CY2011 Plan Benefit Package (PBP) Software and Formulary Submission - CMS-R-262

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 1 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 2 SCREEN

Appendix C

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Page 2 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 3 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 4 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 5 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 6 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 7 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 7 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 8 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 8 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 9 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 9 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE – BASE 10 SCREEN

Appendix C

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Page 10 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE (B ONLY) – BASE 1 SCREEN

Appendix C

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Page 11 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE (B ONLY) – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 12 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE (B ONLY) – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 13 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1A – INPATIENT HOSPITAL ACUTE (B ONLY) – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 14 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 15 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 16 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 17 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 18 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 19 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 20 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 7 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 21 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 8 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 22 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 9 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 23 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL – BASE 10 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 24 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL (B ONLY) – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 25 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL (B ONLY) – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 26 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL (B ONLY) – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 27 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL (B ONLY) – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 28 of 223

PBP 2011 Data Entry System Screens

SECTION B – 1B – INPATIENT PSYCHIATRIC HOSPITAL (B ONLY) – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 29 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 30 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 31 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 32 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 33 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 34 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 35 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF – BASE 7 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 36 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF (B ONLY) – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 37 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF (B ONLY) – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 38 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF (B ONLY) – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 39 of 223

PBP 2011 Data Entry System Screens

SECTION B – 2 – SNF (B ONLY) – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 40 of 223

PBP 2011 Data Entry System Screens

SECTION B – 3 – CORF – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 41 of 223

PBP 2011 Data Entry System Screens

SECTION B – 3 – CORF – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 42 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4A – EMERGENCY CARE – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 43 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4A – EMERGENCY CARE – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 44 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4A – EMERGENCY CARE – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 45 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4A – EMERGENCY CARE – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 46 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4B –URGENTLY NEEDED SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 47 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4B – URGENTLY NEEDED SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 48 of 223

PBP 2011 Data Entry System Screens

SECTION B – 4B – URGENTLY NEEDED SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 49 of 223

PBP 2011 Data Entry System Screens

SECTION B – 5 – PARTIAL HOSPITALIZATION – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 50 of 223

PBP 2011 Data Entry System Screens

SECTION B – 5 – PARTIAL HOSPITALIZATION – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 51 of 223

PBP 2011 Data Entry System Screens

SECTION B – 6 –HOME HEALTH – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 52 of 223

PBP 2011 Data Entry System Screens

SECTION B – 6 –HOME HEALTH – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 53 of 223

PBP 2011 Data Entry System Screens

SECTION B – 6 –HOME HEALTH – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 54 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7A – PRIMARY CARE PHYSICIAN – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 55 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7A – PRIMARY CARE PHYSICIAN – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 56 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7A – PRIMARY CARE PHYSICIAN – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 57 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7B – CHIROPRACTIC SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 58 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7B – CHIROPRACTIC SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 59 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7B – CHIROPRACTIC SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 60 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7B – CHIROPRACTIC SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 61 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7C – OCCUPATIONAL THERAPY – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 62 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7C – OCCUPATIONAL THERAPY – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 63 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7D – PHYSICIAN SPECIALIST – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 64 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7D – PHYSICIAN SPECIALIST – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 65 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7E – MENTAL HEALTH SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 66 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7E – MENTAL HEALTH SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 67 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7E – MENTAL HEALTH SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 68 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7E – MENTAL HEALTH SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 69 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7E – MENTAL HEALTH SERVICES – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 70 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7F – PODIATRY SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 71 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7F – PODIATRY SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 72 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7F – PODIATRY SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 73 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7G – OTHER HEALTH CARE PROFESSIONALS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 74 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7G – OTHER HEALTH CARE PROFESSIONALS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 75 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7H – PSYCHIATRIC SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 76 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7H – PSYCHIATRIC SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 77 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7H – PSYCHIATRIC SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 78 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7H – PSYCHIATRIC SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 79 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7H – PSYCHIATRIC SERVICES – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 80 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7I – PHYSICAL THERAPY AND SPEECH-LANGUAGE SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 81 of 223

PBP 2011 Data Entry System Screens

SECTION B – 7I – PHYSICAL THERAPY AND SPEECH-LANGUAGE SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 82 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8A – OUTPATIENT DIAGNOSTIC PROCEDURES AND TESTS AND LAB SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 83 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8A – OUTPATIENT DIAGNOSTIC PROCEDURES AND TESTS AND LAB SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 84 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8A – OUTPATIENT DIAGNOSTIC PROCEDURES AND TESTS AND LAB SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 85 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8A – OUTPATIENT DIAGNOSTIC PROCEDURES AND TESTS AND LAB SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 86 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8B – OUTPATIENT DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 87 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8B – OUTPATIENT DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 88 of 223

PBP 2011 Data Entry System Screens

SECTION B – 8B – OUTPATIENT DIAGNOSTIC AND THERAPEUTIC RADIOLOGICAL SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 89 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9A – OUTPATIENT HOSPITAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 90 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9A – OUTPATIENT HOSPITAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 91 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9A – OUTPATIENT HOSPITAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 92 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9B – AMBULATORY SURGICAL CENTER SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 93 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9B – AMBULATORY SURGICAL CENTER SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 94 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9B – AMBULATORY SURGICAL CENTER SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 95 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9C – OUTPATIENT SUBSTANCE ABUSE SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 96 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9C – OUTPATIENT SUBSTANCE ABUSE SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 97 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9C – OUTPATIENT SUBSTANCE ABUSE SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 98 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9C – OUTPATIENT SUBSTANCE ABUSE SERVICES – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 99 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9C – OUTPATIENT SUBSTANCE ABUSE SERVICES – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 100 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9D – CARDIAC REHAB SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 101 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9D – CARDIAC REHAB SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 102 of 223

PBP 2011 Data Entry System Screens

SECTION B – 9D – CARDIAC REHAB SERVICES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 103 of 223

PBP 2011 Data Entry System Screens

SECTION B – 10A – AMBULANCE – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 104 of 223

PBP 2011 Data Entry System Screens

SECTION B – 10A – AMBULANCE – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 105 of 223

PBP 2011 Data Entry System Screens

SECTION B – 10B – TRANSPORTATION – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 106 of 223

PBP 2011 Data Entry System Screens

SECTION B – 10B – TRANSPORTATION – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 107 of 223

PBP 2011 Data Entry System Screens

SECTION B – 10B – TRANSPORTATION – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 108 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11A – DME – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 109 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11A – DME – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 110 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11B – PROSTHETICS AND MEDICAL SUPPLIES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 111 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11B – PROSTHETICS AND MEDICAL SUPPLIES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 112 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11B – PROSTHETICS AND MEDICAL SUPPLIES – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 113 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11C – DIABETES MONITORING SUPPLIES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 114 of 223

PBP 2011 Data Entry System Screens

SECTION B – 11C – DIABETES MONITORING SUPPLIES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 115 of 223

PBP 2011 Data Entry System Screens

SECTION B – 12 – RENAL DIALYSIS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 116 of 223

PBP 2011 Data Entry System Screens

SECTION B – 12 – RENAL DIALYSIS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 117 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13A – BLOOD SERVICES – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 118 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13A – BLOOD SERVICES – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 119 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13B – ACUPUNCTURE – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 120 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13B – ACUPUNCTURE – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 121 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13B – ACUPUNCTURE – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 122 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13C – PART-C OTC DRUGS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 123 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13C – PART-C OTC DRUGS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 124 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13C – PART-C OTC DRUGS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 125 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13D – MEAL BENEFIT – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 126 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13D – MEAL BENEFIT – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 127 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13D – MEAL BENEFIT – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 128 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13E – OTHER 1 – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 129 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13E – OTHER 1 – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 130 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13E – OTHER 1 – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 131 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13F – OTHER 2 – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 132 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13F – OTHER 2 – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 133 of 223

PBP 2011 Data Entry System Screens

SECTION B – 13F – OTHER 2 – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 134 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14A – HEALTH EDUCATION AND WELLNESS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 135 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14A – HEALTH EDUCATION AND WELLNESS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 136 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14A – HEALTH EDUCATION AND WELLNESS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 137 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14A – HEALTH EDUCATION AND WELLNESS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 138 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14A – HEALTH EDUCATION AND WELLNESS – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 139 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14B – IMMUNIZATIONS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 140 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14B – IMMUNIZATIONS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 141 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14B – IMMUNIZATIONS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 142 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14C –PHYSICAL EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 143 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14C – PHYSICAL EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 144 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14C – PHYSICAL EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 145 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14C –PHYSICAL EXAMS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 146 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14D – PAP/PELVIC EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 147 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14D – PAP/PELVIC EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 148 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14D – PAP/PELVIC EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 149 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14D – PAP/PELVIC EXAMS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 150 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14D – PAP/PELVIC EXAMS – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 151 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14E – PROSTATE SCREENING – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 152 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14E – PROSTATE SCREENING – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 153 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14E – PROSTATE SCREENING – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 154 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14E – PROSTATE SCREENING – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 155 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14F – COLORECTAL SCREENING – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 156 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14F – COLORECTAL SCREENING – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 157 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14F – COLORECTAL SCREENING – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 158 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14F – COLORECTAL SCREENING – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 159 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14F – COLORECTAL SCREENING – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 160 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14G – BONE MASS MEASUREMENT – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 161 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14G – BONE MASS MEASUREMENT – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 162 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14G – BONE MASS MEASUREMENT – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 163 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14H – MAMMOGRAPHY – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 164 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14H – MAMMOGRAPHY – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 165 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14H – MAMMOGRAPHY – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 166 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14H – MAMMOGRAPHY – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 167 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14I – DIABETES MONITORING – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 168 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14I – DIABETES MONITORING – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 169 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14I – DIABETES MONITORING – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 170 of 223

PBP 2011 Data Entry System Screens

SECTION B – 14J – NUTRITION THERAPY FOR DIABETES AND RENAL DISEASE – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 171 of 223

PBP 2011 Data Entry System Screens

SECTION B –14J – NUTRITION THERAPY FOR DIABETES AND RENAL DISEASE – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 172 of 223

PBP 2011 Data Entry System Screens

SECTION B –14J – NUTRITION THERAPY FOR DIABETES AND RENAL DISEASE – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 173 of 223

PBP 2011 Data Entry System Screens

SECTION B – 15 – MEDICARE PART B PRESCRIPTION DRUGS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 174 of 223

PBP 2011 Data Entry System Screens

SECTION B – 15 – MEDICARE PART B PRESCRIPTION DRUGS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 175 of 223

PBP 2011 Data Entry System Screens

B – 15 – MEDICARE PART B PRESCRIPTION DRUGS – NOTES (OPTIONAL)

Appendix C

CY 2011 PBP PRA Package – Section B

Page 176 of 223

PBP 2011 Data Entry System Screens

B – 15 – PART C HOME INFUSION DRUGS

Appendix C

CY 2011 PBP PRA Package – Section B

Page 177 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 178 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 179 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 180 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 181 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 182 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16A – PREVENTIVE DENTAL – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 183 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 184 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 185 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 186 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 187 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 188 of 223

PBP 2011 Data Entry System Screens

SECTION B – 16B – COMPREHENSIVE DENTAL – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 189 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17A – EYE EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 190 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17A – EYE EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 191 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17A – EYE EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 192 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 193 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 194 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 195 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 196 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 197 of 223

PBP 2011 Data Entry System Screens

SECTION B – 17B – EYE WEAR – BASE 6 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 198 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18A – HEARING EXAMS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 199 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18A – HEARING EXAMS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 200 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18A – HEARING EXAMS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 201 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18A – HEARING EXAMS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 202 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18B – HEARING AIDS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 203 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18B – HEARING AIDS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 204 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18B – HEARING AIDS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 205 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18B – HEARING AIDS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 206 of 223

PBP 2011 Data Entry System Screens

SECTION B – 18B – HEARING AIDS – BASE 5 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 207 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 208 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 209 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – BASE 3 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 210 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – BASE 4 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 211 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – NOTES (OPTIONAL)

Appendix C

CY 2011 PBP PRA Package – Section B

Page 212 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 1- BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 213 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 1- BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 214 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 2- BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 215 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 2- BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 216 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 3- BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 217 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 3- BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 218 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 4- BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 219 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 4- BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 220 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 5- BASE 1 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 221 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – OUTPNT DRUGS – GROUP 5- BASE 2 SCREEN

Appendix C

CY 2011 PBP PRA Package – Section B

Page 222 of 223

PBP 2011 Data Entry System Screens

SECTION B – 20 – HOME INFUSION DRUGS

Appendix C

CY 2011 PBP PRA Package – Section B

Page 223 of 223