PATIENT ACCOUNTS:
Can I please speak to someone in your Medical Staffing department, Credentialing department, or whichever department handles contact information for doctors who provide services at your hospital?
IF THE PERSON YOU NEED TO TALK TO IS UNAVAILABLE ATTEMPT TO GET THEIR CONTACT INFORMATION VIA THE CONTACT BLOCK AND SET AN APPOINTMENT IF POSSIBLE.
- CONTINUE, THIS PERSON CAN HELP = 1
- COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2 (LINK TO Contact Block)
- UNCLEAR WHO TO SPEAK TO = 3 (DCS WILL EXIT CONTACT GUIDE)
IF DCS SELECTS 3 (UNCLEAR WHO TO SPEAK TO), DISPLAY UNDER RESPONSE OPTIONS: “THANK YOU: Thank you for your time. PLEASE RETURN TO THE POC GRID NOW.”
[POC NAME] SHOULD FILL WITH THE POC MARKED AS PRIMARY AO POC
[IF AO_A2= 1 GO TO AO_A3,
IF AO_A2=2, GO TO CONTACT BLOCK,
IF AO_A2=3 GO TO POC GRID]
AO_A3. Hello, my name is [YOUR NAME].
I am calling on behalf of the U.S. Department of Health and Human Services.
We are conducting MEPS which is a study about how people in the United States use and pay for healthcare.
Earlier, your medical records department gave us information about the care that some of our study participants received at your facility and the names of the providers of that care. Now we need locating information for those providers and whether the charges for their services would be included in the facility’s bill or billed separately by the provider. Can you provide this information?
POC: [POC NAME]
IF THIS PERSON CANNOT HELP, ASK TO BE TRANSFERRED TO SOMEONE WHO CAN.
- CONTINUE, THIS PERSON CAN HELP = 1
- COLLECT CONTACT INFORMATION FOR SOMEONE ELSE = 2
[POC NAME] should fill with the name flagged as primary AO POC
[IF AO_A3=1, GO TO AO_A4,
IF AO_A3=2, GO TO CONTACT BLOCK]
AO_A4. For quality assurance and training purposes, this call may be monitored. If it is convenient for you, I can collect this locating information over the phone right now. I’d be happy to hold on while you get the information you need from your records.
[IF AO_A4=1 GO TO AO_A5;
IF AO_A4=2 GO TO AO_A4a]
AO_4a. I understand. What would be the best day and time to call you back to collect this information?
ASK WHICH DAY OF THE WEEK IS BEST.
ASK WHICH SECTIONS OF A DAY (MORNING, AFTERNOON) ARE BEST AND USE THE FOLLOWING GUIDELINES FOR SCHEDULING:
[DISPLAY CALENDAR TO COLLECT DATE, TIME, AM/PM, AND TIMEZONE]
AO_A5.
PULL UP THE LIST OF PROVIDERS THAT WAS COLLECTED IN MR SECTION OF EVENT FORMS WITHIN THE CONTACT GROUP
GO TO SBD SUBROUTINE [SBD_CGINTRO]
SBD_CGINTRO. I want to ask about [PHYSICIAN NAME], whose specialty is [SPECIALTY]. This doctor was reported as someone who bills separately for services.
SBD_CG8a. Can you tell whether this physician bills separately or has charges included in your facility’s bill?
IF SBD_CG8a=3, “OTHER SPECIFY” TEXT BOX TO RECORD DETAILS OF HOW THE PHYSICIAN’S BILLING PRACTICES VARY.
SBD_CG7. What is the business practice phone number and location for [FILL_PHYSICIAN_NAME]?
Name of Group Practice (If applicable):
[DK/REF - CONTINUE TO SBD_CG8B]
SBD_CG8b. Does this physician use a billing service or have billing contact information that is different than his or her business practice location?
[(IF R_BILLSRVC = 1 (YES), GO TO SBD_CG9;
IF R_BILLSRVC = 2 (NO), GO TO SBD_CG10]
SBD_CG9. What is the billing contact information?
Use Previously entered billing services for this Contact Group
Name of Billing Service:
PHONE of billing service:
PHONE EXTENSION:
Address of billing service:
STREET
CITY
STATE
ZIP
[DK/REF - CONTINUE TO SBD_CG10]
SBD_CG10. RECORD ANY NOTES AO GIVES ABOUT [FILL_PHYSICIAN_NAME]
GENERAL NOTES: R_GENNOTE
How are you finalizing this SBD? SELECT ONE.
Done with this SBD- contacting information collected or confirmed does not bill separately = 1
Done with this SBD - unable to collect contacting information = 2
Still working to obtain contact information for this SBD = 3
AFTER ALL SBDs HAVE BEEN FINALIZED, CLICKING THE “Continue” BUTTON WILL TAKE YOU TO SBD_CG11.
SBD_CG11. Have you obtained contact information for all providers/SBDs in the list?
[IF SBD_CG11 = 1 (YES) GO TO EXIT SCREEN THANKING POC FOR THEIR TIME
(“Thank you for your time.”) - FROM EXIT SCREEN, EXIT TO POC
GRID;
IF SBD_CG11 = 2 (NO) GO TO SBD_CG12.]
SBD_CG12. Who would be able to help me with the information for the remaining providers?
[IF SBD_CG12 = 1 GO TO CONTACT BLOCK,;
OR IF SBD_CG12 = 2 GO TO EXIT SCREEN THANKING POC FOR THEIR TIME
(“Thank you for your time.”) - FROM EXIT SCREEN, EXIT TO POC
GRID].