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Charge/Payment (CP) Section
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, CP14A, CP20, CP23, AND CP25) 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}'
- 'CHIP/{STATE NAME FOR CHIP}'
-' VA/VETERAN'S ADMINISTRATION'
- 'TRICARE/CHAMPVA'
- '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.
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 AND IS OM TYPE 2 OR 3, GO TO CP03.
IF EVENT TYPE IS PM AND IS NOT OM TYPE 2 OR 3, CONTINUE WITH BOX_02.
OTHERWISE, GO TO BOX_03.
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Charge/Payment (CP) Section
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} {EV} {EVN-DT}
Comment Enabled
Jump Back Enabled
Help Enabled
(THIRDPARTY)
(Have/Has) (PERSON) used a third party payer for prescription medicines
since START DATE?
Size
Variable Name
Label
PRND.THRDPRES
2
THIRD PARTY PAYER FOR PRESCRIPTION
1
YES
{CP01B}
2
NO
{CP01}
RF
Refused
{CP01}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP01}
HELP AVAILABLE FOR DEFINITION OF THIRD PARTY PAYER.
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CP01B
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {EVN-DT}
Comment Enabled
Jump Back Enabled
Help Enabled
(THIRDPARTY)
Who has been the usual third party payer for (PERSON)'s prescription
medicines since START DATE?
Size
Variable Name
Label
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
PRND.THRDPAYR
10
THIRD PARTY PAYER PRESCRIPTION
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
{CP01C}
HELP AVAILABLE FOR DEFINITION OF THIRD PARTY PAYER.
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE SOURCES-OF-PAYMENTS ROSTER.
Title:
RU_SOP_2
Roster Details
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
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
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
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Charge/Payment (CP) Section
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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
Display all sources of payment that are not PERSON/FAMILY.
CP01C
{PERSON'S FIRST MIDDLE AND LAST NAME}
Comment Enabled
Jump Back Enabled
Help Enabled
How much did (PERSON) pay out-of-pocket for (PERSON)'S last
prescription?
Size
Variable Name
Label
PRND.TYPPPAY
IS ANSWER IN DOLLARS OR PERCENT?
1
DOLLARS
{CP01COV1}
2
PERCENT
{CP01COV2}
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Charge/Payment (CP) Section
CP01COV1
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PRND.EXPTPPAY
{CP01}
DOLLARS: _______
RF
Refused
{CP01}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP01}
Soft CHECK:
$0 - $10,000
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CP01COV2
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PRND.PCTPPAY
{CP01}
PERCENT: _______
RF
Refused
{CP01}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP01}
Soft CHECK:
1% - 100%
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Charge/Payment (CP) Section
CP01
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {EVN-DT}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP01Help)
(Do/Does) (PERSON) (or someone in the family) send in a claim form to the
insurance company for (PERSON)’s prescription medicines or does the
pharmacy automatically do this for (PERSON)’s prescription medicines?
Size
Variable Name
Label
PRND.PMEDCLM
2
WHO SENDS IN CLAIM FORMS
1
FAMILY SENDS IN CLAIM FORMS
{CP03}
2
PHARMACY AUTOMATICALLY FILES
CLAIM
{BOX_26}
3
NOT EITHER TYPE OF SITUATION
{BOX_26}
RF
Refused
{CP03}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP03}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
PROGRAMMER NOTES:
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), ‘RF’ (REFUSED),
OR ‘DK’ (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.
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Charge/Payment (CP) Section
CP02
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP02Help)
Before we talk about the charges for (PERSON)’s visit to (PROVIDER) on
(VISIT DATE), let me take a moment to verify some information.
Last time we recorded that (PERSON) (or someone in the family) usually
pay(s) a {$ AMT COPAY} copayment to (PROVIDER). Is this still the correct
copayment amount?
Size
Variable Name
Label
EVPV.CPAYSAME
2
COPAYMENT SAME AS PREVIOUS RND COPAYMENT
EVPV.CPAYFLAG
2
COPAY INTRO QUESTION ASKED
CPAY.CPAYID
20
CPAY ID KEY: PERSID + PROVID + ROUND
CPAY.CPAYRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
CPAY.CREATEQ
2
CREATION STAMP
CPAY.CPAYEVPV
23
CPAY CREATED BY THIS EVPVID
CPAY.CPAYAMT
2
CORRECT COPAYMENT AMOUNT
CPAY.CPAYSAME
2
COPAYMENT SAME AS PREVIOUS RND COPAYMENT
1
YES
{CP03}
2
NO
{CP02OV}
99
NOT A COPAYMENT SITUATION
ANYMORE
{CP03}
RF
Refused
{CP03}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP03}
HELP AVAILABLE FOR DEFINITION OF COPAYMENT.
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DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES)
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{$ AMT COPAY}: DISPLAY THE CP11OV1 AMOUNT FLAGGED AS
'COPAYMENT SITUATION' DURING THE PREVIOUS ROUND FOR THIS
PERSON-PROVIDER PAID.
PROGRAMMER NOTES:
IF CODED ‘99’ (NOT A COPAYMENT SITUATION ANYMORE), FLAG THIS
PERSON-PROVIDER AND THIS PERSON AS ‘NOT A COPAYMENT SITUATION’
FOR THE CURRENT ROUND.
IF CODED ‘1’ (YES), ‘RF’ (REFUSED), OR ‘DK’ (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.
Hard CHECK:
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Charge/Payment (CP) Section
CP02OV
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP02Help)
What is the correct copayment amount?
Size
Variable Name
Label
CPAY.CPAYAMT
2
CORRECT COPAYMENT AMOUNT
AMOUNT: $ _________________
{CP03}
99
NOT A COPAYMENT SITUATION
ANYMORE
{CP03}
RF
Refused
{CP03}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP03}
HELP AVAILABLE FOR DEFINITION OF COPAYMENT.
PROGRAMMER NOTES:
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 ‘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 AS
COPAYMENT AMOUNT FOR THE CURRENT ROUND.
Hard CHECK:
COPAYMENT DOLLAR AMOUNT MUST BE WHOLE DOLLAR AMOUNT < OR = $50.
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Charge/Payment (CP) Section
CP03
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP03Help)
Now I'd like to ask you about the charges for {(PERSON)'s stay at
(HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER)
on (VISIT DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE}
for (PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the {OME
ITEM GROUP NAME} used by (PERSON) since (START DATE)/services
received at home from (PROVIDER) during (MONTH) for (PERSON)}.
{Let's begin with the charges from the hospital itself, not including any
separate physician services or lab tests.}
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
HELP AVAILABLE FOR DEFINITION OF CHARGE.
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES)
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES)
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
DISPLAY '(PERSON)'s stay at (HOSPITAL) that began on (ADMIT
DATE)' IF EVENT TYPE IS HS.
DISPLAY '(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 (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 (PERSON)' IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
DISPLAY the {OME ITEM GROUP NAME} used by (PERSON) since
(START DATE) IF EVENT TYPE IS OM.
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).
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Charge/Payment (CP) Section
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.
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’ FOR OM EVENTS THAT ARE
‘ADDITIONAL’ GROUP TYPE (EV02A=2).
DISPLAY 'services received at home from (PROVIDER) during
(MONTH) for (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.
ROUTING INSTRUCTION:
IF PERSON-PROVIDER PAIR FLAGGED AS ‘COPAYMENT SITUATION’ FOR
THE CURRENT ROUND, AND THIS EVENT-PROVIDER PAIR DOES NOT
REPRESENT A FLAT FEE GROUP, CONTINUE WITH CP04.
IF EVENT TYPE IS OM AND OM GROUP TYPE IS ‘ADDITIONAL’
(EV02A=2), CONTINUE WITH CP03A.
OTHERWISE, GO TO CP05.
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Charge/Payment (CP) Section
CP03A
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Did (PERSON) (or anyone in the family) purchase or rent the {OME ITEM
GROUP NAME} used by (PERSON)?
Size
Variable Name
Label
EVPV.OMCHARGE
2
WAS OM ITEM PURCHASED OR RENTED?
SELECT 'NO CHARGE' IF RESPONDENT VOLUNTEERS OME ITEM
GROUP HAD NO CHARGE BECAUSE IT WAS BORROWED OR FREE
FROM A CHARITY, ETC.
1
PURCHASED
{CP05}
2
RENTED
{CP05}
95
NO CHARGE: BORROWED, FREE
FROM CHARITY/ORGANIZATION, ETC.
{BOX_26}
RF
Refused
{CP05}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP05}
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Charge/Payment (CP) Section
CP04
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP04Help)
Is this the type of situation where (PERSON) (or someone in the family) only
paid the {$ AMT COPAY} copayment for this visit and (PERSON) (do/does)
not know the total charge?
Size
Variable Name
Label
EVPV.KNOWCPAY
2
ONLY KNOW COPAYMENT AMOUNT
1
YES
{CP37}
2
NO
{CP05}
RF
Refused
{CP05}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP05}
HELP AVAILABLE FOR DEFINITION OF COPAYMENT AND TOTAL
CHARGE.
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES)
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES)
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{$ AMT COPAY}: DISPLAY THE CP02OV OR CP11OV1 AMOUNT FLAGGED
AS ‘COPAYMENT SITUATION’ FOR THE CURRENT ROUND FOR THIS PERSON-
PROVIDER PAIR.
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
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),
IGNORE ‘COPAYMENT SITUATION’ FLAG FOR THIS PERSON-PROVIDER
PAIR FOR THIS EVENT (THAT IS, COLLECT CHARGE/PAYMENT
INFORMATION FOR THIS EVENT-PROVIDER PAIR).
ROUTING INSTRUCTION:
IF CODED ‘1’ (YES), GO TO CP37.
IF CODED ‘2’ (NO), 'RF' (REFUSED), OR ‘DK’ (DON’T KNOW),
CONTINUE WITH CP05.
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Charge/Payment (CP) Section
CP05
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP05Help)
(Have/Has) (PERSON) (or anyone in the family) received anything in writing,
such as a bill, receipt, or statement, for {(PERSON)'s stay at (HOSPITAL) that
began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT
DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the {OME
ITEM GROUP NAME} used by (PERSON) since (START DATE)/services
received at home from (PROVIDER) during (MONTH) for (PERSON)}?
PROBE: Include anything in writing received by family members living with
(PERSON) as well as those living somewhere else.
Size
Variable Name
Label
EVPV.RCVDBILL
2
ANY BILL/STATEMENT RECEIVED
FFEE.RCVDBILL
2
ANY BILL/STATEMENT RECEIVED
1
YES, AND DOCUMENTATION AVAILABLE
{CP08}
2
YES, BUT DOCUMENTATION NOT
AVAILABLE
{CP08}
3
NO
{CP06}
4
{NO, FREE SAMPLE}
{CP37}
RF
Refused
{CP06}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP06}
HELP AVAILABLE FOR DEFINITION OF ANYTHING IN WRITING.
17
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, OR DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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).
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Charge/Payment (CP) Section
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.
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’ FOR OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
PROGRAMMER NOTES:
DISPLAY NO, FREE SAMPLE RESPONSE CATEGORY AND THE
CORRESPONDING RADIO BUTTON ONLY IF THE EVENT TYPE OF THE EVENT-
PROVIDER PAIR IS PM.
19
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Charge/Payment (CP) Section
CP06
SHOW CARD CP-1.
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP06Help)
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Why (have/has) (PERSON) (or anyone in the family) not received anything in
writing?
Size
Variable Name
Label
EVPV.YNOBILL
2
WHY BILL/STATEMENT NOT RECEIVED
FFEE.YNOBILL
2
WHY BILL/STATEMENT NOT RECEIVED
{SELECT 'INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE
SITUATION.}
1
PAID AT TIME OF VISIT
{CP08}
2
MADE A COPAYMENT
{CP08}
3
BILL SENT DIRECTLY TO OTHER
SOURCE
{CP07}
4
BILL HAS NOT ARRIVED
{CP08}
NO BILL SENT:
5
HMO PLAN
{BOX_04}
6
VA
{BOX_04}
7
MILITARY FACILITY
{BOX_04}
8
WELFARE/MEDICAID
{BOX_04}
9
WORKER'S COMPENSATION
{BOX_04}
10
PRIVATE HEALTH CENTER/CLINIC
{BOX_04}
11
PUBLIC CLINIC/HEALTH CENTER
OR PRIVATE CHARITY
{BOX_04}
12
NO CHARGE: TELEPHONE CALL
{CP37}
13
FREE FROM PROVIDER
{CP37}
14
GOVERNMENT-FINANCED RESEARCH
AND CLINICAL TRIALS
{CP37}
20
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Charge/Payment (CP) Section
95
INCLUDED WITH OTHER CHARGES
RF
Refused
{CP08}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP08}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES AND
FLAT FEE.
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE CONTEXT HEADER
IF THE EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM'
(OTHER MEDICAL EXPENSES).
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.
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.
PROGRAMMER NOTES:
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 SERVICES)’. 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' 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' 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' 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.'
21
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Charge/Payment (CP) Section
ROUTING INSTRUCTION:
IF 'INCLUDED WITH OTHER CHARGES' IS SELECTED, AND THE EVENT
TYPE IS NOT PM AND THE THE EVENT-PROVIDER-PAIR DOES NOT
REPRESENTA FLAT FEE GROUP OR A VISIT GROUP, ASK THE FLAT FEE
(FF) SECTION.
22
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Charge/Payment (CP) Section
CP07
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
To whom was the bill sent?
Size
Variable Name
Label
EVPV.WHOBILL1
45
WHERE BILL SENT - VERBATIM 1
EVPV.WHOBILL2
45
WHERE BILL SENT - VERBATIM 2
EVPV.WHOBILL3
45
WHERE BILL SENT - VERBATIM 3
FFEE.WHOBILL1
45
WHERE BILL SENT - VERBATIM 1
FFEE.WHOBILL2
45
WHERE BILL SENT - VERBATIM 2
FFEE.WHOBILL3
45
WHERE BILL SENT - VERBATIM 3
{CP07OV1}
_______________________
RECORD VERBATIM:
DISPLAY INSTRUCTIONS:
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
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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Charge/Payment (CP) Section
CP07OV1
INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL WAS
SENT:
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP07OV1Help)
Size
Variable Name
Label
EVPV.WHOBILLC
2
WHERE BILL SENT - CODE
FFEE.WHOBILLC
2
WHERE BILL SENT - CODE
1
HMO
{BOX_04}
2
VA
{BOX_04}
3
TRICARE/CHAMPVA
{CP08}
4
OTHER MILITARY
{BOX_04}
5
WELFARE/MEDICAID
{BOX_04}
6
WORKER'S COMPENSATION
{BOX_04}
7
PRIVATE INSURANCE COMPANY
{BOX_04}
91
OTHER
{CP08}
RF
Refused
{CP08}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP08}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
24
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Charge/Payment (CP) Section
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.
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Charge/Payment (CP) Section
CP08
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP08Help)
Do you know the total charge for {(PERSON)'s stay at (HOSPITAL) that
began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT
DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the {OME
ITEM GROUP NAME} used by (PERSON) since (START DATE)/services
received at home from (PROVIDER) during (MONTH) for (PERSON)}?
Size
Variable Name
Label
EVPV.KNOWCHRG
2
KNOW THE TOTAL CHARGE
FFEE.KNOWCHRG
2
KNOW THE TOTAL CHARGE
{SELECT 'INCLUDED WITH OTHER CHARGES' IF THIS IS A FLAT FEE
SITUATION.}
1
YES
{CP09}
2
NO
95
INCLUDED WITH OTHER CHARGES
RF
Refused
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
HELP AVAILABLE FOR DEFINITIONS OF TOTAL CHARGE AND FLAT FEE
26
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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.
DISPLAY '(PERSON)'s stay at (HOSPITAL) that began on (ADMIT
DATE' IF EVENT TYPE IS HS.
DISPLAY '(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 (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 (PERSON)' IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
DISPLAY' the {OME ITEM GROUP NAME} used by (PERSON) since
(START DATE)' IF EVENT TYPE IS OM. 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).
27
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Charge/Payment (CP) Section
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.
FOR ‘(START DATE)’ 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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
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.
PROGRAMMER NOTES:
IF 'INCLUDED WITH OTHER CHARGES' 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' 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' 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.'
28
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Charge/Payment (CP) Section
ROUTING INSTRUCTION:
IF 'INCLUDED WITH OTHER CHARGES' 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), 'RF' (REFUSED), OR 'DK' (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), 'RF' (REFUSED), OR 'DK' (DON'T KNOW)
AND
EVENT TYPE IS ER, OP, MV, OR DN,
GO TO CP10.
29
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Charge/Payment (CP) Section
CP09
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP09Help)
How much was the total charge for {(PERSON)'s stay at (HOSPITAL) that
began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT
DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the {OME
ITEM GROUP NAME} used by (PERSON) since (START DATE)/services
received at home from (PROVIDER) during (MONTH) for (PERSON)}?
Please include any amounts that may be paid by health insurance or other
sources. {However, please do not include any services billed for separately
such as physician charges or other services.}
{If charges for procedures such as x-rays, lab tests, or diagnostic procedures
are listed separately on the bill or statement, include those in the total charge.}
Size
Variable Name
Label
EVPV.TYPECHRG
2
TYPE OF TOTAL CHARGE-AMOUNT OR FF
FFEE.TYPECHRG
2
TYPE OF TOTAL CHARGE-AMOUNT OR FF
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.}
1
AMOUNT
{CP09OV}
95
INCLUDED WITH OTHER CHARGES
HELP AVAILABLE FOR DEFINITION OF WHAT MAKES UP TOTAL
CHARGE AND FLAT FEE.
30
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
DISPLAY ‘However, please 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 ‘If charges for procedures such as x-rays, lab tests,
or diagnostic procedures are listed separately on the bill or
statement, include those in the total charge.’ IF CP05 IS
CODED ‘1’ (YES, AND DOCUMENTATION AVAILABLE). OTHERWISE, USE
A NULL DISPLAY.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, or DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE...} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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
31
Beta
Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH. DISPLAY 'However,
please 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 'If charges for procedures such as x-rays, lab tests,
or diagnostic procedures are listed separately on the bill or
statement, include those in the total charge.' IF CP05 IS
CODED '1' (YES, AND DOCUMENTATION AVAILABEL). 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.
32
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
IF 'INCLUDED WITH OTHER CHARGES' DISPLAY THE FOLLOWING
MESSAGE: 'THIS CODE IS NOT AVAILABLE FOR A PM EVENT.'
IF 'INCLUDED WITH OTHER CHARGES' 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' 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.'
ROUTING INSTRUCTION:
IF 'INCLUDED WITH OTHER CHARGES' IS SELECTED AND EVENT TYPE IS
NOT PM AND THE EVENT-PROVIDER-PAIR DOES NOT REPRESENTVA FLAT
FEE GROUP OR A REPEAT VISIT GROUP, ASK THE FLAT FEE (FF)
SECTION.
33
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Charge/Payment (CP) Section
CP09OV
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
EVPV.TLCHRG
9
TOTAL CHARGE FOR VISIT
FFEE.TLCHRG
9
TOTAL CHARGE FOR VISIT
$ AMOUNT: _______________________
RF
Refused
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
ROUTING INSTRUCTION:
IF THE AMOUNT IS $0, GO TO CP37.
IF THE AMOUNT IS NOT $0
AND
(EVENT TYPE IS OM OR PM
OR
THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP
OR
(EVENT TYPE IS HS AND THE EVENT-PROVIDER PAIR IS NOT FLAGGED
AS ‘SEPARATELY BILLING’))
GO TO CP11.
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 'RF' (REFUSED) OR 'DK' (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 - $100,000
34
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Charge/Payment (CP) Section
35
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Charge/Payment (CP) Section
CP09A
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Let me be sure I recorded this correctly. The total charge for the services
received at home from (PROVIDER) during (MONTH) for (PERSON) was {$
AMOUNT}.
Is that correct?
Size
Variable Name
Label
EVPV.HHVERIFY
2
TOTAL CHARGE VERIFICATION
FFEE.HHVERIFY
2
TOTAL CHARGE VERIFICATION
1
YES
{CP11}
2
NO
RF
Refused
{CP11}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP11}
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{$ AMOUNT}: DISPLAY AMOUNT ENTERED AT CP09OV.
36
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
IF CODED ‘2’ (NO), DISPLAY THE FOLLOWING MESSAGE: ‘USE BACKUP
TO CORRECT TOTAL CHARGE FOR THIS MONTH.
37
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Charge/Payment (CP) Section
CP10
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP10Help)
Is this a situation in which (PERSON) (are/is) required to pay a certain set
amount each time (PERSON) (visit/visits) (PROVIDER) regardless of what
happens during the visit?
PROBE: For example, is this the type of situation in which (PERSON) always
(make/makes) the same set dollar amount copayment?
Size
Variable Name
Label
EVPV.SETAMT
2
PAY A CERTAIN SET AMOUNT EACH TIME
1
YES
{CP11}
2
NO
{CP11}
RF
Refused
{CP11}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP11}
HELP AVAILABLE FOR DEFINITION OF SET AMOUNT AND COPAYMENT
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
38
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Charge/Payment (CP) Section
CP11
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP11Help)
How much of the {{AMT TOT CH}/total charge} did anyone in the family pay
for {(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/
(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of
{NAME OF PRESCRIBED MEDICINE} for (PERSON)/the services for (FLAT
FEE GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used by
(PERSON) since (START DATE)/services received at home from
(PROVIDER) during (MONTH) for (PERSON)}? Please include all amounts
paid ‘out-of-pocket,’ that is, amounts paid before any reimbursements.
Size
Variable Name
Label
EVPV.TYPFAMP
2
TYPE OF FAMILY PAYMENT $ OR %
FFEE.TYPFAMP
2
TYPE OF FAMILY PAYMENT $ OR %
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYM.PAYTYPE
2
TYPE OF PAYMENT
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.PAYTYPE
2
TYPE OF PAYMENT
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
IF AMOUNT PAID IS NOTHING, DK, OR RF, SELECT 'DOLLARS', THEN
ENTER 0, DK, OR RF.
IS ANSWER IN DOLLARS OR PERCENT?
1
DOLLARS
{CP11OV1}
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Charge/Payment (CP) Section
2
PERCENT
{CP11OV2}
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
40
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{{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), ‘RF’ (REFUSED), ‘DK’
(DON’T KNOW), OR IS NOT ASKED OR IF IS CODED ‘RF’ (REFUSED) OR
‘DK’ (DON’T KNOW).
{AMT TOT CH}: DISPLAY THE DOLLAR AMOUNT ENTERED AT CP09OV.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, OR DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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.
{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).
41
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
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Charge/Payment (CP) Section
CP11OV1
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP11Help)
Size
Variable Name
Label
EVPV.AMTUPAY
9
AMOUNT OF TOTAL CHARGE FAMILY PAID
FFEE.AMTUPAY
9
AMOUNT OF TOTAL CHARGE FAMILY PAID
PAYM.AMTPAID
9
AMOUNT PAID
PAYF.AMTPAID
9
AMOUNT PAID
{BOX_05}
DOLLARS: $ _______________________
RF
Refused
{BOX_05}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{BOX_05}
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
PROGRAMMER NOTES:
WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF-PAYMENT-ROSTER.
WRITE 'PERSON/FAMILY' TO THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER.
Soft CHECK:
SOFT RANGE CHECK: $0 - $10,000
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Charge/Payment (CP) Section
CP11OV2
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP11Help)
Size
Variable Name
Label
EVPV.AMTUPCT
3
PERCENT YOU/FAMILY PAID
FFEE.AMTUPCT
3
PERCENT YOU PAID
PAYM.PCTPAID
3
PERCENT PAID
PAYF.PCTPAID
3
PERCENT PAID
{BOX_05}
PERCENT: _______________________
HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.
PROGRAMMER NOTES:
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 'RF' (REFUSED), OR 'DK' (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:
SOFT RANGE CHECK: 1% - 100%
44
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Charge/Payment (CP) Section
BOX_05
IF:
CP11OV1 OR CP11OV2 IS CODED 'RF' (REFUSED) OR 'DK' (DON'T KNOW)
AND
CP08 IS CODED '2' (NO), 'RF' (REFUSED), OR 'DK' (DON'T KNOW)
AND
CP10 IS CODED '2' (NO), 'RF' (REFUSED), OR 'DK' (DON'T KNOW),
DISPLAY THE FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT RESOLUTION WILL BE
NEEDED FOR THIS CASE. CONTINUE.'
THEN GO TO CP37.
OTHERWISE, CONTINUE WITH LOOP_01.
LOOP_01
FOR EACH OF THE FOLLOWING:
SOURCE OF DIRECT PAYMENT 1
SOURCE OF DIRECT PAYMENT 2
SOURCE OF DIRECT PAYMENT 3
SOURCE OF DIRECT PAYMENT 4
ASK BOX_LP01-END_LP01
LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION ON SOURCES OF DIRECT
PAYMENTS AND ASSOCIATED PAYMENT AMOUNTS, OTHER THAN PERSON/FAMILY. THE
RESPONSE TO CP13OV DETERMINES WHETHER THE LOOP CYCLES AGAIN. SUBSEQUENT
CYCLES, IF ANY, COLLECT ADDITIONAL SOURCES OF DIRECT PAYMENT AND
ASSOCIATED AMOUNTS. IF CP13OV IS CODED ‘1’ (YES), THE LOOP CYCLES AGAIN.
IF CP13OV IS NOT ASKED OR IS CODED ‘2’ (NO), THE LOOP ENDS.
BOX_LP01
IF FIRST CYCLE OF LOOP_01, CONTINUE WITH CP12.
OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE FIRST CYCLE OF LOOP_01),
GO TO CP12A.
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Charge/Payment (CP) Section
CP12
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP12Help)
Has any {other} source already paid {(PROVIDER)} for any of the charges for
{(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s
visit to (PROVIDER) on (VISIT DATE)/the last purchase of {NAME OF
PRESCRIBED MEDICINE} for (PERSON)/the services for (FLAT FEE
GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used by (PERSON)
since (START DATE)/for services received at home from (PROVIDER) during
(MONTH) for (PERSON)}?
Size
Variable Name
Label
EVPV.SRCPDANY
2
ANY SOURCE ALREADY PAY
FFEE.SRCPDANY
2
ANY SOURCE ALREADY PAY
1
YES
{CP12A}
2
NO
{END_LP01}
RF
Refused
{END_LP01}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{END_LP01}
HELP AVAILABLE FOR A DEFINITION OF SOURCE AND ‘ALREADY PAID’
46
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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.
'(PROVIDER)' IF EVENT TYPE IS NOT PM OR OM. IF EVENT TYPE IS
PM OR OM, USE A NULL DISPLAY.
DISPLAY '(PERSON)'s stay at (HOSPITAL) that began on (ADMIT
DATE)' IF EVENT TYPE IS HS.
DISPLAY '(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 (PERSON)' 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) for (PERSON)' IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
DISPLAY 'the {OME ITEM GROUP NAME} used by (PERSON) since
(START DATE)' 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
47
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
48
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Charge/Payment (CP) Section
CP12A
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Who else paid?
PROBE:
Anyone else?
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYM.PAYTYPE
2
TYPE OF PAYMENT
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PAYTYPE
2
TYPE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
{CP13}
49
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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.
{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 OM 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.
50
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-PAYMENT-
ROSTER.
Title:
RU_SOP_2
Roster Details
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
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 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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
Display all sources of payment on the roster except
PERSON/FAMILY.
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
51
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Charge/Payment (CP) Section
CP13
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
How much did (SOURCE) pay?
ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.
TOTAL CHARGE: {$XXXXXXXXX}
|-------------------|---------------------|-----------------------|
|SOURCE OF PAYMENT |DOLLAR AMOUNT PAID | PERCENT AMOUNT PAID |
|-------------------|-------------------- |-----------------------|
| PERSON/Family $ Amount % Amount |
|-------------------| --------------------|-----------------------|
| Source of Payment | $ Amount] | % Amount] |
|-------------------|---------------------|-----------------------|
| Source of Payment | $ Amount] | % Amount] |
|-------------------|---------------------|-----------------------|
Size
Variable Name
Label
PAYM.AMTPAID
9
AMOUNT PAID
PAYM.PCTPAID
3
PERCENT PAID
PAYF.AMTPAID
9
AMOUNT PAID
PAYF.PCTPAID
3
PERCENT PAID
52
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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 HEADER IF THIS EVENT IS A FLAT FEE STEM.
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
DISPLAY THE RESPONSE TO CP11 IN THE '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 OR PERCENT AMOUNT IS CODED ‘DK’ (DON’T KNOW), DISPLAY
‘DK’ FOR THE AMOUNT IN BOTH COLUMNS. IF DOLLAR OR PERCENT
AMOUNT IS CODED ‘RF’ (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 OM 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).
53
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
PROGRAMMER NOTES:
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS ‘DIRECT PAYMENT’.
NOTE: FEATURES OF THE SOURCE OF PAYMENT MATRIX.
1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO MOVE TO
EITHER THE PERCENT OR DOLLARAMOUNT COLUMN
ASSOCIATED WITH THAT SOURCE. INTERVIEWER USES THE UP AND
DOWN ARROW KEYS TO MOVE BETWEEN AMOUNT
PAID COLUMNS FOR DIFFERENT SOURCES.
2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT ENTER THIS
COLUMN, SO NO CHANGES AREA ALLOWED TO SOURCES
AT THE SCREEN.
3. INTERVIEWER ENTERS EITHER A DOLLAR OR A PERCENTAGE AMOUNT
FOR EACH SOURCE DISPLAYED. AMOUNTS CAN BE
CHANGED AS MANY TIMES AS NECESESSARY BEFORE THE
INTERVIEWER LEAVES THE SCREEN.
4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE CHANGED OR
CORRECTED.
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.
8. THE CURSOR SHOULD FIRST APPEAR IN THE DOLLAR AMOUNT PAID
COLUMN FOR THE FIRST SOURCE ADDED/SELECTED
AT THE PREVIOUS SCREEN (NOT IN THE PERSON/FAMILY COLUMN).
Soft CHECK:
$0 - $10,000
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Charge/Payment (CP) Section
Title:
EVNT_SOP_1
Roster Details
Col #
Header
Instructions
1
SOURCE OF
PAYMENT
Display Payment Source Name
PAYM.REIMNAM/
PAYF.REIMNAM
2
DOLLAR AMOUNT
PAID
Enter $ Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
3
PERCENT AMOUNT
PAID
Enter % Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
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.
Roster Definition:
Display the Event’s-Sources-Of-Payment-Roster for Entry.
55
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Charge/Payment (CP) Section
CP13OV
DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE
PROVIDER?
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(PAYMENTS)
1
YES
{END_LP01}
2
NO
{END_LP01}
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY
TO PROVIDER.
END_LP01
IF CP13OV IS CODED ‘1’ (YES), CYCLE TO COLLECT NEXT SOURCE OF PAYMENT.
IF CP13OV IS NOT ASKED OR IS CODED ‘2’ (NO), END LOOP_01 AND CONTINUE WITH
BOX_06.
BOX_06
IF 'AMOUNT PAID' BY PERSON/FAMILY > $0, CONTINUE WITH LOOP_02.
OTHERWISE, GO TO BOX_07.
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Charge/Payment (CP) Section
LOOP_02
FOR EACH OF THE FOLLOWING:
SOURCE OF REIMBURSEMENT 1
SOURCE OF REIMBURSEMENT 2
SOURCE OF REIMBURSEMENT 3
SOURCE OF REIMBURSEMENT 4
ASK BOX_LP02-END_LP02
LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION ON SOURCES OF REIMBURSEMENT
TO PERSON/FAMILY AND ASSOCIATED REIMBURSEMENT AMOUNTS. THE RESPONSE TO
CP15OV DETERMINES WHETHER THE LOOP CYCLES AGAIN. SUBSEQUENT CYCLES, IF
ANY, COLLECT ADDITIONAL SOURCES OF REIMBURSEMENT AND ASSOCIATED AMOUNTS.
IF CP15OV IS CODED ‘1’ (YES), THE LOOP CYCLES AGAIN. IF CP15OV IS NOT
ASKED OR IS CODED ‘2’ (NO), THE LOOP ENDS.
BOX_LP02
IF FIRST CYCLE OF LOOP_02, CONTINUE WITH CP14.
OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE FIRST CYCLE OF LOOP_02),
GO TO CP14A.
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Charge/Payment (CP) Section
CP14
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP14Help)
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Has any source reimbursed or paid back anything to (PERSON) (or anyone in
the family) for the amount paid ‘out-of-pocket’? That is, has any source
reimbursed any of the {$/% FAMILY PAID} paid?
Size
Variable Name
Label
EVPV.PAYBACK
2
DOES R EXPECT SOURCE TO REIMBURSE
FFEE.PAYBACK
2
DOES R EXPECT SOURCE TO REIMBURSE
1
YES
{CP14A}
2
NO
{END_LP02}
RF
Refused
{END_LP02}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{END_LP02}
HELP AVAILABLE FOR DEFINITION OF SOURCE AND REIMBURSEMENT
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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.
{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 OM EVENT.
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 OM EVENTS.
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’ FOR OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).
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Charge/Payment (CP) Section
{$/% 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).
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Charge/Payment (CP) Section
CP14A
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Who reimbursed or paid anyone in the family back?
PROBE: Anyone else?
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYM.PAYTYPE
2
TYPE OF PAYMENT
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PAYTYPE
2
TYPE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
[Name of Source of Reimbursement]
[Name of Source of Reimbursement]
[Name of Source of Reimbursement]
{CP15}
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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.
{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 OM EVENT.
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 OM EVENTS.
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’ FOR OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-PAYMENT-
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.
Title:
RU_SOP_2
Roster Details
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
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 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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
Display all soources of payment on the roster except
PERSON/FAMILY.
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
63
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Charge/Payment (CP) Section
CP15
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
How much did (SOURCE) reimburse or pay anyone in the family back?
ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.
PERSON/FAMILY PAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}
|------------------------|-----------------|------------------|
|SOURCE OF REIMBURSEMENT | DOLLAR AMOUNT | PERCENT AMOUNT |
| | REIMBURSED | REIMBURSED |
|------------------------|-----------------|------------------|
|Source of Reimbursement | $ Amount | % Amount |
|------------------------|-----------------|------------------|
|Source of Reimbursement | $ Amount | % Amount |
|------------------------|-----------------|------------------|
Size
Variable Name
Label
PAYM.AMTPAID
9
AMOUNT PAID
PAYM.PCTPAID
3
PERCENT PAID
PAYF.AMTPAID
9
AMOUNT PAID
PAYF.PCTPAID
3
PERCENT PAID
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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 OM 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.
FOR ‘(START DATE)’, DISPLAYED IN THE CONTEXT HEADER,
65
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Charge/Payment (CP) Section
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
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), ‘DK’ (DON’T KNOW), OR IF
CP09 IS CODED ‘DK’ (DON’T KNOW), DISPLAY ‘UNKNOWN’ FOR
{$XXXXXXXXX}. IF CP08 IS CODED ‘RF’ (REFUSED) OR IF CP09 IS
CODED ‘RF’ (REFUSED), DISPLAY ‘REFUSED’ FOR {$XXXXXXXXX}.
PROGRAMMER NOTES:
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS ‘REIMBURSEMENT’.
Soft CHECK:
0 - 999999
Title:
EVNT_SOP_1
Roster Details
Col #
Header
Instructions
1
SOURCE OF
PAYMENT
Display Payment Source Name
PAYM.REIMNAM/
PAYF.REIMNAM
2
DOLLAR AMOUNT
PAID
Enter $ Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
3
PERCENT AMOUNT
PAID
Enter % Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
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.
Roster Definition:
Display the Event’s-Sources-Of-Payment-Roster for selection.
66
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Charge/Payment (CP) Section
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 ‘REIMBURSED AMOUNT GREATER
THAN FAMILY PAYMENT. VERIFY REIMBURSED AMOUNT
AND RE-ENTER OR JUMPBACK TO CP13.’ If the
interviewer reenters the same amounts, CAPI will
accept it.
6. Interviewers will be instructed to enter only
reimbursements made to the family at the screen.
7. The same source can be flagged or 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.
67
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Charge/Payment (CP) Section
CP15OV
ARE THERE ANY OTHER SOURCES OF REIMBURSEMENT?
Comment Enabled
Jump Back Enabled
Help Enabled
(REIMBURS)
1
YES
{END_LP02}
2
NO
{END_LP02}
HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.
END_LP02
IF CP15OV CODED ‘1’ (YES), CYCLE TO COLLECT NEXT SOURCE OF REIMBURSEMENT.
IF CP15OV IS NOT ASKED OR IS CODED ‘2’ (NO), END LOOP_02 AND CONTINUE WITH
BOX_07.
BOX_07
GO TO BOX_11.
BOX_11
IF CP14 IS CODED '2' (NO), 'RF' (REFUSED), OR 'DK' (DON'T KNOW) AND CP10
IS CODED '1' (YES), GO TO BOX_09.
OTHERWISE, CONTINUE WITH BOX_10.
NOTE: THIS BOX SKIPS PEOPLE OVER CP18 (EXPECT ANY REIMBURSEMENT) FOR
INDIVIDUALS WHO HAVE ALREADY TOLD US THAT THE PAYMENT WAS A COPAYMENT
(CP10 IS CODED ‘1’) AND THEY HAVE NOT BEEN REIMBURSED FOR ANY AMOUNT PAID
(CP14 IS CODED ‘2’, ‘RF’, OR ‘DK’).
BOX_10
IF AMOUNT PAID BY PERSON/FAMILY IS > $0, CONTINUE WITH CP18.
OTHERWISE, GO TO BOX_09.
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Charge/Payment (CP) Section
CP18
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(REIMBURS)
Do you expect any {other} source to reimburse anyone in the family for what
has been paid?
Size
Variable Name
Label
EVPV.OTHSRCS
2
OTHER SOURCES EXPECTED TO REIMBURSE
FFEE.OTHSRCS
2
OTHER SOURCES EXPECTED TO REIMBURSE
1
YES
{CP19}
2
NO
{BOX_09}
RF
Refused
{BOX_09}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{BOX_09}
HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
DISPLAY 'other' IF CP14 IS CODED ‘1’ (YES). OTHERWISE, USE A
NULL DISPLAY.
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Charge/Payment (CP) Section
CP19
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
How much does anyone in the family expect to be reimbursed?
PROBE: Include amounts to be reimbursed from all sources.
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.TYPPBCK
2
CP19/34 REIMBURSEMENT TYPE $ OR %
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.TYPPBCK
2
CP19/34 REIMBURSEMENT TYPE $ OR %
IS ANSWER IN DOLLARS OR PERCENT?
1
DOLLARS
{CP19OV1}
2
PERCENT
{CP19OV2}
DISPLAY INSTRUCTIONS:
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.
70
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Charge/Payment (CP) Section
CP19OV1
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.EXPTPBCK
9
CP19/34 AMT FAMILY EXPECTS REIMBURSED
PAYF.EXPTPBCK
9
CP19/34 AMOUNT FAM EXPECTS REIMBURSED
{CP20}
DOLLARS: $ _______________________
RF
Refused
{CP20}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP20}
Soft CHECK:
SOFT RANGE CHECK: $0 - $10,000
71
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Charge/Payment (CP) Section
CP19OV2
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.PCTPBCK
3
CP19/34 PERCENT FAM EXPECTS REIMBURSED
PAYF.PCTPBCK
3
CP19/34 PERCENT FAM EXPECTS REIMBURSED
{CP20}
PERCENT: _______________________
RF
Refused
{CP20}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP20}
Soft CHECK:
SOFT RANGE CHECK: 1% - 100%
72
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Charge/Payment (CP) Section
CP20
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
From whom do you expect these reimbursements to come?
Size
Variable Name
Label
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.REIMNAM
30
SOURCE OF PAYMENT
IF MORE THAN ONE SOURCE OF REIMBURSEMENT, PROBE FOR THE
MAIN SOURCE (I.E., THE SOURCE REIMBURSING THE MOST).
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
{BOX_09}
DISPLAY INSTRUCTIONS:
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.
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Charge/Payment (CP) Section
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-PAYMENT-
ROSTER.
Title:
RU_SOP_2
Roster Details
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
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 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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
Display all sources of payment on the resoter except but
PERSON/FAMILY.
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
74
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Charge/Payment (CP) Section
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, DISPLAY THE FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT RESOLUTION
NEEDED FOR THIS CASE. PRESS ENTER TO CONTINUE.' THEN GO TO CP37
BOX_12
IF CP09 (TOTAL CHARGE) OR 'AMOUNT PAID' BY ANY SOURCE OF DIRECT PAYMENT
(INCLUDING PERSON/FAMILY, BUT EXCLUDING REIMBURSEMENTS) IS CODED 'RF'
(REFUSED) OR 'DK' (DON'T KNOW), DISPLAY THE FOLLOWING MESSAGE: 'NO CHARGE-
PAYMENT RESOLUTION NEEDED FOR THIS CASE. PRESS ENTER TO CONTINUE.' THEN 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.
IF THE OVERPAYMENT IS > 3% OR $5 (WHICHEVER IS HIGHER) OF THE TOTAL
CHARGE, GO TO LOOP_04.
75
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Charge/Payment (CP) Section
CP21
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Does anyone in the family or any other source expect to make additional
payments for {(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/
(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last purchase of
{NAME OF PRESCRIBED MEDICINE} for (PERSON)/the services for (FLAT
FEE GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used by
(PERSON) since (START DATE)/services received at home from
(PROVIDER) during (MONTH) for (PERSON)}?
Size
Variable Name
Label
EVPV.ELSEPAY
2
DOES R EXPECT SOMEONE ELSE TO PAY
FFEE.ELSEPAY
2
DOES R EXPECT SOMEONE ELSE TO PAY
1
YES
{CP22}
2
NO
{LOOP_03}
RF
Refused
{LOOP_03}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{LOOP_03}
76
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, OR DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE...} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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).
77
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
78
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Charge/Payment (CP) Section
CP22
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
How much more does anyone in the family or any other source expect to pay?
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.TYPFPAY
2
CP22/32 FAMILY PAY TYPE $ OR %
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.TYPFPAY
2
CP22/32 FAMILY PAY TYPE $ OR %
IS ANSWER IN DOLLARS OR PERCENT?
1
DOLLARS
{CP22OV1}
2
PERCENT
{CP22OV2}
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
79
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Charge/Payment (CP) Section
CP22OV1
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.EXPTFPAY
9
CP22/32 AMOUNT FAMILY EXPECTS TO PAY
PAYF.EXPTFPAY
9
CP22/32 AMOUNT FAMILY EXPECTS TO PAY
{BOX_14}
DOLLARS: $ _______________________
RF
Refused
{BOX_14}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{BOX_14}
Soft CHECK:
SOFT RANGE CHECK: $0 - $10,000
80
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Charge/Payment (CP) Section
CP22OV2
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.PCTFPAY
3
CP22/32 PERCENT FAMILY EXPECTS TO PAY
PAYF.PCTFPAY
3
CP22/32 PERCENT FAMILY EXPECTS TO PAY
{BOX_14}
PERCENT: _______________________
RF
Refused
{BOX_14}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{BOX_14}
Soft CHECK:
SOFT RANGE CHECK: 0% - 100%
BOX_14
IF AN AMOUNT IS ENTERED AT CP22OV1 OR AT CP22OV2 OR IF CP22OV1 OR CP22OV2
ARE CODED 'RF' (REFUSED) OR 'DK' (DON'T KNOW), DISPLAY THE FOLLOWING
MESSAGE: 'NO CHARGE-PAYMENT RESOLUTION NEEDED FOR THIS CASE. CONTINUE.'
THEN GO TO CP37.
81
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Charge/Payment (CP) Section
LOOP_03
FOR EACH OF THE FOLLOWING:
SOURCE OF DIRECT PAYMENT 1
SOURCE OF DIRECT PAYMENT 2
SOURCE OF DIRECT PAYMENT 3
SOURCE OF DIRECT PAYMENT 4
ASK BOX_LP03-END_LP03
LOOP DEFINITION: LOOP_03 REVIEWS PAYMENT INFORMATION WHERE AN
UNDERPAYMENT HAS BEEN REPORTED AND EITHER VERIFIES THE UNDERPAYMENT OR
COLLECTS CORRECTIONS AND ADDITIONAL PAYMENT INFORMATION TO RESOLVE THE
UNDERPAYMENT. THE FIRST CYCLE OF THIS LOOP COLLECTS CORRECTIONS OF
ERRONEOUS INFORMATION ON DIRECT PAYMENTS AND THE THE ASSOCIATED AMOUNTS
PAID. SUBSEQUENT LOOP CYCLES, IF ANY, COLLECT ADDITIONAL SOURCES OF
DIRECT PAYMENT AND ASSOCIATED AMOUNTS. THE RESPONSE TO CP24OV DETERMINES
WHETHER THE LOOP CYCLES AGAIN. IF CP24OV IS CODED ‘1’ (YES), THE LOOP
CYCLES AGAIN. IF CP24OV IS CODED ‘2’ (NO), THE LOOP ENDS.
BOX_LP03
IF FIRST CYCLE OF LOOP_03, GO TO CP24.
OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE FIRST CYCLE OF LOOP_03),
CONTINUE WITH CP23.
82
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Charge/Payment (CP) Section
CP23
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Who else paid?
PROBE:
Anyone else?
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYM.PAYTYPE
2
TYPE OF PAYMENT
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PAYTYPE
2
TYPE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
{CP24}
83
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
{NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME 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 OM 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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE EVENT’S-SOURCE-OF-PAYMENT-ROSTER.
Title:
RU_SOP_2
Roster Details
84
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Charge/Payment (CP) Section
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
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 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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
None, display all.
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
85
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Charge/Payment (CP) Section
CP24
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
At the moment, it appears that {AMOUNT REMAINING} of the total charge for
{(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s
visit to (PROVIDER) on (VISIT DATE)/the last purchase of {NAME OF
PRESCRIBED MEDICINE} for (PERSON)/the services for (FLAT FEE
GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used by (PERSON)
since (START DATE)/services received at home from (PROVIDER) during
(MONTH) for (PERSON)} is still unpaid. Let me be sure I have entered
everything correctly.
REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH
RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.
IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.
UNDERPAYMENT: {$XXXXXXXXX) TOTAL CHARGE: {$XXXXXXXXX)
|-------------------|---------------------|-----------------------|
|SOURCE OF PAYMENT |DOLLAR AMOUNT PAID | PERCENT AMOUNT PAID |
|-------------------|-------------------- |-----------------------|
| PERSON/Family | $ Amount | % Amount |
|-------------------| --------------------|-----------------------|
| Source of Payment | $ Amount | % Amount |
|-------------------|---------------------|-----------------------|
| Source of Payment | $ Amount | % Amount |
|-------------------|---------------------|-----------------------|
Size
Variable Name
Label
PAYM.AMTPAID
9
AMOUNT PAID
PAYM.PCTPAID
3
PERCENT PAID
PAYF.AMTPAID
9
AMOUNT PAID
PAYF.PCTPAID
3
PERCENT PAID
86
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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 HEADER IF THIS EVENT IS A FLAT FEE STEM.
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
IF THE AMOUNT PAID BY PERSON/FAMILY WAS ADJUSTED AT CP13,
DISPLAY ADJUSTED AMOUNT. IF AMOUNT PAID BY PERSON/FAMILY WAS
NOT ADJUSTED, DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT
PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO
CP11 IS A DOLLAR 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 OR PERCENT AT CP11
IS CODED ‘DK’ (DON’T KNOW), DISPLAY ‘DK’ FOR THE AMOUNT IN
BOTH COLUMNS. IF THE DOLLAR AMOUNT OR PERCENT AT CP11 IS
CODED ‘RF’ (REFUSED), DISPLAY ‘REF’ FOR THE AMOUNT IN BOTH
COLUMNS.
{AMOUNT REMAINING}: DISPLAY THE AMOUNT OF THE CALCULATED
UNDERPAYMENT.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, OR DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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).
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
UNDERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT OF THE
CALCULATED UNDERPAYMENT.
TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT ENTERED AT
CP09OV.
PROGRAMMER NOTES:
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS ‘DIRECT PAYMENTS’.
Soft CHECK:
SOFT RANGE: 0 - $100,000
Title:
EVNT_SOP_1
Roster Details
88
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Charge/Payment (CP) Section
Col #
Header
Instructions
1
SOURCE OF
PAYMENT
Display Payment Source Name
PAYM.REIMNAM/
PAYF.REIMNAM
2
DOLLAR AMOUNT
PAID
Enter $ Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
3
PERCENT AMOUNT
PAID
Enter % Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
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. No corrections or updates may be made to source
names or amounts of reimbursement.
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.
6. Only new sources of direct payments may be
added.
Roster Filter:
Display all sources flagged as ‘DIRECT PAYMENT’ for this event.
Roster Definition:
Display the Event’s-Sources-Of-Payment-Roster for entry.
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Charge/Payment (CP) Section
CP24OV
DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE
PROVIDER?
Comment Enabled
Jump Back Enabled
Help Enabled
(PAYMENTS)
1
YES
{END_LP03}
2
NO
{END_LP03}
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY
TO PROVIDER.
END_LP03
IF CP24OV IS CODED ‘1’ (YES), CYCLE TO COLLECT ADDITIONAL SOURCES OF
PAYMENT.
IF CP24OV IS CODED ‘2’ (NO), END LOOP_03 AND GO TO BOX_15.
LOOP_04
FOR EACH OF THE FOLLOWING:
SOURCE OF DIRECT PAYMENT 1
SOURCE OF DIRECT PAYMENT 2
SOURCE OF DIRECT PAYMENT 3
SOURCE OF DIRECT PAYMENT 4
ASK BOX_LP04-END_LP04
LOOP DEFINITION: LOOP_04 REVIEWS PAYMENT INFORMATION WHERE AN OVERPAYMENT
HAS BEEN REPORTED AND EITHER VERIFIES THE OVERPAYMENT OR COLLECTS
CORRECTIONS AND ADDITIONAL PAYMENT INFORMATION TO RESOLVE THE
OVERPAYMENT. THE FIRST CYCLE OF THIS LOOP COLLECTS CORRECTIONS OF
ERRONEOUS INFORMATION ON DIRECT PAYMENTS AND ASSOCIATED AMOUNTS PAID.
SUBSEQUENT LOOP CYCLES, IF ANY, COLLECT ADDITIONAL SOURCES OF DIRECT
PAYMENT AND ASSOCIATED AMOUNTS. THE RESPONSE TO CP26OV DETERMINES WHETHER
THE LOOP CYCLES AGAIN. IF CP26OV IS CODED ‘1’ (YES), THE LOOP CYCLES
AGAIN. IF CP26OV IS CODED ‘2’ (NO), THE LOOP ENDS.
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Charge/Payment (CP) Section
BOX_LP04
IF FIRST CYCLE OF LOOP_04, GO TO CP26.
OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE FIRST CYCLE OF LOOP_04),
CONTINUE WITH CP25.
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Charge/Payment (CP) Section
CP25
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}
Who else paid?
PROBE:
Anyone else?
Size
Variable Name
Label
SRCS.SRCSID
10
SRCS ID KEY: RUNTID + COUNTER(3)
SRCS.SRCSRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
SRCS.CREATEQ
5
QUESTION THAT CREATED SRCS SEGMENT
SRCS.SRCNAME
35
SOURCE OF PAYMENT NAME
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.REIMNAM
30
SOURCE OF PAYMENT
PAYM.PAYTYPE
2
TYPE OF PAYMENT
PAYM.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.REIMNAM
30
SOURCE OF PAYMENT
PAYF.PAYTYPE
2
TYPE OF PAYMENT
PAYF.PSRCSID
3
POINTER TO SOURCE OF PAYMENT RECORD
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
[Name of Source of Direct Payment]
{CP26}
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{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 OM 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.
FOR ‘(START DATE)’, DISPLAYED IN THE CONTEXT HEADER,
DISPLAY THE START DATE OF THE CURRENT ROUND FOR
OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE
93
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Charge/Payment (CP) Section
(EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
PROGRAMMER NOTES:
WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF-PAYMENT-
ROSTER.
Title:
RU_SOP_2
Roster Details
Col #
Header
Instructions
1
Reimbursement Source
Reimbursement Source Name
SRCS.SRCNAME
Roster Behavior:
1. Multiple add and 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 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. In 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: "EITHER THE ROSTER IS
EMPTY OR YOUR SEARCH HAS NOT TURNED UP ANY
CHOICES."
Roster Filter:
None, display all.
Roster Definition:
Display the RU-Sources-Of-Payment-Roster for selection.
94
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Charge/Payment (CP) Section
CP26
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
The payments you reported for {(PERSON)'s stay at (HOSPITAL) that began
on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last
purchase of {NAME OF PRESCRIBED MEDICINE} for (PERSON)/the
services for (FLAT FEE GROUP) for (PERSON)/the {OME ITEM GROUP
NAME} used by (PERSON) since (START DATE)/services received at home
from (PROVIDER) during (MONTH) for (PERSON)} exceed the charge I have
recorded by {$ DISCREPANCY}. Let me be sure I have all the information
recorded correctly.
REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH
RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.
IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.
OVERPAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}
|-------------------|-------------------- |-----------------------|
| Source of Payment | Dollar Amount Paid | Percent Amount Paid |
|-------------------| --------------------|-----------------------|
| PERSON/Family | $ Amount | % Amount |
|-------------------|---------------------|-----------------------|
| Source of Payment | $ Amount | % Amount |
|-------------------|---------------------|-----------------------|
| Source of Payment | $ Amount | % Amount |
|-------------------|---------------------|-----------------------|
Size
Variable Name
Label
PAYM.AMTPAID
9
AMOUNT PAID
PAYM.PCTPAID
3
PERCENT PAID
PAYF.AMTPAID
9
AMOUNT PAID
PAYF.PCTPAID
3
PERCENT PAID
95
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
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 HEADER IF THIS EVENT IS A FLAT FEE STEM.
TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09.
DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF PAYMENT.
IF THE AMOUNT PAID BY PERSON/FAMILY WAS ADJUSTED AT CP13,
DISPLAY ADJUSTED AMOUNT. IF AMOUNT PAID BY PERSON/FAMILY WAS
NOT ADJUSTED, DISPLAY THE RESPONSE TO CP11 IN THE 'AMOUNT
PAID' COLUMN FOR PERSON/FAMILY. THAT IS, IF THE RESPONSE TO
CP11 IS A DOLLAR 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 OR PERCENT AT CP11
IS CODED ‘DK’ (DON’T KNOW), DISPLAY ‘DK’ FOR THE AMOUNT IN
BOTH COLUMNS. IF THE DOLLAR AMOUNT OR PERCENT AT CP11 IS
CODED ‘RF’ (REFUSED), DISPLAY ‘REF’ FOR THE AMOUNT IN BOTH
COLUMNS.
(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE):
DISPLAY IF EVENT TYPE IS HS.
(PERSON)'s visit to (PROVIDER) on (VISIT DATE): DISPLAY IF
EVENT TYPE IS ER, OP, MV, OR DN.
the last purchase of {NAME OF PRESCRIBED MEDICINE} for
(PERSON): 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) for (PERSON): DISPLAY IF
EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP.
the {OME ITEM GROUP NAME} used by (PERSON) since (START
DATE): 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).
96
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
services received at home from (PROVIDER) during (MONTH) for
(PERSON): DISPLAY IF EVENT TYPE IS HH.
{$ DISCREPANCY}: DISPLAY THE AMOUNT OF THE CALCULATED
OVERPAYMENT.
OVERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT OF THE
CALCULATED OVERPAYMENT.
TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT ENTERED AT
CP09OV.
PROGRAMMER NOTES:
FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS ‘DIRECT PAYMENTS’.
Soft CHECK:
SOFT RANGE CHECK: 0 - $100,000
97
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Charge/Payment (CP) Section
Title:
EVNT_SOP_1
Roster Details
Col #
Header
Instructions
1
SOURCE OF
PAYMENT
Display Payment Source Name
PAYM.REIMNAM/
PAYF.REIMNAM
2
DOLLAR AMOUNT
PAID
Enter $ Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
3
PERCENT AMOUNT
PAID
Enter % Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
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. No corrections or updates may be made to source
names or amounts of reimbursement.
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.
6. Only new sources of direct payments may be
added.
Roster Filter:
Display all sources flagged as ‘DIRECT PAYMENT’.
Roster Definition:
Display the Event’s-Sources-Of-Payment-Roster for entry.
98
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Charge/Payment (CP) Section
CP26OV
DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE
PROVIDER?
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(PAYMENTS)
1
YES
{END_LP04}
2
NO
{END_LP04}
HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY
TO PROVIDER.
END_LP04
IF CP26OV IS CODED ‘1’ (YES), CYCLE TO COLLECT ADDITIONAL SOURCES OF
PAYMENT.
IF CP26OV IS CODED ‘2’ (NO), END LOOP_04 AND CONTINUE WITH BOX_15.
BOX_15
RECALCULATE AMOUNT OF UNDERPAYMENT OR OVERPAYMENT.
IF UNDERPAYMENT IS > 3% OR $5 (WHICHEVER IS HIGHER) OF TOTAL CHARGE,
CONTINUE WITH BOX_19.
OTHERWISE, GO TO CP37.
BOX_19
IF CP21 WAS ASKED, GO TO CP37.
OTHERWISE, CONTINUE WITH BOX_20.
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Charge/Payment (CP) Section
BOX_20
IF UNDERPAYMENT IS STILL > 3% OR $5 (WHICHEVER IS HIGHER) OF TOTAL CHARGE,
CONTINUE WITH CP31 USING THE DIFFERENCE IN THE DISPLAY.
IF UNDERPAYMENT IS NOT > 3% OR $5 (WHICHEVER IS HIGHER) OF THE TOTAL
CHARGE, GO TO CP37.
100
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Charge/Payment (CP) Section
CP31
TOTAL CHARGE: {$XXXXXXXXX} DIFFERENCE: {$XXXXXXXXX}
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
--------------------|---------------------|-----------------------|
| SOURCE OF | DOLLAR AMOUNT | PERCENT OF |
| REIMBURSEMENT | OF REIMBURSEMENT | REIMBURSEMENT |
|-------------------|-------------------- |-----------------------|
| PERSON/Family $ Amount % Amount |
|-------------------| --------------------|-----------------------|
| Source of Payment | $ Amount] | % Amount] |
|-------------------|---------------------|-----------------------|
| Source of Payment | $ Amount] | % Amount] |
|-------------------|---------------------|-----------------------|
TOTAL CHARGE: {$XXXXXXXXX} DIFFERENCE: {$XXXXXXXXX}
Do you expect anyone in the family to pay any {amount/more}?
Size
Variable Name
Label
EVPV.UPAYMOR
2
EXPECT ANYONE IN FAMILY TO PAY MORE
FFEE.UPAYMOR
2
EXPECT ANYONE IN FAMILY TO PAY MORE
1
YES
{CP32}
2
NO
{CP37}
RF
Refused
{CP37}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP37}
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{amount/more}: DISPLAY 'amount' IF PERSON/FAMILY PAYMENT IS
$0/0%. DISPLAY 'more' IF PERSON/FAMILY PAYMENT IS NOT EQUAL
TO $0/0% (INCLUDING DON'T KNOW AND REFUSED RESPONSES).
TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT ENTERED AT
CP09OV.
DIFFERENCE: {$XXXXXXXXX}: DISPLAY THE AMOUNT OF THE RE-
CALCULATED UNDERPAYMENT.
Title:
EVNT_SOP_1
Roster Details
Col #
Header
Instructions
1
SOURCE OF
PAYMENT
Display Payment Source Name
PAYM.REIMNAM/
PAYF.REIMNAM
2
DOLLAR AMOUNT
PAID
Enter $ Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
3
PERCENT AMOUNT
PAID
Enter % Amount Paid
PAYM.AMTPAID/
PAYF.AMTPAID
Roster Behavior:
1.This matrix is read-only.
Roster Filter:
Display all sources flagged as ‘DIRECT PAYMENT’.
Roster Definition:
Display the Event’s-Sources-Of-Payment-Roster for display.
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103
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Charge/Payment (CP) Section
CP32
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
How much do you expect anyone in the family to pay?
Size
Variable Name
Label
PAYM.PAYMID
25
PAYM ID KEY: EVPVID + COUNTER(2)
PAYM.PAYMRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYM.CREATEQ
5
QUESTION THAT CREATED PAYM SEGMENT
PAYM.TYPFPAY
2
CP22/32 FAMILY PAY TYPE $ OR %
PAYF.PAYFID
12
PAYF ID KEY: FFEEID + COUNTER(2)
PAYF.PAYFRURN
2
ROUND STAMP: RU LETTER + ROUND NUMBER
PAYF.CREATEQ
5
QUESTION WHERE PAYM RECORD CREATED
PAYF.TYPFPAY
2
CP22/32 FAMILY PAY TYPE $ OR %
IS ANSWER IN DOLLARS OR PERCENT?
1
DOLLARS
{CP32OV1}
2
PERCENT
{CP32OV2}
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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Charge/Payment (CP) Section
CP32OV1
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.EXPTFPAY
9
CP22/32 AMOUNT FAMILY EXPECTS TO PAY
PAYF.EXPTFPAY
9
CP22/32 AMOUNT FAMILY EXPECTS TO PAY
{CP37}
DOLLARS: $ _______________________
RF
Refused
{CP37}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP37}
Soft CHECK:
SOFT RANGE CHECK: $0 - $10,000
105
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Charge/Payment (CP) Section
CP32OV2
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
Size
Variable Name
Label
PAYM.PCTFPAY
3
CP22/32 PERCENT FAMILY EXPECTS TO PAY
PAYF.PCTFPAY
3
CP22/32 PERCENT FAMILY EXPECTS TO PAY
{CP37}
PERCENT: _______________________
RF
Refused
{CP37}
----------------------------------------------------------------------------------------------------------------------------------
DK
Don't Know
{CP37}
Soft CHECK:
SOFT RANGE CHECK: 1% - 100%
106
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Charge/Payment (CP) Section
CP37
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
INTERVIEWER: WHAT RECORDS WERE USED IN COMPLETING THE
CHARGE/PAYMENT INFORMATION FOR THE {VISIT TO (PROVIDER) ON
(VISIT DATE)/THE VISITS FOR (FLAT FEE GROUP)/THE LAST PURCHASE
OF {NAME OF PRESCRIBED MEDICINE}/THE {OME ITEM GROUP NAME}
USED BY (PERSON) SINCE (START DATE)/SERVICES RECEIVED AT
HOME FROM (PROVIDER) DURING (MONTH) FOR (PERSON)}?
Size
Variable Name
Label
EVPV.MEMCHRG
2
SOURCE OF INFO USED-R'S MEMORY OF CHARGE
EVPV.CKBOOK
2
SOURCE OF INFO USED - CHECKBOOK
EVPV.PROVBILL
2
SOURCE OF INFO USED-BILL FROM PROVIDER
EVPV.EXPLNMED
2
SOURCE OF INFO USED-EXPLANATION MEDICARE
EVPV.EXPLNPRV
2
SOURCE OF INFO USED-EXPLANATION PRIV INS
EVPV.NMES
2
SOURCE OF INFO USED - NMES CALENDAR
EVPV.PMCNTNR
2
SOURCE OF INFO USED - PM COUNTAINER
EVPV.SRCOTH
2
SOURCE OF INFO USED - OTHER
FFEE.MEMCHRG
2
SOURCE USED - R'S MEMORY OF CHARGES
FFEE.CKBOOK
2
SOURCE USED - CHECKBOOK
FFEE.PROVBILL
2
SOURCE USED - BILL FROM PROVIDER
FFEE.EXPLNMED
2
SOURCE USED - EXPLANATION MEDICARE
FFEE.EXPLNPRV
2
SOURCE USED - EXPLAINATION PRIVATE INS
FFEE.NMES
2
SOURCE OF INFO USED - CALENDAR
FFEE.PMCNTNR
2
SOURCE OF INFO USED-PM CONTAINER
FFEE.SRCOTH
2
SOURCE OF INFO USED - OTHER
CHECK ALL THAT APPLY.
1
RESPONDENT'S/FAMILY MEMBER'S
MEMORY
2
RESPONDENT'S/FAMILY MEMBER'S
CHECK BOOK
3
STATEMENT, BILL OR RECEIPT FROM
PROVIDER'S OFFICE
EXPLANATION OF BENEFITS FROM:
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Charge/Payment (CP) Section
4
MEDICARE
5
PRIVATE INSURANCE CARRIER
6
CALENDAR
7
PRESCRIBED MEDICINE BOTTLE, BAG,
OR CONTAINER
91
OTHER
{CP37OV}
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Charge/Payment (CP) Section
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
{THE VISIT TO (PROVIDER) ON (VISIT DATE): DISPLAY IF EVENT
TYPE IS HS, OP, ER, MV, OR DN.
THE VISITS FOR (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} USED BY (PERSON) SINCE (START
DATE): 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).
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Charge/Payment (CP) Section
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.
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’ FOR
OM EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE
(EV02A=2).
SERVICES RECEIVED AT HOME FROM (PROVIDER) DURING (MONTH) FOR
(PERSON): DISPLAY IF EVENT TYPE IS HH.
ROUTING INSTRUCTION:
IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION WITH OTHER
CODES, CONTINUE WITH CP37OV.
OTHERWISE, GO TO BOX_23.
110
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Charge/Payment (CP) Section
CP37OV
Comment Enabled
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Size
Variable Name
Label
EVPV.SRCOTHOS
25
SOURCE OF INFO USED OTHER SPECIFY
FFEE.SRCOTHOS
25
SOURCE OF INFO USED OTHER SPECIFY
{BOX_23}
_______________________
OTHER 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.
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Charge/Payment (CP) Section
CP38
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
Help Enabled
(CP38Help)
INTERVIEWER: DOES THE PAPERWORK SHOW THAT (PROVIDER) HAS
ANOTHER NAME?
Size
Variable Name
Label
EVPV.OTHPRVNM
2
DOES PROVIDER HAVE OTHER NAME
FFEE.OTHPRVNM
2
DOES PROVIDER HAVE OTHER NAME
1
YES
{CP39}
2
NO
{BOX_24}
HELP AVAILABLE FOR DEFINITION OF PROVIDER NAME.
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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Charge/Payment (CP) Section
CP39
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER} {EV} {EVN-DT/REF-DT}
{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE GROUP: {NAME
OF FLAT FEE EVENT GROUP}}
Comment Enabled
Jump Back Enabled
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INTERVIEWER: ENTER OTHER NAME FOR (PROVIDER).
Size
Variable Name
Label
EVPV.OTHRNAME
30
OTHER NAME FOR PROVIDER
FFEE.OTHRNAME
30
OTHER NAME FOR PROVIDER
{BOX_24}
MEDICAL PROVIDER: _______________________
DISPLAY INSTRUCTIONS:
DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE HEADER IF THE
EVENT TYPE IS NOT 'PM' (PRESCRIBED MEDICINES) OR 'OM' (OTHER
MEDICAL EXPENSES). OTHERWISE, USE NULL VALUE.
DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS NOT 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS 'PM'
(PRESCRIBED MEDICINES) OR 'OM' (OTHER MEDICAL EXPENSES).
DISPLAY 'REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}' IN THE
HEADER IF THIS EVENT IS A REPEAT VISIT STEM.
DISPLAY 'FLAT FEE GROUP: {NAME OF FLAT FEE EVENT GROUP}' IN
THE HEADER IF THIS EVENT IS A FLAT FEE STEM.
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Charge/Payment (CP) Section
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), 'RF' (REFUSED), OR 'DK' (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) OR '8' (NO BILL SENT: WELFARE/ MEDICAID)]
AND
CP10 IS CODED '1' (YES)
AND
CP11 IS CODED '1' (DOLLARS) AND A WHOLE DOLLAR AMOUNT GREATER (>) THAN $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.
114
| File Type | application/pdf |
| File Title | \\rk29\vol2905\MEPSWVS\SpecWriter\BETA\CP (BETA).snp |
| Author | miller_n |
| File Modified | 2006-02-06 |
| File Created | 2006-02-06 |