Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Medicare Current Beneficiary Survey (MCBS)

Attachment 4 Questionnaire Comprehensive Format Section by Section CPS_07.01.0000

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0568 can be found here:
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BOX CPSBEG

BOX CPSBEG

2:02:34 PM Wednesday, May 27, 2009

Page Order # :

10


Page 1 of 151


BOX CPSBEG
BOX INSTRUCTIONS
( CPS1010 )	

CPS REASON HAS ALREADY BEEN ASSIGNED TO ALL CHARGE
BUNDLES ENTERED IN THE PAST 2 ROUNDS THAT HAVE MISSING
CHARGE DATA.
CPS REASON 1 = NO STATEMENT CHARGE BUNDLE, SP EXPECTED TO
RECEIVE A STATEMENT
CPS REASON 2 = NO STATEMENT CHARGE BUNDLE, NO PAYMENTS
HAVE BEEN MADE.
CPS REASON 3 = STATEMENT CHARGE BUNDLE, NO PAYMENTS HAVE
BEEN MADE.
CPS REASON 4 = NO STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS
LESS THAN TOTAL CHARGE.
CPS REASON 5 = STATEMENT CHARGE BUNDLE, TOTAL PAYMENTS
LESS THAN AMOUNT REMAINING.
CPS REASON 6 = SP MADE PAYMENT AND EXPECTED
REIMBURSEMENT.
CPS REASON 7 = SP MADE PAYMENT AND DID NOT KNOW IF
REIMBURSEMENT EXPECTED.
CPS REASON 8 = NO STATEMENT CHARGE BUNDLE ENTERED AT
HOME OFFICE, SP EXPECTED TO RECEIVE A STATEMENT.
IN CPS, WE WILL REVIEW THIS LIST OF CHARGE BUNDLES AND WILL
EXCLUDE ANY CHARGE BUNDLE WITH AN EVENT THAT HAS BEEN
DELETED, HAS BEEN LINKED TO A STATEMENT CHARGE BUNDLE IN
THE CURRENT ROUND, OR WAS ASKED ABOUT IN THE CURRENT
ROUND NO STATEMENT SECTION AND THE SP IS NOT EXPECTING TO
RECEIVE A STATEMENT FOR THIS EVENT.
THE REMAINING LIST OF CHARGE BUNDLES WILL BE ELIGIBLE FOR
CPS. WE WILL SORT THIS LIST BY CPS REASON. WE WILL THEN
COLLECT CPS DETAILS FOR THE FIRST CHARGE BUNDLE IN THIS LIST.
AFTER COMPLETING THE CPS DETAILS FOR THIS CHARGE BUNDLE,
WE WILL RETURN TO BOX CPSBEG. BECAUSE THE DATA THAT
DETERMINES IF A CHARGE BUNDLE IS ELIGIBLE FOR CPS MAY BE
UPDATED WHILE ADMINISTERING CPS, THE LIST OF ELIGIBLE CHARGE
BUNDLES WILL BE RECREATED AT THE BEGINNING OF EACH LOOP IN
CPS .
IF AT LEAST ONE CHARGE BUNDLE HAS BEEN IDENTIFIED AS ELIGIBLE
FOR CPS, GO TO CPS1_IN - NAVIGATOR ( CPS1015 ).
ELSE GO TO BOX CPSEND - (CPS1785 ).

ASSIGNMENTS
Each time BOX CPSBEG is executed, a new list of charge bundles eligible for CPS will be

generated. To generate list of charge bundles that will be asked about in CPS, execute the

following steps:


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Page 2 of 151

BOX CPSBEG
STEP 1:

Include only charge bundles flagged as expected to receive CPS in the current round:

If (COST.CPROUND = current round and COST.CPREASN ^= empty and

COST.EXCPSFLG ^= 2/NotIndicated), go to STEP 2 for this charge bundle. (Note:

COST.EXCPSFLG may be set to 2/NotIndicated in an earlier execution of BOX CPSBEG.)

Else repeat STEP 1 for next charge bundle.

STEP 2:

Eliminate any Charge Bundle if at least one event linked to the charge bundle is also

((linked to a current round Statement COST) or (linked to a current round No Statement

COST and SP does not expect to receive a statement or event was entered in error) or

(event was flagged as deleted in the current round)).

Description:

1) If the SP enters a new statement in the current round ST section, the SP can then link

events to the statement. Each event will then be linked to a current round COST where 

COST.COSTTYPE = 'ST'. If there is a CPS charge bundle linked to at least one of these

events, the CPS charge bundle linked to this event will not get asked about in the CPS

section.

2) If the SP reports an ongoing EVNT, such as home health event, PM event, OM

purchase, or OM rental, in the current round and does not link the event to a statement, we 

will probe for charge data in the NS section. Each event will then be linked to a current

round COST where COST.COSTTYPE = 'NS'. If the SP is not expecting to receive a

statement and event was not entered in error (i.e. COST.EXMCMAIL ^= 1 and

COST.EXMCMAIL ^= 3), we will collect charge data in NS. If there is a CPS charge

bundle linked to at least one of these events where we collect charge data in NS, the CPS

charge bundle linked to this event will not get asked about in the CPS section.

The exception to this are events that do not get asked COST.EXMCMAIL in NS (see BOX

NS1 specs). For these events where COST.COSTTYPE = 'NS' and COST.EXMCMAIL =

NULL, if there is a CPS charge bundle linked to at least one of these events where we

collect charge data in NS, the CPS charge bundle linked to this event will still get asked

about in the CPS section.

3) If in HHS, when probing about HH providers from the previous round, the SP can report

that the HH event was entered in error. If there is a CPS charge bundle linked to at least 

one of these HH provider events, the CPS charge bundle linked to this event will not get

asked about in the CPS section.

4) There are a few places in the instrument where the SP can report that an event was

entered in error. Per specifications, we set EVNT.EVNTDFLG = 1/Yes. If there is a CPS

charge bundle linked to at least one of these deleted events, the CPS charge bundle linked

to this event will not get asked about in the CPS section. 

CONDITION:

If (Event linked to charge bundle is also linked to a second charge bundle where

((COST.COSTRNDC = current round) and ((COST.COSTTYPE = 'ST') or 

(COST.COSTTYPE = 'NS' and COST.EXMCMAIL ^= 1/Yes and COST.EXMCMAIL ^=

3/EventEnteredInError)))), OR

If (Event linked to charge bundle has (EVNT.EVNTTYPE = ‘HF’ or ‘HP’) and there is a
HERO where HERO.HEROEVNT = EVNT.EVNTNUM and (HERO.PROFPROB =
3/HomeHealthEnteredInError or HERO.FRNDPROB = 3/HomeHealthEnteredInError)), OR
If (Event linked to charge bundle has EVNT.EVNTDFLG = 1/Yes), then do;
Set COST.EXCPSFLG = 2/NotIndicated.

Set COST.EXMCRND = current round.

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Page 3 of 151

BOX CPSBEG
End;

(NOTE: By setting COST.EXCPSFLG = 2/NotIndicated, this will eliminate this charge

bundle as eligible for CPS in Step 1 the next time BOX CPSBEG is executed.)

If this charge bundle COST.EXCPSFLG ^= 2/NotIndicated, add Charge Bundle to list of 

eligible Charge Bundles for CPS.

If another charge bundle, return to STEP 1 for next charge bundle.

Else go to STEP 3.

STEP 3:

If no charge bundles flagged as eligible at STEP2, go to BOX CPEND.

Else sort all charge bundles flagged at STEP 2 by COST.CPREASN in the following order:

COST.CPREASN = 1

COST.CPREASN = 8

COST.CPREASN = 2

COST.CPREASN = 3

COST.CPREASN = 4

COST.CPREASN = 5

COST.CPREASN = 6

COST.CPREASN = 7

Go to STEP 4.

STEP 4:

We will only collect details for the first Charge Bundle in the list sorted at STEP 3 in this

loop. Once the detail loop is complete, the route will return to BOX CPSBEG to generate a

new list of charge bundles eligible for CPS. The purpose of this is to exclude any charge 

bundles which were flagged for CPS, but are no longer eligble because an event has been

linked to a new current round charge bundle.

For the first Charge Bundle in the list sorted at STEP 3, create a current round CORO. A

current round CORO may have already been generated if CPS REASON 1 or 8.

CORO Key = CORO.COROBASE + CORO.COROCOST + CORO.CORORND

For the first Charge Bundle in the list sorted at STEP 3 only, set the following fields:

CORO.COROCOST

CORO.CORORND

CORO.COROTYPE

CORO.CPSREASN

CORO.RECDSTAT

See detailed instructions below.

GO TO CPS1_IN for first Charge Bundle in the list sorted at STEP 3.

COROCOST	

For charge bundle eligible for CPS, if current round 

CORO does not exist, create CORO where
CORO.COROCOST = COST.COSTNUM.

CORORND	

For charge bundle eligible for CPS, if current round
CORO does not exist, create CORO where
CORO.CORORND = current round.

COROTYPE	

For charge bundle eligible for CPS, set
CORO.COROTYPE = 3/CPS.

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Page 4 of 151

BOX CPSBEG
CPSREASN	

For charge bundle eligible for CPS, set
CORO.CPSREASN = COST.CPREASON

RECDSTAT	

For charge bundle eligible for CPS, if current round
CORO exists and CORO.RECDSTAT =
1/StatementReceivedAndAvailable, update
CORO.RECDSTAT = empty.

EXCPSFLG	

For all Charge Bundles excluded at STEP 2, set
COST.EXCPSFLG = 2/NotIndicated.

EXMCRND	

For all Charge Bundles at STEP 2 excluded at STEP
2, set
COST.EXMCRND = Current Round.

TECHNICAL NOTES
275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

DESIGN NOTES

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Page 5 of 151

CPS1_IN

CPS1_IN

Page Order # :

Design Screen Type:	

Instance Navigator

Fields:	

Field 1:

NAVIGATOR

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
No
No

15

Roster Name:
Roster Type:
Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Ask CPS details for charge bundle identified as eligible for CPS at
BOX CPSBEG. Only one charge bundle will be asked about.
Invoke NO TRAVEL I/N.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:02:35 PM Wednesday, May 27, 2009	

Page 6 of 151

CPS1_IN
NAVIGATOR

Field1:
Cheshire Name:

( CPS1015 )

N/A

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS1 - CPSINT ( CPS1020 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview
BOX CPSBEG - (CPS1010 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:02:37 PM Wednesday, May 27, 2009

Page 7 of 151

CPS1

CPS1

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

CPSINT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If CPS1 - CPSINT has not been asked in the current round, display
1st sentence "Next, I will ask about..."
Else do not display.
TOTAL NUMBER OF CPS EVENTS = Display total number of
events in list generated at BOX CPSBEG.
If CPS1 - CPSINT has already been asked in the current round,
display "REMAINING".
Else do not display.
If CPS1 - CPSINT has not been asked in the current round, display
"First".
Else display "Next".

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

2:02:38 PM Wednesday, May 27, 2009

EVENT: (CHARGE BUNDLE EVENT)

Page 8 of 151

CPS1
(CHARGE BUNDLE EVENT) (etc.)
Int. Instr I:
(Next, I will ask about some medical care that we talked about in a
previous interview.)

Question Text:

THERE ARE (TOTAL NUMBER OF CPS EVENTS) EVENTS OR
BUNDLES (REMAINING) FOR SUMMARY.
(First/Next), I want to ask about [READ EVENT(S) ABOVE].
Int. Instr II:

INPUT FIELDS / ROUTING

CPSINT

Field1:
Cheshire Name:

( CPS1020 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS1A - (CPS1030 )

English text: CONTINUE
Attribute
Empty

Route
BOX CPS1A - (CPS1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

2:02:40 PM Wednesday, May 27, 2009

Page 9 of 151

CPS1

DESIGN NOTES

2:02:40 PM Wednesday, May 27, 2009

Page 10 of 151


BOX CPS1A

BOX CPS1A

Page Order # :

30

BOX INSTRUCTIONS
( CPS1030 )

IF CPS REASON = 1 OR 8, GO TO CPS2 - RECDSTAT ( CPS1040 ).
ELSE GO TO BOX CPS1B - (CPS1035 ).

ASSIGNMENTS

TECHNICAL NOTES
275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

DESIGN NOTES

2:02:40 PM Wednesday, May 27, 2009

Page 11 of 151

BOX CPS1B

BOX CPS1B

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Page Order # :

40


Page 12 of 151


BOX CPS1B
BOX INSTRUCTIONS
( CPS1035 )	

CREATE SOURCE OF PAYMENT ROSTER .
IF CPS REASON = 2, 6 OR 7, GO TO BOX CPS2 - (CPS1050 ).
ELSE IF CPS REASON = 3, GO TO CPS11 - CPTCHGPAID2 ( CPS1250 ).
ELSE IF CPS REASON = 4, GO TO CPS13 - CPTCHGPAID3 ( CPS1300 ).
ELSE IF CPS REASON = 5, GO TO CPS15 - CPTCHGPAID4 ( CPS1350 ).

ASSIGNMENTS
TSOP table is loaded once for each new Charge Bundle being asked about in CPS.
TSOP key = TSOP.TSOPBASE + TSOP.TSOPNUM.
Before proceeding, delete all TSOP records and load all eligible Sources of Payments:
1st Record:
Always store SP/FAMILY:
TSOP.TSOPTEXT = "SP/FAMILY"
TSOP.TSOPTYPE = 1/SPFamily
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

2nd Record:
Always store Provider discount:
TSOP.TSOPTEXT = "PROVIDER DISCOUNT/COURTESY"
TSOP.TSOPTYPE = 2/ProvDiscount
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

3rd Record:
Always store Medicare:
TSOP.TSOPTEXT = "MEDICARE".
TSOP.TSOPTYPE = 6/Medicare
TSOP.TSOPPLAN = '01'
TSOP.TSOPPTYP = 1/Medicare
TSOP.TSOPDISP = "(MCAR)".
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE and
PAYM.PAYMPLAN = TSOP.TSOPPLAN, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Next, store all Medicare HMOs SP was covered by during the survey reference period (not
flagged as deleted).

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Page 13 of 151

BOX CPS1B
If there is a PLAN with PLAN.PLANTYPE = 5/MHMO and a PLRO where PLRO.PLRORND
>= (current round -2), store MHMO plan:
TSOP.TSOPTEXT = PLAN.PLNAME
TSOP.TSOPTYPE = 8/MHMO
TSOP.TSOPPLAN = PLAN.PLANNUM of MHMO plan
TSOP.TSOPPTYP = PLAN.PLANTYPE of MHMO plan
TSOP.TSOPDISP = "(MHMO)".
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE and
PAYM.PAYMPLAN = TSOP.TSOPPLAN, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Repeat for all MHMO plans.

Next, store VA if elibigle.

If (INTTYPE=8/ExitInterviewHadPrev and previous round HRND.VACOVER=1/Yes) or

(INTTYPE ^= 8/ExitInterviewHadPrev and current round HRND.VACOVER=1/Yes), store

VA:

TSOP.TSOPTEXT = "V.A. - DEPT. OF VETERANS AFFAIRS"

TSOP.TSOPTYPE = 5/VA.

Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Next, store MEDICARE SUBSIDY:
TSOP.TSOPTEXT = "MEDICARE SUBSIDY"
TSOP.TSOPTYPE = 11/MedicareSubsidy.
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Next, store EXTRA HELP:
TSOP.TSOPTEXT = "EXTRA HELP"
TSOP.TSOPTYPE = 12/ExtraHelp.
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Next, store Medicaid, Public, Private, and Tricare plans SP was covered by during the

survey reference period (not flagged as deleted).

If there is a PLAN with (PLAN.PLANTYPE = 2/Medicaid, 3/PublicPlan, 4/PrivatePlan, 

6/Tricare or 7/MPDP) and a PLRO where PLRO.PLRORND >= (current round -2), store 

Plan:

TSOP.TSOPTEXT =
If PLAN.PLANTYPE = 2/Medicaid, TSOP.TSOPTEXT = 'MEDICAID/MEDICAID HMO';
Else if PLAN.PLANTYPE = 6/Tricare, TSOP.TSOPTEXT = "TRICARE".
Else TSOP.TSOPTEXT = PLAN.PLNAME;
If PLAN.PLANTYPE = 7/MPDP, set TSOP.TSOPTYPE = 10/MedicarePartD.

Else set TSOP.TSOPTYPE = 3/PlanNotMHMO

2:02:40 PM Wednesday, May 27, 2009

Page 14 of 151

BOX CPS1B
TSOP.TSOPPLAN = PLAN.PLANNUM of HI plan.

TSOP.TSOPPTYP = PLAN.PLANTYPE of HI plan.

TSOP.TSOPDISP =

If PLAN.PLANTYPE = 2/Medicaid, TSOP.TSOPDISP = "(MCAD)".

Else if PLAN.PLANTYPE = 3/PublicPlan, TSOP.TSOPDISP = "(PUBL)".

Else if PLAN.PLANTYPE = 4/PrivatePlan, TSOP.TSOPDISP = "(PRIV)".

Else if PLAN.PLANTYPE = 6/Tricare, TSOP.TSOPDISP = "(TRIC)".

Else if PLAN.PLANTYPE = 7/MPDP, TSOP.TSOPDISP = "(MPDP)".

Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE and
PAYM.PAYMPLAN = TSOP.TSOPPLAN, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Repeat for all Medicaid, Public, Private, Tricare and Medicare Prescription Drug plans.

Next, store Discount Membership Plans SP was covered by during the current round:

If there is a DMEM and a DMRO where DMRO.DMRORND = current round, store Discount 

Membership plan:

TSOP.TSOPTEXT = DMEM.DMNAMEX

TSOP.TSOPTYPE = 9/DM

TSOP.TSOPDMEM = DMEM.DMEMNUM

Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE and
PAYM.PAYMDMEM = TSOP.TSOPDMEM, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Repeat for all DMEMs.
Next, store all Other Sources of Payments (not flagged as deleted).
Store OSOP:
TSOP.TSOPTEXT = OSOP.OSOPTEXT
TSOP.TSOPTYPE = 4/OSOP
TSOP.TSOPOSOP = OSOP.OSOPNUM
TSOP.TSOPDISP = "(OTHER)".
Check to see if any Payments of this type have been made for this charge bundle:
If there is a PAYM where PAYM.PAYMCOST = charge bundle COST.COSTNUM
and PAYM.PAYMDFLG ^= 1/Yes and PAYM.PAYMTYPE = TSOP.TSOPTYPE and
PAYM.PAYMOSOP = TSOP.TSOPOSOP, set:
TSOP.TSOPPAYM = PAYM.PAYMCOST + PAYM.PAYMNUM.

TSOP.TSOPAMT = PAYM.PAYMAMT.

Repeat for all OSOPs.
TSOPNUM	

Beginning with 01, create TSOP where
TSOP.TSOPNUM = highest TSOP.TSOPNUM + 01.

TSOPTEXT	

Set TSOP.TSOPTEXT as specified above.

TSOPTYPE	

Set TSOP.TSOPTYPE as specified above.

LOADFLAG	

Set TSOP.LOADFLAG = 1/Yes.

TSOPPTYP	

If SOP is a Health Insurance plan, set
TSOP.TSOPPTYP = PLAN.PLANTYPE.

TSOPPLAN	

If SOP is a Health Insurance plan, set
TSOP.TSOPPLAN = PLAN.PLANNUM.

2:02:40 PM Wednesday, May 27, 2009	

Page 15 of 151

BOX CPS1B
TSOPOSOP	

If SOP is an Other Source of Payment, set
TSOP.TSOPOSOP = OSOP.OSOPNUM.

TSOPDISP	

Set TSOP.TSOPDISP as specified above.

TSOPPAYM	

If PAYM.PAYMAMT exists and is > 0 for this charge
bundle, set TSOP.TSOPPAYM = PAYM.PAYMCOST
+ PAYM.PAYMNUM.

TSOPAMT	

If PAYM.PAYMAMT exists and is > 0 for this charge
bundle, set TSOP.TSOPAMT = PAYM.PAYMAMT.

TSOPDMEM	

If SOP is a Discount Membership plan, set
TSOP.TSOPDMEM = DMEM.DMEMNUM.

TECHNICAL NOTES
52

DeletedPlans	

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

53

PlanTypes	

Medicare: PLANTYPE=1/Medicare.
Medicaid: PLANTYPE=2/Medicaid.
Medicare Advantage: PLANTYPE=5/MHMO.
Tricare: PLANTYPE=6/Tricare.
Public: PLANTYPE=3/PublicPlan.
Private: PLANTYPE=4/PrivatePlan.
Medicare Prescription Drug: PLANTYPE=7/MPDP.

252

DeletedOSOPs	

Deleted OSOPs that are not valid for displays or checks =
Any OSOP where (OSOP.OSOPHIDE=1/Yes or
OSOP.LOSEOSFG ^=EMPTY) is a deleted OSOP.

117

DeletedDM	

Deleted Discount Membership plans that are not valid for
displays or checks =
Any DMEM where (DMEM.LOSEDMFG ^= EMPTY) is a
deleted DM.

38

DMCurrentRnd	

SP reported having a Discount Membership plan anytime
during the current round =
There is a DMEM and DMRO where
(DMRO.DMRODMEM = DMEM.DMEMNUM and
DMRO.DMRORND = current round and DMRO.DMHAVE
= 1/Yes).
Exclude Deleted DM's. See T.N. 117.

DESIGN NOTES

2:02:40 PM Wednesday, May 27, 2009	

Page 16 of 151

CPS2

CPS2

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

RECDSTAT

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

50

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If CPS Reason = 1, display 1st sentence "At the last interview…" .
Else do not display.
If CPS Reason = 1, display "since then" .

Else display "since the last interview".

If SP was covered by TRICARE and any other insurance plan

besides Medicare during the current round, display "Medicare,

Insurance, and TRICARE".

Else if SP was covered by TRICARE and is not covered by any

other insurance plan besides Medicare during the current round,

display "Medicare and TRICARE"

Else if SP was not covered by TRICARE and was covered by any

other insurance plan besides Medicare during the current round,

display "Medicare and Insurance".

Else display "Medicare".

If a PM event is linked to the charge bundle and ((SP has reported a

Medicare Prescription Drug Plan) or (SP has reported having a

Medicare Managed Care plan with RX coverage in the past year)),

display "[PROBE IF NECESSARY: Please…]".
Else do not display sentence.

Multi Field display:

Roster/Grid Instructions:

2:02:42 PM Wednesday, May 27, 2009	

Page 17 of 151

CPS2
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

[At the last interview, [you were/(SP) was] expecting to receive a
statement or paper from (Medicare, Insurance, and
TRICARE/Medicare and TRICARE/Medicare and
Insurance/Medicare).] [Have you/Has (SP)] received a statement for
the [READ EVENT(S) ABOVE] (since then/since the last interview)?
([PROBE IF NECESSARY: Please include any statements received
about (your/(SP's)] Medicare prescription drug benefit.])

Int. Instr II:
INPUT FIELDS / ROUTING

2:02:45 PM Wednesday, May 27, 2009

Page 18 of 151

CPS2
( CPS1040 )

RECDSTAT

Field1:
Cheshire Name:

CORO.RECDSTAT

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TRecdstat

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 StatementReceivedAndAvailable
2
3

Route
ST4 - MATCHST ( STQ1110 )

English text: STATEMENT RECEIVED AND AVAILABLE
StatementReceivedNotAvailable
BOX NS4A - (NSQ1127 )
English text: STATEMENT RECEIVED, NOT AVAILABLE
StatementNotReceived
BOX NS4A - (NSQ1127 )
English text: STATEMENT NOT RECEIVED

Attribute
Don't know

Route
BOX NS4A - (NSQ1127 )

Refusal

BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
275

CPSReason

2:02:48 PM Wednesday, May 27, 2009

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
Page 19 of 151

CPS2
= 7/SPPaidREIMDK

= 8/NSExpectStatementDP

52

DeletedPlans

Deleted plans that are not valid for displays or checks =

Any PLAN where (PLAN.PLANDFLG=1/Yes or 

PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or 

PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.


258	

TricarePlan

SP covered by TRICARE during the current round =

There is a PLAN where PLAN.PLANTYPE = 6/Tricare

& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM & 

PLRO.PLRORND = current round & PLRO.COVTIME^=

empty).

Exclude Deleted Plans. See T.N. 52.


259	

InsurancePlan

SP covered by Insurance plan other than Medicare

during current round =

PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or 

4/PrivatePlan) & PLRO where

(PLROPLAN=PLAN.PLANNUM & PLRORND=current

round & COVTIME^=empty).

Exclude Deleted Plans. See T.N. 52.


369	

SPReportedMPDP

SP reported an Medicare prescription drug plan =

There is a PLAN where PLAN.PLANTYPE = 7/MPDP.

Exclude Deleted Plans. See T.N. 52.


370	

MHMORxPastYear

SP report Medicare Managed Care plan (Medicare

Advantage plan) with RX coverage in past year=

There is a PLAN where PLANTYPE = 5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND>=(current

round - 2) & MHMORX=1/Yes).

Exclude Deleted Plans. See T.N. 52.


371	

PMLinkedChargeBundl
e

There is a PM Event linked to charge bundle =

For this COST, there is an XCEV where 

(XCEV.XCEVCOST=COST.COSTNUM & 

XCEV.DELLINK^=1/Yes &

XCEV.XCEVEVNT=EVNT.EVNTNUM for EVNT where

(EVNT.EVNTTYPE=PM & EVNT.EVNTDFLG^=1/Yes)).


DESIGN NOTES

2:02:48 PM Wednesday, May 27, 2009	

Page 20 of 151

BOX CPS2

BOX CPS2

60

Page Order # :

BOX INSTRUCTIONS
( CPS1050 )	

IF TOTAL CHARGE = DK OR RF AND ((ASKING ABOUT A NO STATEMENT
CHARGE BUNDLE) OR (ASKING ABOUT A STATEMENT CHARGE BUNDLE
AND TYPE OF STATEMENT IS NOT A MEDICARE PRESCRIPTION DRUG
BENEFIT STATEMENT)), GO TO CPS3 - KNOWTOTL ( CPS1110 ).
ELSE IF CPS REASON = 2, GO TO CPS9 - CPTCHGPAID1 ( CPS1210 ).
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT ( CPS1450
).

ASSIGNMENTS

TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

366

STChargeBundle

Charge Bundle is a Statement Charge Bundle =
COST.COSTTYPE = 1/ST.

367

NSChargeBundle

Charge Bundle is a No Statement Charge Bundle =
COST.COSTTYPE = 2/NS.

368

MPDPBenefitStatement

Statement Charge Bundle is a Medicare Prescription
Drug Benefit Statement =
COST.STATTYPE = 8/MPDPBenefit.

DESIGN NOTES

2:02:48 PM Wednesday, May 27, 2009	

Page 21 of 151

CPS3

CPS3

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

KNOWTOTL

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

70

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

If Total charge was collected for charge bundle, display "total
charge".
Else if CoPayment was collected for charge bundle, display
"copayment amount".

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:	

Do you happen to know the (total charge/copayment amount) for the
[READ EVENT(S) ABOVE]?

Int. Instr II:
INPUT FIELDS / ROUTING

2:02:50 PM Wednesday, May 27, 2009	

Page 22 of 151

CPS3
KNOWTOTL

Field1:
Cheshire Name:

( CPS1110 )

CORO.KNOWTOTL

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoRF

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 Yes
2

Route
BOX CPS3 - (CPS1120 )

English text: YES
No

BOX CPS3 - (CPS1120 )

English text: NO
Attribute
Refusal

Route
BOX CPS3 - (CPS1120 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
270

TotalCharge	

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

2:02:53 PM Wednesday, May 27, 2009	

Page 23 of 151

CPS3
269

TotalChargeCollected

Total Charge was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round &
CORO.TOTALTYP=1/TotalCharge).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

268

CoPaymentCollected

CoPayment was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST = COST.COSTNUM &
CORO.CORORND = current round & CORO.TOTALTYP
= 2/CoPayment).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

DESIGN NOTES

2:02:53 PM Wednesday, May 27, 2009

Page 24 of 151

BOX CPS3

BOX CPS3

2:02:53 PM Wednesday, May 27, 2009

Page Order # :

80


Page 25 of 151


BOX CPS3
BOX INSTRUCTIONS
( CPS1120 )	

IF CPS3 - KNOWTOTL = 1/Yes AND (TOTAL CHARGE WAS COLLECTED
FOR CHARGE BUNDLE), GO TO CPS4 - TOTALCHG ( CPS1130 ).
ELSE IF CPS3 - KNOWTOTL = 1/Yes AND (COPAYMENT WAS
COLLECTED FOR CHARGE BUNDLE), GO TO CPS5 - TOTALCHG (
CPS1140 ).
ELSE IF (CPS3 - KNOWTOTL = 2/No OR RF) AND (CPS REASON = 2), GO
TO CPS9 - CPTCHGPAID1 ( CPS1210 ).
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT ( CPS1450
).

ASSIGNMENTS

TECHNICAL NOTES
275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

269

TotalChargeCollected

Total Charge was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round &
CORO.TOTALTYP=1/TotalCharge).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

268

CoPaymentCollected

CoPayment was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST = COST.COSTNUM &
CORO.CORORND = current round & CORO.TOTALTYP
= 2/CoPayment).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

DESIGN NOTES

2:02:53 PM Wednesday, May 27, 2009	

Page 26 of 151

CPS4

CPS4

Page Order # :

Design Screen Type:	

Numeric

Fields:	

Field 1:

TOTALCHG

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

90

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "[that is, the amount billed]" in brackets.


Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:	

Including any amounts that may be paid by Medicare or anyone else,
what was the total charge [that is, the amount billed]?

Int. Instr II:	

ENTER 0 IF NO CHARGE FOR THE EVENT.

INPUT FIELDS / ROUTING

2:02:54 PM Wednesday, May 27, 2009	

Page 27 of 151

CPS4
TOTALCHG

Field1:
Cheshire Name:

( CPS1130 )

CORO.TOTALCHG

Item Text display:
Item Text:
Label:
Label Position:

TOTAL AMOUNT:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TAmt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX CPS5A - (CPS1150 )

Refusal

BOX CPS5A - (CPS1150 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99

Route
BOX CPS5A - (CPS1150 )

BACKGROUND VARIABLE ASSIGNMENTS
TOTALAMT

COST.TOTALAMT = CPS4 - TOTALCHG.

TOTALTYP

CORO.TOTALTYP = 1/TotalCharge.

SOFT EDIT CHECKS
TOTALCHG = 4.99 - 20,000, RF.

If not true, display message "UNLIKELY RESPONSE. PLEASE

VERIFY".

HARD EDIT CHECKS
TOTALCHG ^= DK.

If not true, display message "INVALID ENTRY. PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

2:02:55 PM Wednesday, May 27, 2009

Page 28 of 151

CPS5

CPS5

Page Order # :

Design Screen Type:

Numeric

Fields:

Field 1:

TOTALCHG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

100

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

What was the copayment amount for the [READ EVENT(S) ABOVE]?
[EXPLAIN IF NECESSARY: Managed care plans commonly charge
a fixed amount, or copayment, for health services provided. For
example, the person may pay $10 for each office visit and $5 for
each drug prescription.]

Int. Instr II:

2:02:56 PM Wednesday, May 27, 2009

ENTER 0 IF NO COPAYMENT FOR THE EVENT.

Page 29 of 151

CPS5
INPUT FIELDS / ROUTING
TOTALCHG

Field1:
Cheshire Name:

( CPS1140 )

CORO.TOTALCHG

Item Text display:
Item Text:
Label:
Label Position:

COPAY AMOUNT:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TAmt
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX CPS5A - (CPS1150 )

Refusal

BOX CPS5A - (CPS1150 )

FieldSize:
Min Value:
Max Value:
Mask:

0
999999.99

Route
BOX CPS5A - (CPS1150 )

BACKGROUND VARIABLE ASSIGNMENTS
TOTALAMT

COST.TOTALAMT = CPS5 - TOTALCHG.

TOTALTYP

CORO.TOTALTYP = 2/CoPayment.

SOFT EDIT CHECKS
TOTALCHG = 2.00 - 50.00, RF.

If not true, display message "UNLIKELY RESPONSE. PLEASE

VERIFY".

HARD EDIT CHECKS
TOTALCHG ^= DK.

If not true, display message "INVALID ENTRY. PLEASE REENTER."

TECHNICAL NOTES

DESIGN NOTES

2:02:57 PM Wednesday, May 27, 2009

Page 30 of 151

BOX CPS5A

BOX CPS5A

Page Order # :

110

BOX INSTRUCTIONS
( CPS1150 )	

IF (CPS REASON = 2) AND (TOTAL CHARGE = 0) AND (SP IS CURRENTLY
COVERED BY MEDICAID), GO TO BOX CPS32 - (CPS1770 ).
ELSE IF (CPS REASON = 6 OR 7) AND (TOTAL CHARGE = RF), GO TO
CPS19 - CPSREIMINT ( CPS1450 ).
ELSE GO TO BOX CPS5B - (CPS1160 ).

ASSIGNMENTS

TECHNICAL NOTES
275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

276

CurrentMedicaid

SP currently covered by Medicaid =
There is a PLAN where PLANTYPE=2/Medicaid & PLRO
where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round & (PLRO.COVTIME =
1/WholeTime or PLRO.COVNOW = 1/Yes)).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

2:02:57 PM Wednesday, May 27, 2009	

Page 31 of 151

BOX CPS5B

BOX CPS5B

Page Order # :

120

BOX INSTRUCTIONS
( CPS1160 )	

FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE BUNDLE, IF
EVENT TYPE = 'OM' AND EVENT IS A RENTAL ITEM, GO TO CPS6 MONTHCOV ( CPS1170 ).
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE
BUNDLE, IF (EVENT TYPE = 'PM') OR (EVENT TYPE = 'OM' AND (OTHER
MEDICAL EXPENSE IS OSTOMY SUPPLIES, INCONTINENCE SUPPLIES
OR BANDAGES)), GO TO CPS7 - NUMLINKS ( CPS1180 ).
ELSE FOR THE FIRST/NEXT EVENT INCLUDED IN THE CHARGE
BUNDLE, IF (EVENT WAS ENTERED AS A REPEAT VISIT), GO TO CPS8 RVLINKS ( CPS1190 ).
ELSE GO TO BOX CPS8A - (CPS1195 ).

ASSIGNMENTS

TECHNICAL NOTES
257

EventsInChargeBundle

Events included in this charge bundle =
For this COST, there is an XCEV where
(XCEV.XCEVCOST = COST.COSTNUM &
XCEV.DELLINK ^= 1/Yes & XCEV.XCEVEVNT =
EVNT.EVNTNUM of EVNT linked to charge bundle).

242

OMRental

Other Medical Expense Item is Rented =
EVNT.RENTPROB = 2/Rent.

247

OMPurchases

Other Medical Expense Item is Ostomy Supplies,
Incontinence Supplies, or Bandages =
EVNT.OTHRTYPE = 5/OstomySupplies,
6/IncontinenceSupplies, or 7/Bandages.

135

RepeatVisitEvent

If Event entered as a Repeat Visit =
EVNT.VISTTYPE=2/RepeatVisit.

DESIGN NOTES

2:02:57 PM Wednesday, May 27, 2009	

Page 32 of 151

CPS6

CPS6

Page Order # :

Design Screen Type:	

Numeric

Fields:	

Field 1:

MONTHCOV

Field 2:

MONCOV96

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

Enable Functions:	

130

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:	

Display date and OME ITEM TYPE for the Rental event being asked
about.

Question display:

Multi Field display:

Vertical Alignment

Display all fields at one time.

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:	

TOTAL CHARGE = $(TOTAL CHARGE)
EVENT: (EVENT)

Int. Instr I:
Question Text:	

For the [READ OME ITEM ABOVE], how many months are covered
by the charge for the period of time between (CHARGE BUNDLE
REFERENCE PERIOD)?

Int. Instr II:
INPUT FIELDS / ROUTING
2:02:59 PM Wednesday, May 27, 2009	

Page 33 of 151

CPS6
MONTHCOV

Field1:
Cheshire Name:

( CPS1170 )

XCEV.MONTHCOV

Item Text display:
Item Text:
Label:
Label Position:

MONTHS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TMonthcov
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Empty

Route
CPS6 - MONCOV96 ( CPS1171 )

Don't know

CPS6 - MONCOV96 ( CPS1171 )

Refusal

CPS6 - MONCOV96 ( CPS1171 )

2:03:03 PM Wednesday, May 27, 2009

FieldSize:

Min Value:
Max Value:
Mask:


1

72


Route
CPS6 - MONCOV96 ( CPS1171 )

Page 34 of 151

CPS6
MONCOV96

Field2:
Cheshire Name:

( CPS1171 )

NONE
WE NEED TO TRANSFORM MONCOV96=1 BACK TO
XCEV.MONTHCOV=96.

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Enumerated
TMonCov96
1
No
No

Number Label
1 LessThanOneMonth

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS8A - (CPS1195 )

English text: LESS THAN 1 MONTH
Attribute
Empty

Route
BOX CPS8A - (CPS1195 )

BACKGROUND VARIABLE ASSIGNMENTS
Collect # of months on XCEV:

XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +

XCEV.XCEVEVNT

XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.

XCEV.XCEVEVNT = EVNT.EVNTNUM of OM Rental event being asked about.


SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1

MONTHCOV and MONCOV96 cannot both be EMPTY.

If not true, display message "ENTRY REQUIRED. PLEASE ENTER

NUMBER OF MONTHS OR SELECT "LESS THAN 1 MONTH".

Edit #2

MONTHCOV and MONCOV96 cannot both be FILLED.

If not true, display message "INVALID ENTRY. PLEASE ENTER

NUMBER OF MONTHS OR SELECT "LESS THAN 1 MONTH"."


2:03:06 PM Wednesday, May 27, 2009

Page 35 of 151

CPS6
TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

DESIGN NOTES

2:03:06 PM Wednesday, May 27, 2009

Page 36 of 151

CPS7

CPS7

Page Order # :

Design Screen Type:

Numeric

Fields:

Field 1:

NUMLINKS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

140

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

(MEDICINE NAME/OME ITEM TYPE):

If EVENT TYPE = 'PM', display "(MEDICINE NAME)". .

Else if EVENT TYPE = 'OM', display '(OME ITEM TYPE)".

If Total charge was collected for charge bundle then:

If CPS4 - TOTALCHG = DK or RF, display "were covered by the
total charge".
Else if CPS4-TOTALCHG = 0, display "was there no charge".
Else display "were covered by the (CPS4 - TOTAL CHARGE)".
Display CPS4 - TOTALCHG.
Else if CoPayment was collected for charge bundle then:
If CPS5 - TOTALCHG = DK or RF, display "were covered by the
copayment".
Else if CPS5 - TOTALCHG = 0, display "was there no
copayment".
Else display "were covered by the (CPS5 - COPAYMENT)".
Display CPS5 - TOTALCHG.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

2:03:07 PM Wednesday, May 27, 2009

Page 37 of 151

CPS7
TEXT:
TOTAL CHARGE = $(TOTAL CHARGE)

Context Header:
Int. Instr I:

How many of the times [you/(SP)] obtained (MEDICINE NAME/OME
ITEM TYPE) for the period between (CHARGE BUNDLE
REFERENCE PERIOD) [were covered by the total charge/were
covered by the (CPS4 - TOTAL CHARGE)/was there no charge/were
covered by the copayment/were covered by the (CPS5 
COPAYMENT)/was there no copayment]?

Question Text:

Int. Instr II:
INPUT FIELDS / ROUTING
NUMLINKS

Field1:
Cheshire Name:

( CPS1180 )

XCEV.NUMLINKS

Item Text display:
Item Text:
Label:

Label Position:


NUMBER OF PURCHASES:
Left

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Integer
TNumlinks
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX CPS8A - (CPS1195 )

Refusal

BOX CPS8A - (CPS1195 )

FieldSize:
Min Value:
Max Value:
Mask:

1
100

Route
BOX CPS8A - (CPS1195 )

BACKGROUND VARIABLE ASSIGNMENTS
Collect # of purchases on XCEV:
XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +

XCEV.XCEVEVNT

XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.

XCEV.XCEVEVNT = EVNT.EVNTNUM of (OM Ostomy Supplies, Incontinence supplies, or

bandages) or (PM) being asked about.


2:03:08 PM Wednesday, May 27, 2009

Page 38 of 151

CPS7

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

269

TotalChargeCollected

Total Charge was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round &
CORO.TOTALTYP=1/TotalCharge).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

268

CoPaymentCollected

CoPayment was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST = COST.COSTNUM &
CORO.CORORND = current round & CORO.TOTALTYP
= 2/CoPayment).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

DESIGN NOTES

2:03:09 PM Wednesday, May 27, 2009

Page 39 of 151

CPS8

CPS8

Page Order # :

Design Screen Type:

Numeric

Fields:

Field 1:

RVLINKS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

150

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Display date of Repeat Visit event being asked about.

Question display:

If Total charge was collected for charge bundle then:
If CPS4 - TOTALCHG = DK or RF, display "were covered by the
total charge".
Else if CPS4-TOTALCHG = 0, display "was there no charge".
Else display "were covered by the (CPS4 - TOTAL CHARGE)".
Display CPS4 - TOTALCHG.
Else if CoPayment was collected for charge bundle then:
If CPS5 - TOTALCHG = DK or RF, display "were covered by the
copayment".
Else if CPS5 - TOTALCHG = 0, display "was there no
copayment".
Else display "were covered by the (CPS5 - COPAYMENT)".
Display CPS5 - TOTALCHG.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

2:03:09 PM Wednesday, May 27, 2009

TOTAL CHARGE = $(TOTAL CHARGE)

Page 40 of 151

CPS8
EVENT: (EVENT)
Int. Instr I:
How many of the [READ EVENT ABOVE] [were covered by the total
charge/were covered by the (CPS4 - TOTAL CHARGE)/was there no
charge/were covered by the copayment/were covered by the
(CPS5 - COPAYMENT)/was there no copayment]?

Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING

RVLINKS

Field1:

( CPS1190 )

XCEV.RVLINKS

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:

NUMBER OF VISITS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Integer
TRvtimes
1
No
No

Number Label
1 [Continuous answer.]
Attribute
Don't know

Route
BOX CPS8B - (CPS1200 )

Refusal

BOX CPS8B - (CPS1200 )

FieldSize:
Min Value:
Max Value:
Mask:

1
90

Route
BOX CPS8B - (CPS1200 )

BACKGROUND VARIABLE ASSIGNMENTS
Collect # of visits on XCEV:

XCEV key = XCEV.XCEVBASE + XCEV.XCEVCOST + XCEV.XCEVBAS2 +

XCEV.XCEVEVNT

XCEV.XCEVCOST = COST.COSTNUM of charge bundle being asked about.

XCEV.XCEVEVNT = EVNT.EVNTNUM of Repeat Visit event currently being asked about.


SOFT EDIT CHECKS

2:03:11 PM Wednesday, May 27, 2009

Page 41 of 151

CPS8
HARD EDIT CHECKS

TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

269

TotalChargeCollected

Total Charge was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round &
CORO.TOTALTYP=1/TotalCharge).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

268

CoPaymentCollected

CoPayment was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST = COST.COSTNUM &
CORO.CORORND = current round & CORO.TOTALTYP
= 2/CoPayment).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

DESIGN NOTES

2:03:11 PM Wednesday, May 27, 2009

Page 42 of 151

BOX CPS8A

BOX CPS8A

Page Order # :

160

BOX INSTRUCTIONS
( CPS1195 )	

IF ANOTHER EVENT IS INCLUDED IN THE CHARGE BUNDLE, GO TO BOX
CPS5B - (CPS1160 ).
ELSE GO TO BOX CPS8B - (CPS1200 ).

ASSIGNMENTS

TECHNICAL NOTES
257

EventsInChargeBundle

Events included in this charge bundle =
For this COST, there is an XCEV where
(XCEV.XCEVCOST = COST.COSTNUM &
XCEV.DELLINK ^= 1/Yes & XCEV.XCEVEVNT =
EVNT.EVNTNUM of EVNT linked to charge bundle).

DESIGN NOTES

2:03:11 PM Wednesday, May 27, 2009	

Page 43 of 151

BOX CPS8B

BOX CPS8B

Page Order # :

170

BOX INSTRUCTIONS
( CPS1200 )	

IF CPS REASON = 2 AND TOTAL CHARGE ^= 0, GO TO CPS9 
CPTCHGPAID1 ( CPS1210 ).
ELSE IF CPS REASON = 2 AND TOTAL CHARGE = 0, GO TO BOX CPS10 (CPS1230 ).
ELSE IF CPS REASON = 6 OR 7, GO TO CPS19 - CPSREIMINT ( CPS1450
).

ASSIGNMENTS

TECHNICAL NOTES
275

CPSReason

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP

270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

DESIGN NOTES

2:03:11 PM Wednesday, May 27, 2009	

Page 44 of 151

CPS9

CPS9

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

CPTCHGPAID1

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

180

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If CPS3 - KNOWTOTL was not asked for this charge bundle, then:
Display 1st sentence "Last time, we recorded…".
If Total charge was collected for charge bundle, display "total
charge".
Else if CoPayment was collected for charge bundle, display
"copayment amount".
Else do not display 1st sentence.

If SP was covered by TRICARE and any other insurance plan

besides Medicare during the current round, display "such as

TRICARE or an insurance plan".

Else if SP was covered by TRICARE and is not covered by any

other insurance plan besides Medicare during the current round,

display "such as TRICARE"

Else if SP was not covered by TRICARE and was covered by any

other insurance plan besides Medicare during the current round,

display "such as an insurance plan".

Else do not display.

[total charge/copayment amount/this (TOTAL CHARGE)]:
If CPS3 - KNOWTOTL was not asked for this charge bundle, then:
If Total charge was collected for charge bundle, display "the total
charge".
Else if CoPayment was collected for charge bundle, display "the
copayment amount".
Else display "this (TOTAL CHARGE)".

2:03:13 PM Wednesday, May 27, 2009

Page 45 of 151

CPS9
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

[Last time, we recorded that the (total charge/copayment amount) for
the [READ EVENT(S) ABOVE] was (TOTAL CHARGE)), and that no
payment had been made.] [Have you/Has (SP)] or any other source
[, such as (an insurance plan/TRICARE/TRICARE or an insurance
plan),] now paid any of [the total charge/the copayment amount/this
(TOTAL CHARGE)]?

Int. Instr II:

INPUT FIELDS / ROUTING


2:03:16 PM Wednesday, May 27, 2009

Page 46 of 151

CPS9
CPTCHGPAID1

Field1:
Cheshire Name:
Item Text display:

( CPS1210 )

TEMP
(TOTAL CHARGE/COPAYMENT AMOUNT):

If Total charge was collected for charge bundle, display

"TOTAL CHARGE".

Else if CoPayment was collected for charge bundle,

display "COPAYMENT AMOUNT".


Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Enumerated

TCPTchgPaid1
1
No
No

Number Label
1 SomeonePaid	

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS10 - (CPS1230 )

2

English text: SP OR ANY SOURCE PAID
NothingPaid	

BOX CPS10 - (CPS1230 )

3

English text: NOTHING HAS BEEN PAID
TotalChargeWrong	

CPS10 - TCHGWRONG ( CPS1220 )

English text: (TOTAL CHARGE/COPAYMENT AMOUNT) IS WRONG
Attribute
Don't know

Route
BOX CPS10 - (CPS1230 )

Refusal

BOX CPS10 - (CPS1230 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGPAID	

If CPS9 - CPTCHGPAID1
= 1/SomeonePaid, set CORO.TCHGPAID = 1/Yes.
= 2/NothingPaid, set CORO.TCHGPAID = 2/No.
= DK, set CORO.TCHGPAID = DK.
= RF, set CORO.TCHGPAID = RF.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
2:03:19 PM Wednesday, May 27, 2009	

Page 47 of 151

CPS9
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

269

TotalChargeCollected

Total Charge was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST=COST.COSTNUM &
CORO.CORORND=current round &
CORO.TOTALTYP=1/TotalCharge).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

268

CoPaymentCollected

CoPayment was collected for Charge Bundle =
For this COST, there is a CORO where
(CORO.COROCOST = COST.COSTNUM &
CORO.CORORND = current round & CORO.TOTALTYP
= 2/CoPayment).
If administering CPS, check most recent CORO where
CORO.TOTALTYP ^= empty.

52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

258

TricarePlan

SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.

259

InsurancePlan

SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

2:03:19 PM Wednesday, May 27, 2009

Page 48 of 151

CPS10

CPS10

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

TCHGWRONG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

190

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:

YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE
ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY
PORTION OF THE CHARGE.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:03:20 PM Wednesday, May 27, 2009

Page 49 of 151

CPS10
TCHGWRONG

Field1:

( CPS1220 )

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS9 - CPTCHGPAID1 ( CPS1210 )

English text: CONTINUE
Attribute
Empty

Route
CPS9 - CPTCHGPAID1 ( CPS1210 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGFLG

Set CORO.TCHGFLG = 2/TotalChargeNotedWrong.

TCHGPAID

Update CORO.TCHGPAID = empty.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:03:22 PM Wednesday, May 27, 2009

Page 50 of 151

BOX CPS10

BOX CPS10

Page Order # :

200

BOX INSTRUCTIONS
( CPS1230 )	

IF (CPS9 - CPTCHGPAID1 = 1/SomeonePaid) OR (TOTAL CHARGE = 0),
GO TO NS65 - NSADDSOP1 ( NSQ2702 ).
ELSE IF (CPS9 - CPTCHGPAID1 = 2/NothingPaid), GO TO CPS17 EXPAYOUT ( CPS1400 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

DESIGN NOTES
Calls NS SOP roster.
NS returns to CPS at BOX CPSBEG.

2:03:22 PM Wednesday, May 27, 2009	

Page 51 of 151

CPS11

CPS11

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

CPTCHGPAID2

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

210

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If Medicare Payment Amount, COST.MCPAYAMT >=0, then:
Display "Medicare had paid…".
If COST.MCPAYAMT = 0, display "nothing".
Else display Medicare Payment Amount, COST.MCPAYAMT.
Else do not display.
If SP was covered by TRICARE and any other insurance plan

besides Medicare during the current round, display "such as

TRICARE or an insurance plan".

Else if SP was covered by TRICARE and is not covered by any

other insurance plan besides Medicare during the current round,

display "such as TRICARE"

Else if SP was not covered by TRICARE and was covered by any

other insurance plan besides Medicare during the current round,

display "such as an insurance plan".

Else do not display.


Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

2:03:24 PM Wednesday, May 27, 2009

Page 52 of 151

CPS11
TEXT:
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Context Header:
Int. Instr I:

Last time, we recorded that [Medicare had paid
[nothing/(MEDICARE PAYMENT AMOUNT)] and] after Medicare
paid, there was an amount remaining of (AMOUNT REMAINING) for
the [READ EVENT(S) ABOVE.]

Question Text:

[Have you/Has (SP)] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] now paid any of
this (AMOUNT REMAINING)?
Int. Instr II:

INPUT FIELDS / ROUTING

CPTCHGPAID2

Field1:
Cheshire Name:

( CPS1250 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TTchgPaid1
1
No
No

Number Label
1 SomeonePaid

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS12 - (CPS1280 )

2

English text: SP OR ANY SOURCE PAID
NothingPaid

BOX CPS12 - (CPS1280 )

3

English text: NOTHING HAS BEEN PAID
AmountRemainingWrong

CPS12 - TCHGWRONG ( CPS1260 )

English text: AMOUNT REMAINING SEEMS WRONG
Attribute
Don't know

Route
BOX CPS12 - (CPS1280 )

Refusal

BOX CPS12 - (CPS1280 )

2:03:27 PM Wednesday, May 27, 2009

Page 53 of 151

CPS11
BACKGROUND VARIABLE ASSIGNMENTS
TCHGPAID	

If CPS11 - CPTCHGPAID2
= 1/SomeonePaid, set CORO.TCHGPAID = 1/Yes.
= 2/NothingPaid, set CORO.TCHGPAID = 2/No.
= DK, set CORO.TCHGPAID = DK.
= RF, set CORO.TCHGPAID = RF.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

258

TricarePlan

SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.

259

InsurancePlan

SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

230

AmountRemaining

Amount Remaining =
COST.AREMAING.

DESIGN NOTES

2:03:27 PM Wednesday, May 27, 2009	

Page 54 of 151

CPS12

CPS12

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

TCHGWRONG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

220

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:

YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE
ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:03:28 PM Wednesday, May 27, 2009

Page 55 of 151

CPS12
TCHGWRONG

Field1:
Cheshire Name:

( CPS1260 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS11 - CPTCHGPAID2 ( CPS1250 )

English text: CONTINUE
Attribute
Empty

Route
CPS11 - CPTCHGPAID2 ( CPS1250 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGFLG

Set CORO.TCHGFLG = 2/TotalChargeNotedWrong.

TCHGPAID

Update CORO.TCHGPAID = empty.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:03:30 PM Wednesday, May 27, 2009

Page 56 of 151

BOX CPS12

BOX CPS12

Page Order # :

230

BOX INSTRUCTIONS
( CPS1280 )	

IF (CPS11 - CPTCHGPAID2 = 1/SomeonePaid), GO TO ST65 - STADDSOP1
( STQ2702 ).
ELSE IF (CPS11 - CPTCHGPAID2 = 2/NothingPaid), GO TO CPS17 EXPAYOUT ( CPS1400 ).
ELSE IF (CPS11 - CPTCHGPAID2 = DK), GO TO CPS23 - RRDETAIL (
CPS1540 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
Calls ST SOP roster.

ST returns to CPS at BOX CPSBEG.


2:03:30 PM Wednesday, May 27, 2009	

Page 57 of 151

CPS13

CPS13

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

CPTCHGPAID3

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

240

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
DIFFERENCE = Display the remainder of (Total Charge - Total
Payments).
If SP was covered by TRICARE and any other insurance plan
besides Medicare during the current round, display ", such as
TRICARE or an insurance plan, ".
Else if SP was covered by TRICARE and is not covered by any
other insurance plan besides Medicare during the current round,
display ", such as TRICARE, "
Else if SP was not covered by TRICARE and was covered by any
other insurance plan besides Medicare during the current round,
display ", such as an insurance plan, ".
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

Display report above question text.
Display all Source of Payments where TSOP.TSOPAMT ^= empty in

2:03:32 PM Wednesday, May 27, 2009

Page 58 of 151

CPS13
the following order based on TSOP.TSOPTYPE:

= 1/SPFamily

= 2/ProvDiscount

=11/MedicareSubsidy

=12/ExtraHelp

= 6/Medicare

= 8/MHMO

=10/MedicarePartD

= 5/VA

= 3/PlanNotMHMO

= 4/OSOP

= 9/DM

If there is more than Source of Payment per Source of Payment

Type, display in order of entry in TSOP.

Not all TSOP.TSOPTYPEs will be applicable.

Report header:

"ALL PAYMENTS"

Report layout:

Column 1, header="SOP NAME".

Column 1, display = TSOP.TSOPTEXT.

Column 2, header = "PAYMENT".

Column 2, display =

If TSOP.TSOPAMT = DK, display "DK".

Else if TSOP.TSOPAMT = RF, display "RF".

Else display TSOP.TSOPAMT.


TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)

Int. Instr I:
Question Text:

Let me review what we recorded last time.
[REVIEW WITH RESPONDENT.] The total of all payments is
$(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE
BETWEEN PAYMENTS AND TOTAL CHARGE).
[Have you/Has (SP)] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid any additional
amount?

Int. Instr II:

INPUT FIELDS / ROUTING


2:03:33 PM Wednesday, May 27, 2009

Page 59 of 151

CPS13
CPTCHGPAID3

Field1:	
Cheshire Name:

( CPS1300 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCPTchgpaid3
1
No
No

Number Label	
1 SomeonePaid	

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS14 - (CPS1330 )

2

English text: SP OR ANY SOURCE PAID
NothingPaid	

BOX CPS14 - (CPS1330 )

3

English text: NOTHING HAS BEEN PAID
TotalWrong	

CPS14 - TCHGWRONG ( CPS1310 )

4

English text: TOTAL CHARGE SEEMS WRONG
PaymentsWrong	
BOX CPS14 - (CPS1330 )
English text: PAYMENT AMOUNTS WRONG

Attribute
Don't know

Route
BOX CPS14 - (CPS1330 )

Refusal

BOX CPS14 - (CPS1330 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGPAID	

If CPS13 - CPTCHGPAID3
= 1/SomeonePaid, set CORO.TCHGPAID = 1/Yes.
= 2/NothingPaid, set CORO.TCHGPAID = 2/No.
= 4/PaymentsWrong, set CORO.TCHGPAID =
4/PaymentsWrong.
= DK, set CORO.TCHGPAID = DK.
= RF, set CORO.TCHGPAID = RF.

SOFT EDIT CHECKS

HARD EDIT CHECKS

2:03:37 PM Wednesday, May 27, 2009	

Page 60 of 151

CPS13
TECHNICAL NOTES
270

TotalCharge

Total Charge =
COST.TOTALAMT.
When collecting Total charge in the current round, Total
Charge is first collected in CORO.TOTALCHG on CORO
where CORO.CORORND = current round and
CORO.COROCOST = this COST.COSTNUM and then is
copied to COST.TOTALAMT.

255

TotalPayments

Total of non-missing Payments entered in SOP grid =
For each TSOP where (TSOP.TSOPAMT ^= DK and
TSOP.TSOPAMT ^= RF and TSOP.TSOPAMT ^=
EMPTY), then Total Payments = Total Payments +
TSOP.TSOPAMT.

52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

258

TricarePlan

SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.

259

InsurancePlan

SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

2:03:37 PM Wednesday, May 27, 2009

Page 61 of 151

CPS14

CPS14

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

TCHGWRONG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

250

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:

YOU CANNOT CORRECT THE TOTAL CHARGE HERE. THE
ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY
ADDITIONAL AMOUNT.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:03:38 PM Wednesday, May 27, 2009

Page 62 of 151

CPS14
TCHGWRONG

Field1:
Cheshire Name:

( CPS1310 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS13 - CPTCHGPAID3 ( CPS1300 )

English text: CONTINUE
Attribute
Empty

Route
CPS13 - CPTCHGPAID3 ( CPS1300 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGFLG

Set CORO.TCHGFLG = 2/TotalChargeNotedWrong.

TCHGPAID

Update CORO.TCHGPAID = empty.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:03:40 PM Wednesday, May 27, 2009

Page 63 of 151

BOX CPS14

BOX CPS14

Page Order # :

260

BOX INSTRUCTIONS
( CPS1330 )	

IF CPS13 - CPTCHGPAID3 = 1/Yes OR 4/PaymentsWrong, GO TO NS65 
NSADDSOP1 ( NSQ2702 ).
ELSE IF CPS13 - CPTCHGPAID3 = 2/NothingPaid, GO TO CPS17 EXPAYOUT ( CPS1400 ).
ELSE IF (CPS13 - CPTCHGPAID3 = DK), GO TO CPS23 - RRDETAIL (
CPS1540 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
Calls NS SOP roster.

NS returns to CPS at BOX CPSBEG.


2:03:40 PM Wednesday, May 27, 2009	

Page 64 of 151

CPS15

CPS15

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

CPTCHGPAID4

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

270

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:	

If (COST.MCPAYAMT ^= EMPTY and COST.MCPAYAMT ^= DK
and COST.MCPAYAMT ^= RF), display "AFTER MEDICARE
PAYMENT".
Else do not display.

Question display:	

Total Payments = If (TSOP.TSOPAMT ^= DK and TSOP.TSOPAMT
^= RF and TSOP.TSOPAMT ^= EMPTY), Total Payments = Total
Payments + TSOP.TSOPAMT.
DIFFERENCE = Display the remainder of (Amount Remaining 
Total Payments).

If SP was covered by TRICARE and any other insurance plan

besides Medicare during the current round, display ", such as

TRICARE or an insurance plan, ".

Else if SP was covered by TRICARE and is not covered by any

other insurance plan besides Medicare during the current round,

display ", such as TRICARE, "

Else if SP was not covered by TRICARE and was covered by any

other insurance plan besides Medicare during the current round,

display ", such as an insurance plan, ".

Else do not display.


Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:

2:03:42 PM Wednesday, May 27, 2009	

Page 65 of 151

CPS15
Report display:

Display report above question text.
Display all Source of Payments where TSOP.TSOPAMT ^= empty in
the following order based on TSOP.TSOPTYPE:
= 1/SPFamily
= 2/ProvDiscount
= 11/MedicareSubsidy
= 12/ExtraHelp
= 6/Medicare
= 8/MHMO
= 10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
= 9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Not all TSOP.TSOPTYPEs will be applicable.
Report header:
"NON-MEDICARE PAYMENTS"
Report layout:
Column 1, header="SOP NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "PAYMENT".
Column 2, display =
If TSOP.TSOPAMT = DK, display "DK".
Else if TSOP.TSOPAMT = RF, display "RF".
Else display TSOP.TSOPAMT.

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)
AMOUNT REMAINING (AFTER MEDICARE PAYMENT):
$(AMOUNT REMAINING)

Int. Instr I:
Question Text:

Let me review what we recorded last time.
[REVIEW ABOVE WITH RESPONDENT.] There seems to be some
amount still unpaid. The total of non-Medicare payments is
$(TOTAL PAYMENTS). The amount unpaid is $(DIFFERENCE
BETWEEN PAYMENTS AND AMOUNT REMAINING).
[Have you/Has (SP)] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid any additional
amount?

Int. Instr II:

INPUT FIELDS / ROUTING


2:03:43 PM Wednesday, May 27, 2009

Page 66 of 151

CPS15
CPTCHGPAID4

Field1:	
Cheshire Name:

( CPS1350 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TCPTchgpaid4
1
No
No

Number Label	
1 SomeonePaid	

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS16 - (CPS1380 )

2

English text: SP OR ANY SOURCE PAID
NothingPaid	

BOX CPS16 - (CPS1380 )

3

English text: NOTHING HAS BEEN PAID
AmountRemainingWrong	

CPS16 - TCHGWRONG ( CPS1360 )

4

English text: AMOUNT REMAINING SEEMS WRONG
PaymentsWrong	
BOX CPS16 - (CPS1380 )
English text: PAYMENT AMOUNTS WRONG

Attribute
Don't know

Route
BOX CPS16 - (CPS1380 )

Refusal

BOX CPS16 - (CPS1380 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGPAID	

If CPTCHGPAID4
= 1/SomeonePaid, set CORO.TCHGPAID = 1/Yes.
= 2/NothingPaid, set CORO.TCHGPAID = 2/No.
= 4/PaymentsWrong, set CORO.TCHGPAID =
4/PaymentsWrong.
= DK, set CORO.TCHGPAID = DK.
= RF, set CORO.TCHGPAID = RF.

SOFT EDIT CHECKS

HARD EDIT CHECKS

2:03:47 PM Wednesday, May 27, 2009	

Page 67 of 151

CPS15
TECHNICAL NOTES
255

TotalPayments

Total of non-missing Payments entered in SOP grid =
For each TSOP where (TSOP.TSOPAMT ^= DK and
TSOP.TSOPAMT ^= RF and TSOP.TSOPAMT ^=
EMPTY), then Total Payments = Total Payments +
TSOP.TSOPAMT.

52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

258

TricarePlan

SP covered by TRICARE during the current round =
There is a PLAN where PLAN.PLANTYPE = 6/Tricare
& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM &
PLRO.PLRORND = current round & PLRO.COVTIME^=
empty).
Exclude Deleted Plans. See T.N. 52.

259

InsurancePlan

SP covered by Insurance plan other than Medicare
during current round =
PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or
4/PrivatePlan) & PLRO where
(PLROPLAN=PLAN.PLANNUM & PLRORND=current
round & COVTIME^=empty).
Exclude Deleted Plans. See T.N. 52.

230

AmountRemaining

Amount Remaining =
COST.AREMAING.

DESIGN NOTES

2:03:47 PM Wednesday, May 27, 2009

Page 68 of 151

CPS16

CPS16

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

TCHGWRONG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

280

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:

YOU CANNOT CORRECT THE AMOUNT REMAINING HERE. THE
ERROR HAS BEEN NOTED. ANSWER “YES” OR “NO” AS
APPROPRIATE AS TO WHETHER ANY SOURCE HAS PAID ANY
ADDITIONAL AMOUNT.

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:03:48 PM Wednesday, May 27, 2009

Page 69 of 151

CPS16
TCHGWRONG

Field1:
Cheshire Name:

( CPS1360 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS15 - CPTCHGPAID4 ( CPS1350 )

English text: CONTINUE
Attribute
Empty

Route
CPS15 - CPTCHGPAID4 ( CPS1350 )

BACKGROUND VARIABLE ASSIGNMENTS
TCHGFLG

Set CORO.TCHGFLG = 2/TotalChargeNotedWrong.

TCHGPAID

Update CORO.TCHGPAID = empty.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:03:50 PM Wednesday, May 27, 2009

Page 70 of 151

BOX CPS16

BOX CPS16

Page Order # :

290

BOX INSTRUCTIONS
( CPS1380 )	

IF CPS15 - CPTCHGPAID4 = 1/Yes OR 4/PaymentsWrong, GO TO ST65 
STADDSOP1 ( STQ2702 ).
ELSE IF CPS15 - CPTCHGPAID4 = 2/NothingPaid, GO TO CPS17 EXPAYOUT ( CPS1400 ).
ELSE IF (CPS15 - CPTCHGPAID4 = DK), GO TO CPS23 - RRDETAIL (
CPS1540 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES
Calls ST SOP roster.

ST returns to CPS at BOX CPSBEG.


2:03:50 PM Wednesday, May 27, 2009	

Page 71 of 151

CPS17

CPS17

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

EXPAYOUT

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

300

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

IF CPS REASON = 2 or 3, display "of this amount".
Else display "additional amount for [READ EVENT(S) ABOVE]".

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:	

Do you expect that [you/(SP)] or any other source will pay any (of
this amount/additional amount for [READ EVENT(S) ABOVE])?

Int. Instr II:
INPUT FIELDS / ROUTING

2:03:52 PM Wednesday, May 27, 2009	

Page 72 of 151

CPS17
( CPS1400 )

EXPAYOUT

Field1:
Cheshire Name:

CORO.EXPAYOUT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS17 - (CPS1410 )

English text: YES
No

BOX CPS32 - (CPS1770 )

English text: NO
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

Refusal

BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
275

CPSReason

2:03:55 PM Wednesday, May 27, 2009

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
= 8/NSExpectStatementDP
Page 73 of 151

CPS17
DESIGN NOTES

2:03:55 PM Wednesday, May 27, 2009

Page 74 of 151


BOX CPS17

BOX CPS17

Page Order # :

310

BOX INSTRUCTIONS
( CPS1410 )	

IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE), GO TO CPS18 
EXPAYUNT ( CPS1420 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES
271

COST2RoundsOld

Charges first collected 2 rounds previous to current round
=
COST.COSTRNDC = (current round - 2).

16

ExitSample

SP is in the Exit Sample =
(MRES.INTTYPE = 8/ExitInterviewHadPrev or
9/ExitInterviewSkipPrev) on MRES where
MRES.MRESRND = current round.

DESIGN NOTES

2:03:55 PM Wednesday, May 27, 2009	

Page 75 of 151

CPS18

CPS18

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

EXPAYUNT

Field 2:

EXPAYPCT

Field 3:

EXPAYAMT

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

320

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Vertical Alignment

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

How much do you expect will be paid?

Int. Instr II:
INPUT FIELDS / ROUTING

2:03:56 PM Wednesday, May 27, 2009

Page 76 of 151

CPS18
EXPAYUNT

Field1:
Cheshire Name:

( CPS1420 )

CORO.EXPAYUNT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TExpayunt
1
No
No

Number Label
1 Percentage
2

English text: PERCENTAGE
Dollars

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS18 - EXPAYAMT ( CPS1440 )
CPS18 - EXPAYPCT ( CPS1430 )

English text: DOLLARS
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

Refusal

BOX CPS32 - (CPS1770 )

2:04:00 PM Wednesday, May 27, 2009

Page 77 of 151

CPS18

Field2:
Cheshire Name:

EXPAYPCT

( CPS1430 )

CORO.EXPAYPCT

Item Text display:
Item Text:
Label:
Label Position:

PERCENTAGE:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TExpaypctReal
1
No
No

Number Label
1 [Continuous answer.]
Field3:
Cheshire Name:

EXPAYAMT

FieldSize:

Min Value:
Max Value:
Mask:


0.0

100


Route
BOX CPS32 - (CPS1770 )
( CPS1440 )

CORO.EXPAYAMT

Item Text display:
Item Text:
Label:
Label Position:

DOLLARS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TExpayamt
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

0.49
999999.99
Dollars

Route
BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1
2:04:02 PM Wednesday, May 27, 2009

Page 78 of 151

CPS18
If CPS18 - EXPAYUNT = 1/Percentage, then CPS18 - EXPAYPCT

should = 20 - 100.

If not true, display message "PERCENTAGE SEEMS UNLIKELY. 

PLEASE VERIFY."

Edit #2

If CPS18 - EXPAYUNT = 2/Dollars and (SP/Family's payment ^= DK

and ^= RF) and (CPS18 - EXPAYAMT ^= DK and ^= RF), then 

CPS18 - EXPAYAMT should be <= SP/Family's payment.

If not true, display message "THE AMOUNT ENTERED IS

GREATER THAN THE SP/FAMILY PAYMENT. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:02 PM Wednesday, May 27, 2009

Page 79 of 151

CPS19

CPS19

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

CPSREIMINT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

330

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If CPS Reason = 6, display "expected some source to pay ".
Else then:
Display "(weren't/wasn't) sure whether some source would pay
[you/(SP)] back".
If respondent is SP, display "weren't".
Else display "wasn't"
Display SP/Family payment.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

2:04:03 PM Wednesday, May 27, 2009

Last time, [you/(SP)] [expected some source to pay/ (weren’t/wasn't)
sure whether some source would pay [you/(SP)] back] some or all of
Page 80 of 151

CPS19
the (SP/FAMILY PAYMENT) (you/he/she) had paid for [READ
EVENT(S) ABOVE].
Int. Instr II:

INPUT FIELDS / ROUTING

CPSREIMINT

Field1:
Cheshire Name:

( CPS1450 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS20 - GOTPAYBK ( CPS1460 )

English text: CONTINUE
Attribute
Empty

Route
CPS20 - GOTPAYBK ( CPS1460 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
275

CPSReason

2:04:05 PM Wednesday, May 27, 2009

CPS Reasons stored by CPS REASON NUMBER on
CORO.CPSREASN:
= 1/NSExpectStatement
= 2/NSNoPayms
= 3/STNoPayms
= 4/NSPaymsLessTotalCharge
= 5/STPaymsLessAmtRemain
= 6/SPPaidExpectREIM
= 7/SPPaidREIMDK
Page 81 of 151

CPS19
= 8/NSExpectStatementDP
4

Respondent

On MRES where MRES.MRESRND = current round:
A Proxy interview (respondent is a proxy) =
MRES.SPPROXY=2/Proxy.
MRES.RROSTNUM=ROST.ROSTNUM of respondent.
An SP interview (respondent is the SP) =
MRES.SPPROXY=1/SP.
MRES.RROSTNUM='01'.

234

SPFamilyPayment	

SP/Family Payment =
For this COST, there is PAYM where (PAYM.PAYMCOST
= COST.COSTNUM & PAYM.PAYMTYPE = 1/SPFamily
& PAYM.PAYMDFLG^-1/Yes).
SP/family payment = PAYM.PAYMAMT.

DESIGN NOTES

2:04:05 PM Wednesday, May 27, 2009	

Page 82 of 151

CPS20

CPS20

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

GOTPAYBK

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

340

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP was covered by TRICARE and any other insurance plan

besides Medicare during the current round, display ", such as

TRICARE or an insurance plan, ".

Else if SP was covered by TRICARE and is not covered by any

other insurance plan besides Medicare during the current round,

display ", such as TRICARE, "

Else if SP was not covered by TRICARE and was covered by any

other insurance plan besides Medicare during the current round,

display ", such as an insurance plan, ".

Else do not display.

If a PM event is linked to the charge bundle that has Number of

Purchases >0 and ^= DK and ^= RF, and ((SP was covered by a

Medicare Prescription Drug Plan anytime during the current round)

or (SP had a Medicare Managed Care plan with RX coverage 

anytime during the current round)), display "[PROBE IF 

NECESSARY: Please…]".
Else do not display sentence.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

2:04:07 PM Wednesday, May 27, 2009

Page 83 of 151

CPS20
TEXT:
EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)

Context Header:

Int. Instr I:
Has any source [, such as (an insurance plan/TRICARE/TRICARE or
an insurance plan),] paid [you/(SP)] back any of that amount?

Question Text:

([PROBE IF NECESSARY: Please include any payments received
from (your/(SP's)] Medicare prescription drug benefit.])
Int. Instr II:

INPUT FIELDS / ROUTING

GOTPAYBK

Field1:
Cheshire Name:

( CPS1460 )

CORO.GOTPAYBK

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS25 - CPADDSOP ( CPS1600 )

English text: YES
No
English text: NO

Attribute
Don't know

Route
BOX CPS20 - (CPS1480 )

Refusal

BOX CPS20 - (CPS1480 )

BOX CPS20 - (CPS1480 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
2:04:09 PM Wednesday, May 27, 2009

Page 84 of 151

CPS20

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

Deleted plans that are not valid for displays or checks =

Any PLAN where (PLAN.PLANDFLG=1/Yes or 

PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or 

PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.


258	

TricarePlan

SP covered by TRICARE during the current round =

There is a PLAN where PLAN.PLANTYPE = 6/Tricare

& PLRO where (PLRO.PLROPLAN = PLAN.PLANNUM & 

PLRO.PLRORND = current round & PLRO.COVTIME^=

empty).

Exclude Deleted Plans. See T.N. 52.


259	

InsurancePlan

SP covered by Insurance plan other than Medicare

during current round =

PLAN where (PLANTYPE = 2/Medicaid, 3/PublicPlan, or 

4/PrivatePlan) & PLRO where

(PLROPLAN=PLAN.PLANNUM & PLRORND=current

round & COVTIME^=empty).

Exclude Deleted Plans. See T.N. 52.


371	

PMLinkedChargeBundl
e

There is a PM Event linked to charge bundle =

For this COST, there is an XCEV where 

(XCEV.XCEVCOST=COST.COSTNUM & 

XCEV.DELLINK^=1/Yes &

XCEV.XCEVEVNT=EVNT.EVNTNUM for EVNT where

(EVNT.EVNTTYPE=PM & EVNT.EVNTDFLG^=1/Yes)).


351	

MPDPAnytimeCurrRnd

SP covered by an MPDP plan anytime during current

round =

There is a PLAN where PLAN.PLANTYPE=7/MPDP &

PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM & 

PLRO.PLRORND=current round & 

PLRO.COVANYTM=1/Yes).

Exclude Deleted Plans. See T.N. 52.


372	

MHMORxAnytime

SP had Medicare Managed Care plan (Medicare

Advantage plan) with RX coverage during curr.rnd=

There is a PLAN where PLANTYPE=5/MHMO & PLRO

where (PLROPLAN=PLANNUM & PLRORND=curr.rnd &

COVANYTM=1/Yes & MHMORX=1/Yes)). Exclude

Deleted Plans. See T.N.52.


DESIGN NOTES

2:04:09 PM Wednesday, May 27, 2009	

Page 85 of 151

BOX CPS20

BOX CPS20

Page Order # :

350

BOX INSTRUCTIONS
( CPS1480 )	

IF (CPS20 - GOTPAYBK = 2/No) AND (SP PREVIOUSLY EXPECTED A
SOURCE TO PAY BACK ANY AMOUNT), GO TO CPS21 - EXPPAYBK (
CPS1490 ).
ELSE IF CPS20 - GOTPAYBK = DK, GO TO CPS23 - RRDETAIL ( CPS1540
).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES
277

SPPrevExpectPayBack

SP previously expected a source to pay back any amount
=
For this COST, CORO.EXPPAYBK = 1/Yes on most
recent CORO where (CORO.COROCOST =
COST.COSTNUM & CORO.EXPPAYBK ^= empty).

DESIGN NOTES

2:04:09 PM Wednesday, May 27, 2009	

Page 86 of 151

CPS21

CPS21

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

EXPPAYBK

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

360

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:	

Do you still expect any source to pay [you/(SP)] back any amount for
[READ EVENT(S) ABOVE]?

Int. Instr II:
INPUT FIELDS / ROUTING

2:04:11 PM Wednesday, May 27, 2009	

Page 87 of 151

CPS21
EXPPAYBK

Field1:
Cheshire Name:

( CPS1490 )

CORO.EXPPAYBK

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS21 - (CPS1500 )

English text: YES
No

BOX CPS32 - (CPS1770 )

English text: NO
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

Refusal

BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:13 PM Wednesday, May 27, 2009

Page 88 of 151

BOX CPS21

BOX CPS21

Page Order # :

370

BOX INSTRUCTIONS
( CPS1500 )	

IF (CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS TO
CURRENT ROUND) OR (SP IS IN THE EXIT SAMPLE), GO TO CPS22 
EXPAYUNT ( CPS1510 ).
ELSE GO TO BOX CPS32 - (CPS1770 ).

ASSIGNMENTS

TECHNICAL NOTES
271

COST2RoundsOld

Charges first collected 2 rounds previous to current round
=
COST.COSTRNDC = (current round - 2).

16

ExitSample

SP is in the Exit Sample =
(MRES.INTTYPE = 8/ExitInterviewHadPrev or
9/ExitInterviewSkipPrev) on MRES where
MRES.MRESRND = current round.

DESIGN NOTES

2:04:13 PM Wednesday, May 27, 2009	

Page 89 of 151

CPS22

CPS22

Page Order # :

Design Screen Type:

Quantity Unit

Fields:

Field 1:

EXPAYUNT

Field 2:

EXPAYPCT

Field 3:

EXPAYAMT

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No

No

No

No


Grid Functions:

Add Line
Delete Line

No
No

Enable Functions:

380

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:	

Display SP/FAMILY's payment:
If SP/Family's payment = DK or RF, display "NOT KNOWN".
Else display SP/Family's payment.

Question display:

Multi Field display:

Vertical Alignment


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
SP/FAMILY PAYMENT: $(SP/FAMILY PAYMENT)

Int. Instr I:

Question Text:

How much do you expect will be paid?


Int. Instr II:

2:04:14 PM Wednesday, May 27, 2009	

Page 90 of 151

CPS22
INPUT FIELDS / ROUTING
EXPAYUNT

Field1:
Cheshire Name:

( CPS1510 )

CORO.EXPAYUNT

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TExpayunt
1
No
No

Number Label
1 Percentage
2

English text: PERCENTAGE
Dollars

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS22 - EXPAYPCT ( CPS1520 )
CPS22 - EXPAYAMT ( CPS1530 )

English text: DOLLARS
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

Refusal

BOX CPS32 - (CPS1770 )

2:04:17 PM Wednesday, May 27, 2009

Page 91 of 151

CPS22

Field2:
Cheshire Name:

EXPAYPCT

( CPS1520 )

CORO.EXPAYPCT

Item Text display:
Item Text:
Label:
Label Position:

PERCENTAGE:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TExpaypctReal
1
No
No

Number Label
1 [Continuous answer.]
Field3:
Cheshire Name:

EXPAYAMT

FieldSize:

Min Value:
Max Value:
Mask:


0.0

100


Route

( CPS1530 )

CORO.EXPAYAMT

Item Text display:
Item Text:
Label:
Label Position:

DOLLARS:
Left

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TExpayamt
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

0.49
999999.99

Route
BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS
Edit #1
2:04:18 PM Wednesday, May 27, 2009

Page 92 of 151

CPS22
If CPS22 - EXPAYUNT = 1/Percentage, then CPS22 - EXPAYPCT

should = 20 - 100.

If not true, display message "PERCENTAGE SEEMS UNLIKELY. 

PLEASE VERIFY."

Edit #2

If CPS22 - EXPAYUNT = 2/Dollars and (SP/Family's payment ^= DK

and ^= RF) and (CPS22 - EXPAYAMT ^= DK and ^= RF), then 

CPS22 - EXPAYAMT should be <= SP/Family's payment.

If not true, display message "THE AMOUNT ENTERED IS

GREATER THAN THE SP/FAMILY PAYMENT. PLEASE VERIFY."

HARD EDIT CHECKS

TECHNICAL NOTES
234

SPFamilyPayment	

SP/Family Payment =
For this COST, there is PAYM where (PAYM.PAYMCOST
= COST.COSTNUM & PAYM.PAYMTYPE = 1/SPFamily
& PAYM.PAYMDFLG^-1/Yes).
SP/family payment = PAYM.PAYMAMT.

DESIGN NOTES

2:04:18 PM Wednesday, May 27, 2009	

Page 93 of 151

CPS23

CPS23

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

RRDETAIL

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

390

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

If CPSREASON = 1 or 6, display "A".
Else display "AN INSURANCE".

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:	

DID RESPONDENT MENTION (AN INSURANCE/A) REFUND OR
REIMBURSEMENT ABOUT WHICH HE/SHE IS NOT SURE OF
THE DETAILS?

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:04:20 PM Wednesday, May 27, 2009	

Page 94 of 151

CPS23
RRDETAIL

Field1:
Cheshire Name:

( CPS1540 )

CORO.RRDETAIL

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesnodk
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS24 - RRADD ( CPS1545 )

English text: YES
No

BOX CPS32 - (CPS1770 )

English text: NO
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:22 PM Wednesday, May 27, 2009

Page 95 of 151

CPS24

CPS24

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 0:

RRADD

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

400

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:
Int. Instr I:

DO YOU WANT TO ADD A REFUND OR REIMBURSEMENT?


Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING

2:04:23 PM Wednesday, May 27, 2009

Page 96 of 151

CPS24
RRADD

Field0:
Cheshire Name:

( CPS1545 )

CORO.RRADD

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNo
1
No
No

Number Label
1 Yes
2

English text: YES
No

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS25 - CPADDSOP ( CPS1600 )
BOX CPS32 - (CPS1770 )

English text: NO

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:24 PM Wednesday, May 27, 2009

Page 97 of 151

CPS25

CPS25

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

CPADDSOP

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

410

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

Display report above question text.
Display all eligible Source of Payments stored on TSOP based on
the following logic:
Do not display the following SOP's:
1) TSOP.TSOPTYPE = 1/SPFamily.
2) TSOP.TSOPTYPE = 11/MedicareSubsidy
3) TSOP.TSOPTYPE = 12/ExtraHelp
4) If Statement Charge Bundle and type of statement is a Medicare
Prescription Drug Benefit statement, do not display
TSOP.TSOPTYPE = 2/ProvDiscount.
5) If CPS24 is asked and CPS24 - RRDETAIL = 1/Yes and CPS25 
RADD = 1/Yes, do not display TSOP.TSOPTYPE = 2/ProvDiscount.
Display all remaining Source of Payments in the following order
based on TSOP.TSOPTYPE:
= 2/ProvDiscount
= 6/Medicare

2:04:25 PM Wednesday, May 27, 2009	

Page 98 of 151

CPS25
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
=9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Report header: SOURCES OF REIMBURSEMENT
Report layout:
Column 1, header="NAME".
Column 1, display = TSOP.TSOPTEXT.
Column 2, header = "TYPE".
Column 2, display =
If TSOP.TSOPDISP ^= empty, display TSOP.TSOPDISP.
Else do not display.

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:

ARE ALL OF THE SOURCES OF PAYMENT FOR THIS CHARGE
BUNDLE LISTED BELOW?

Question Text:
Int. Instr II:

SELECT "NO" TO ADD A SOURCE OF PAYMENT.

INPUT FIELDS / ROUTING

2:04:27 PM Wednesday, May 27, 2009

Page 99 of 151

CPS25
( CPS1600 )

CPADDSOP

Field1:
Cheshire Name:

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNo

FieldSize:
Min Value:
Max Value:
Mask:

1
No
No

Number Label
1 Yes
2

Route
CPS27 - TSOPREIM ( CPS1650 )

English text: YES
No

CPS26 - SOP_CP ( CPS1630 )

English text: NO

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
366

STChargeBundle

Charge Bundle is a Statement Charge Bundle =
COST.COSTTYPE = 1/ST.

368

MPDPBenefitStatement

Statement Charge Bundle is a Medicare Prescription
Drug Benefit Statement =
COST.STATTYPE = 8/MPDPBenefit.

DESIGN NOTES

2:04:28 PM Wednesday, May 27, 2009

Page 100 of 151

CPS26

CPS26

Page Order # :

Design Screen Type:	

Roster

Fields:	

Field 1:

SOP_CP

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Name:

Source Of Payment Roster

Roster Type:

Multiple Item Select

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

Yes
Yes
No
No

Grid Functions:	

Add Line
Delete Line

No
No

420

Display as ' Add Source of Payment '
Display as ' Edit Source of Payment '

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:	

Display all eligible Source of Payments stored on TSOP based on
the following logic:
Do not display the following SOP's:
1) TSOP.TSOPTYPE = 1/SPFamily.
2) TSOP.TSOPTYPE = 11/MedicareSubsidy
3) TSOP.TSOPTYPE = 12/ExtraHelp
4) If Statement Charge Bundle and type of statement is a Medicare
Prescription Drug Benefit statement, do not display
TSOP.TSOPTYPE = 2/ProvDiscount.
Display all remaining Source of Payments in the following order
based on TSOP.TSOPTYPE:
= 2/ProvDiscount
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
=9/DM
If there is more than Source of Payment per Source of Payment

2:04:29 PM Wednesday, May 27, 2009	

Page 101 of 151

CPS26
Type, display in order of entry in TSOP.

Display all loaded Source of Payments as protected rows.

COL #

Roster/Grid display:

HEADER

INSTRUCTIONS

1

SOP Name

Display TSOP.TSOPTEXT.

2

SOP Type

If TSOP.TSOPDISP ^= empty, display
TSOP.TSOPDISP.
Else do not display.

Report display:

TEXT:
Context Header:


EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:


ADD ALL ADDITIONAL SOURCES OF PAYMENT FOR THIS
CHARGE BUNDLE.

Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING


Field1:
Cheshire Name:

SOP_CP

( CPS1630 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

String
TSOPPick
1
No
No

Number Label
1 [Continuous answer.]

FieldSize:
Min Value:
Max Value:
Mask:

135

Route
CPS27 - TSOPREIM ( CPS1650 )

BACKGROUND VARIABLE ASSIGNMENTS
Roster details will be collected on TSOP:

TSOP key = TSOP.TSOPBASE + TSOP.TSOPNUM.

TSOP.TSOPNUM = Number of Source of Payment selected at CPS26.


2:04:30 PM Wednesday, May 27, 2009

Page 102 of 151

CPS26
If adding SOP, see SOURCE OF PAYMENT ROSTER POP-UP specifications for pop-up
window programming instructions.
Fields collected in Pop-Up window:
TSOP.TSOPNUM
TSOP.TSOPTEXT
TSOP.TSOPISHI

SOFT EDIT CHECKS

HARD EDIT CHECKS
Edit #1

If MEDICAID is already on the Source of Payment roster, CPS26
TSOPISHI should ^= 1/Medicaid.

If not true, display "An add has failed. It was a duplicate."

Edit #2

If TRICARE is already on the Source of Payment roster, CPS26 
TSOPISHI should ^= 9/Tricare.

If not true, display "An add has failed. It was a duplicate."

TECHNICAL NOTES
263

MedicaidSOP

Medicaid already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP=2/Medicaid.

264

TricareSOP

Tricare already on SOP roster =
There is a TSOP where TSOP.TSOPPTYP = 6/Tricare.

366

STChargeBundle

Charge Bundle is a Statement Charge Bundle =
COST.COSTTYPE = 1/ST.

368

MPDPBenefitStatement

Statement Charge Bundle is a Medicare Prescription
Drug Benefit Statement =
COST.STATTYPE = 8/MPDPBenefit.

DESIGN NOTES

2:04:30 PM Wednesday, May 27, 2009

Page 103 of 151

CPS27

CPS27

Page Order # :

Design Screen Type:	

Grid

Fields:	

Field 1:

TSOPREIM

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

430

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Always display "(else)" and "(SOURCE)" in parenthesis.
CALCULATION DISPLAY:

If TSOPREIM added, deleted, or updated, in any row at CPS27,

calculate and display (REIMBURSEMENT AMOUNT). Display only.

(REIMBURSEMENT AMOUNT):

If at least one row at CPS27 has TSOPREIM = DK or RF, display

"NOT KNOWN".

Else display Total Reimbursement.

Total Reimbursement:

For each row at CPS27 where (TSOPREIM ^= EMPTY and

TSOPREIM ^= DK and TSOPREIM ^= RF), calculate Total

Reimbursement = Total Reimbursement + TSOP.TSOPREIM.


Multi Field display:

Roster/Grid Instructions:	

Display all eligible Source of Payments stored on TSOP based on
the following logic:
Do not display the following SOP's:
1) TSOP.TSOPTYPE = 1/SPFamily.
2) TSOP.TSOPTYPE = 11/MedicareSubsidy
3) TSOP.TSOPTYPE = 12/ExtraHelp
4) If Statement Charge Bundle and type of statement is a Medicare
Prescription Drug Benefit statement, do not display

2:04:31 PM Wednesday, May 27, 2009	

Page 104 of 151

CPS27
TSOP.TSOPTYPE = 2/ProvDiscount.
Display all remaining Source of Payments in the following order
based on TSOP.TSOPTYPE:
= 2/ProvDiscount
= 6/Medicare
= 8/MHMO
=10/MedicarePartD
= 5/VA
= 3/PlanNotMHMO
= 4/OSOP
=9/DM
If there is more than Source of Payment per Source of Payment
Type, display in order of entry in TSOP.
Roster/Grid display:

COL #

HEADER	

INSTRUCTIONS

1

Name	

Display TSOP.TSOPTEXT. Display Only.

2

Type	

If TSOP.TSOPDISP ^= empty, display
TSOP.TSOPDISP.
Else do not display.
Display only.

3

Reimbursement	

TSOP.TSOPREIM. Input field 1.

Report display:

TEXT:
Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:
Question Text:

Who (else) paid (besides Medicare)? How much did (SOURCE)
pay?
REIMBURSEMENT AMOUNT: (REIMBURSEMENT AMOUNT)

Int. Instr II:


ENTER ALL REIMBURESMENT AMOUNTS.

INPUT FIELDS / ROUTING


2:04:32 PM Wednesday, May 27, 2009	

Page 105 of 151

CPS27
( CPS1650 )

TSOPREIM

Field1:	
Cheshire Name:

TSOP.TSOPREIM
SQL tblTSOP is not transformed to TSOP Cheshire.

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Real
TTsopamt


FieldSize:

Min Value:
Max Value:
Mask:

1

No
No

Number Label	
1 [Continuous answer.]	

0.01

999999.99
Dollars

Route
BOX CPS27A - (CPS1660 )

Attribute
Empty

Route
BOX CPS27A - (CPS1660 )

Don't know

BOX CPS27A - (CPS1660 )

Refusal

BOX CPS27A - (CPS1660 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS
At least one TSOPREIM = DK or RF or the sum of all TSOPREIM
values for this cost > 0.00.
If not true, display message "THE SUM OF ALL REIMBURSEMENT
AMOUNTS MUST BE GREATER THAN $0.00 OR AT LEAST ONE
REIMBURSEMENT AMOUNT MUST BE 'DON'T KNOW' OR
'REFUSED'."
TECHNICAL NOTES
366

STChargeBundle	

2:04:33 PM Wednesday, May 27, 2009	

Charge Bundle is a Statement Charge Bundle =
COST.COSTTYPE = 1/ST.

Page 106 of 151

CPS27
368

MPDPBenefitStatement

Statement Charge Bundle is a Medicare Prescription
Drug Benefit Statement =
COST.STATTYPE = 8/MPDPBenefit.

DESIGN NOTES

2:04:33 PM Wednesday, May 27, 2009

Page 107 of 151

BOX CPS27A

BOX CPS27A

Page Order # :

440

BOX INSTRUCTIONS
( CPS1660 )	

IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT CPS26, GO TO
BOX CPS27B - (CPS1670 ).
ELSE GO TO BOX CPS29F - (CPS1739 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

2:04:33 PM Wednesday, May 27, 2009	

Page 108 of 151

BOX CPS27B

BOX CPS27B

Page Order # :

450

BOX INSTRUCTIONS
( CPS1670 )	

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A HEALTH
INSURANCE PLAN, GO TO CPS27BINT - PLANINTRO_CPS ( CPS1675 ).
ELSE GO TO BOX CPS29B - (CPS1720 ).

ASSIGNMENTS

TECHNICAL NOTES
248

SOPPlan

Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD

DESIGN NOTES

2:04:33 PM Wednesday, May 27, 2009	

Page 109 of 151

CPS27BINT

CPS27BINT

Page Order # :

Design Screen Type:	

No Entry

Fields:	

Field 1:

PLANINTRO_CPS

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
No
No

455

Roster Name:
Roster Type:
Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "(s)" in parentheses.


Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

Before we continue, I would like to ask you a few questions about

the health insurance plan(s) you just added.

Int. Instr II:
INPUT FIELDS / ROUTING

2:04:35 PM Wednesday, May 27, 2009	

Page 110 of 151

CPS27BINT
PLANINTRO_CPS

Field1:
Cheshire Name:

( CPS1675 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS27B_IN - NAVIGATOR ( CPS1677 )

English text: CONTINUE
Attribute
Empty

Route
CPS27B_IN - NAVIGATOR ( CPS1677 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:36 PM Wednesday, May 27, 2009

Page 111 of 151

CPS27B_IN

CPS27B_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

456

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display all HI SOPs added at CPS26.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:04:37 PM Wednesday, May 27, 2009

Page 112 of 151

CPS27B_IN
NAVIGATOR

Field1:
Cheshire Name:

( CPS1677 )

N/A

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList	
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS27C - (CPS1680 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview	
BOX CPS29B - (CPS1720 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
248

SOPPlan	

Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD

DESIGN NOTES

2:04:39 PM Wednesday, May 27, 2009	

Page 113 of 151

BOX CPS27C

BOX CPS27C

2:04:39 PM Wednesday, May 27, 2009

Page Order # :

460


Page 114 of 151


BOX CPS27C
BOX INSTRUCTIONS
( CPS1680 )	

CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE
OF PAYMENT ADDED AT CPS26 .
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND
SP HAS A MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO
CPS28 - CPMHMOCHNG ( CPS1690 ).
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN
AND SP DOES NOT HAVE A MEDICARE MANAGED CARE PLAN THAT IS
CURRENT, GO TO CPS29 - CPSOPCURR ( CPS1700 ).
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG
PLAN AND SP HAS A MEDICARE PRESCRIPTION DRUG PLAN THAT IS
CURRENT, GO TO CPS29A - CPMPDPCHNG ( CPS1705 ).
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG
PLAN AND SP DOES NOT HAVE A MEDICARE PRESCRIPTION DRUG
PLAN THAT IS CURRENT, GO TO CPS29B - CPSOPCURR2 ( CPS1707 ).
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME (
HIQ4770 ).
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 COVTIME ( HIQ5780 ).
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 COVTIME ( HIQ6230 ).
ELSE GO TO HIT2 - COVTIME ( HIQ5330 ).

ASSIGNMENTS
If SOP added is an MHMO, Public plan, Private plan, or Medicare Prescription Drug plan
create a new PLAN and current round PLRO record. See detailed instructions below.
If SOP added is Medicaid then:
If there is a PLAN where PLAN.PLANTYPE=2/Medicaid, regardless if
PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Medicaid plan will be
restarted. Update existing PLAN flags = empty and create a current round PLRO record.
See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=2/Medicaid, create a new PLAN and
current round PLRO record. Set PLAN.PLNAME = MEDICAID. See detailed instructions
below.
If SOP added is Tricare then:
If there is a PLAN where PLAN.PLANTYPE=6/Tricare, regardless if
PLAN.PLANDFLG=1/Yes or LOSEPLFG ^= empty, this stopped Tricare plan will be
restarted. Update existing PLAN flags = empty and create a current round PLRO record.
See detailed instructions below.
Else if there is no PLAN where PLAN.PLANTYPE=6/Tricare, create a new PLAN and
current round PLRO record. Set PLAN.PLNAME = TRICARE. See detailed instructions
below.
PLAN KEY = PLAN.PLANBASE + PLAN.PLANNUM

2:04:39 PM Wednesday, May 27, 2009	

Page 115 of 151

BOX CPS27C
PLRO KEY = PLRO.PLROBASE + PLRO.PLROPLAN + PLRO.PLRORND
Set PLAN/PLRO fields as instructed below:
PLANNUM	

If creating a new PLAN, create PLAN where
PLAN.PLANNUM = highest PLAN.PLANNUM + 01.

PLANRNDC	

If creating a new PLAN, set PLAN.PLANRNDC =
current round.

PLANTYPE	

Set PLANTYPE based on TSOPISHI:
=1/Medicaid, PLANTYPE=2/Medicaid.
=2/PublicPlan, PLANTYPE=3/PublicPlan.
=3/PrivatePlan, PLANTYPE=4/PrivatePlan.
=7/MHMO, PLANTYPE=5/MHMO.
=9/Tricare, PLANTYPE=6/Tricare.
=10/MedicarePartD, PLANTYPE=7/MPDP.

PLNAME	

If creating a new PLAN,
If SOP is Medicaid, set PLAN.PLNAME =
"MEDICAID".
Else if SOP is Tricare, set PLAN.PLNAME =
"TRICARE".
Else set PLAN.PLNAME = TSOP.TSOPTEXT.

PLROPLAN	

Create PLRO where PLRO.PLROPLAN = new
PLAN.PLANNUM.

PLRORND	

PLRO.PLRORND = current round.

COVANYTM	

If TSOP.TSOPISHI = 7/MHMO or 10/MedicarePartD,
set PLRO.COVANYTM = 1/Yes.

TSOPTYPE	

If TSOP.TSOPISHI = 1/Medicaid, 2/PublicPlan,
3/PrivatePlan, 9/Tricare, set TSOP.TSOPTYPE =
3/PlanNotMHMO.
Else if TSOP.TSOPISHI = 7/MHMO, set
TSOP.TSOPTYPE = 8/MHMO.
Else if TSOP.TSOPISHI=10/MedicarePartD, set
TSOP.TSOPTYPE =10/MedicarePartD.

TSOPPTYP	

Set TSOP.TSOPPTYP = PLAN.PLANTYPE.

TSOPPLAN	

Set TSOP.TSOPPLAN = PLAN.PLANNUM.

TSOPDISP	

Set TSOP.TSOPDISP based on PLAN.PLANTYPE:
= 2/Medicaid, TSOPDISP = "(MCAD)".
= 3/PublicPlan, TSOPDISP = "(PUBL)".
= 4/PrivatePlan, TSOPDISP = "(PRIV)".
= 5/MHMO, TSOPDISP = “(MHMO)”.
= 6/Tricare, TSOPDISP = "(TRIC)".
=7/MPDP, TSOPDISP = "(MPDP)".

PLANDFLG	

If restarting Medicaid or Tricare plan, set
PLAN.PLANDFLG = empty.

LOSEPLFG	

If restarting Medicaid or Tricare plan, set
PLAN.LOSEPLFG = empty.

PLSOPFLG	

If creating new PLAN, set PLAN.PLSOPFLG = 1/Yes.

TECHNICAL NOTES
248

SOPPlan

2:04:39 PM Wednesday, May 27, 2009

Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO

Page 116 of 151

BOX CPS27C
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD
52

DeletedPlans

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.

65

MHMOCurrent

SP has a current Medicare Managed Care plan
(Medicare Advantage plan) =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

342

MPDPCurrent

SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES
BOX CPS27C calls HI section for Medicaid, Tricare, Public Plans, and
Private Plans added to SOP roster.
CPS28 and CPS29 collects status of MHMO plan added to SOP roster.
CPS29 calls HI section for MHMO plan if "current".
HI returns to CPS at BOX CPS29A.
CPS29A and CPS29B collect the status of MPDP plan added to SOP
roster. CPS does not call HI section for MPDP plan details.

2:04:39 PM Wednesday, May 27, 2009

Page 117 of 151

CPS28

CPS28

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

CPMHMOCHNG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

470

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

CPS28 is asked when a MHMO is added at the SOP roster and
there is already a current MHMO reported in the current round. The
purpose of CPS28 is to remind the respondent of the current MHMO
already reported and determine if the plan status has changed.
Display name of current Medicare Managed Care Plan,
PLAN.PLNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

I recorded previously that (CURRENT MEDICARE MANAGED
CARE PLAN NAME) was [your/(SP's)] current Medicare Managed
Care Plan. Has this information changed?

Int. Instr II:
2:04:41 PM Wednesday, May 27, 2009

Page 118 of 151

CPS28
INPUT FIELDS / ROUTING
CPMHMOCHNG

Field1:
Cheshire Name:

( CPS1690 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS29 - CPSOPCURR ( CPS1700 )

English text: YES
No
English text: NO

BOX CPS29A - (CPS1710 )

Attribute
Don't know

Route
BOX CPS29A - (CPS1710 )

Refusal

BOX CPS29A - (CPS1710 )

BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT

If CPS28 - CPMHMOCHNG = 2/No, DK, RF, set
current round PLRO.COVCURNT = 2/No on MHMO
PLAN added to SOP roster.

SOFT EDIT CHECKS
Edit #1:

CPS28 - CPMHMOCHNG = 1/Yes.

If not true, display message "INFORMATION FOR THIS PLAN WILL

NOT BE COLLECTED NOW."

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

2:04:43 PM Wednesday, May 27, 2009

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or

Page 119 of 151

CPS28
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
65

MHMOCurrent	

SP has a current Medicare Managed Care plan
(Medicare Advantage plan) =
There is a PLAN where PLAN.PLANTYPE=5/MHMO &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

2:04:44 PM Wednesday, May 27, 2009	

Page 120 of 151

CPS29

CPS29

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

CPSOPCURR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

480

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP is alive and not institutionalized, display "currently".
Else do not display.
Display name of Medicare Managed Care Plan Name,
PLAN.PLNAME, added at CPS26 Source of Payment Roster.
If SP is deceased or institutionalized, display "on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)".
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

2:04:45 PM Wednesday, May 27, 2009	

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26
SOP MEDICARE MANAGED CARE PLAN NAME) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Page 121 of 151

CPS29
Int. Instr II:
INPUT FIELDS / ROUTING
CPSOPCURR

Field1:
Cheshire Name:

( CPS1700 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
HIMC6 - MHMORX ( HIQ4020 )

English text: YES
No

BOX CPS29A - (CPS1710 )

English text: NO
Attribute
Don't know

Route
BOX CPS29A - (CPS1710 )

Refusal

BOX CPS29A - (CPS1710 )

BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT	

Set PLRO.COVCURNT on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of MHMO
added at SOP roster and PLRO.PLRORND = current
round:
If CPS29 - CPSOPCURR = 1/Yes, set
PLRO.COVCURNT = 1/Yes.
Else set PLRO.COVCURNT = 2/No.

COVCURNT	

If CPS28 - CPMHMOCHNG = 1/Yes and CPS29 
CPSOPCURR = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of pre
existing current MHMO and PLRO.PLRORNDC =
current round.

SOFT EDIT CHECKS

2:04:48 PM Wednesday, May 27, 2009	

Page 122 of 151

CPS29

HARD EDIT CHECKS

TECHNICAL NOTES
59

SPStatus

SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.

DESIGN NOTES
Calls HI section for MHMOs if MHMO added is current.
HI returns to CPS at BOX CPS29A.

2:04:48 PM Wednesday, May 27, 2009

Page 123 of 151

CPS29A

CPS29A

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

CPMPDPCHNG

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
No

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

485

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

CPS29A is asked when a MPDP is added at the SOP roster and
there is already a current MPDP reported in the current round. The
purpose of CPS29A is to remind the respondent of the current
MPDP already reported and determine if the plan status has
changed.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

I recorded previously that (CURRENT MEDICARE PRESCRIPTION
DRUG PLAN) was [your/(SP's)] current Medicare Prescription Drug
Care Plan.
Has this information changed?

Int. Instr II:
2:04:49 PM Wednesday, May 27, 2009	

Page 124 of 151

CPS29A
INPUT FIELDS / ROUTING
CPMPDPCHNG

Field1:
Cheshire Name:

( CPS1705 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS29B - CPSOPCURR2 ( CPS1707 )

English text: YES
No
English text: NO

BOX CPS29A - (CPS1710 )

Attribute
Don't know

Route
BOX CPS29A - (CPS1710 )

Refusal

BOX CPS29A - (CPS1710 )

BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT

If CPS29A - CPMDPDCHNG = 2/No, DK, RF, set
current round PLRO.COVCURNT = 2/No for MPDP
PLAN added to SOP roster.

SOFT EDIT CHECKS
Edit #1:

CPS29A - CPMPDPCHNG = 1/Yes.

If not true, display message "INFORMATION FOR THIS PLAN WILL

NOT BE COLLECTED NOW."

HARD EDIT CHECKS

TECHNICAL NOTES
52

DeletedPlans

2:04:52 PM Wednesday, May 27, 2009

Deleted plans that are not valid for displays or checks =
Any PLAN where (PLAN.PLANDFLG=1/Yes or

Page 125 of 151

CPS29A
PLAN.MHMODFLG=1/Yes or PLAN.PLANHIDE=1/Yes or
PLAN.LOSEPLFG ^=EMPTY) is a deleted PLAN.
342

MPDPCurrent

SP has a "current" Medicare Prescription Drug plan =
There is a PLAN where PLAN.PLANTYPE=7/MPDP &
PLRO where (PLRO.PLROPLAN=PLAN.PLANNUM &
PLRO.PLRORND=current round &
PLRO.COVCURNT=1/Yes).
Exclude Deleted Plans. See T.N. 52.

DESIGN NOTES

2:04:52 PM Wednesday, May 27, 2009

Page 126 of 151

CPS29B

CPS29B

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

CPSOPCURR2

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
No

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

487

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

If SP is alive and not institutionalized, display "currently".
Else do not display.
Display name of Medicare Prescription Drug Plan, PLAN.PLNAME,
added at CPS26 Source of Payment Roster.
If SP is deceased or institutionalized, display "on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)".
Else do not display.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:	

2:04:53 PM Wednesday, May 27, 2009	

[Are you/Is (SP)/Was (SP)] (currently) covered or enrolled in (CPS26
SOP MEDICARE PRESCRIPTION DRUG PLAN) [on (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION)]?
Page 127 of 151

CPS29B
Int. Instr II:
INPUT FIELDS / ROUTING
CPSOPCURR2

Field1:
Cheshire Name:

( CPS1707 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS29A - (CPS1710 )

English text: YES
No

BOX CPS29A - (CPS1710 )

English text: NO
Attribute
Don't know

Route
BOX CPS29A - (CPS1710 )

Refusal

BOX CPS29A - (CPS1710 )

BACKGROUND VARIABLE ASSIGNMENTS
COVCURNT	

Set PLRO.COVCURNT on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of MPDP
added at SOP roster and PLRO.PLRORND = current
round:
If CPS29B - CPSOPCURR2 = 1/Yes, set
PLRO.COVCURNT = 1/Yes.
Else set PLRO.COVCURNT = 2/No.

COVCURNT	

If CPS29A - CPMPDPCHNG = 1/Yes and CPS29B 
CPSOPCURR2 = 1/Yes, update
PLRO.PLROCOVURNT = 2/No on PLRO where
PLRO.PLROPLAN = PLAN.PLANNUM of pre
existing current MPDP and PLRO.PLRORNDC =
current round.

SOFT EDIT CHECKS

2:04:56 PM Wednesday, May 27, 2009	

Page 128 of 151

CPS29B

HARD EDIT CHECKS

TECHNICAL NOTES
59

SPStatus

SP is Alive and not institutionalized =
MRES.SPALIVE=1/Alive or empty
SP is Alive =
MRES.SPALIVE=1/Alive, 2/AliveAndInstitute, or EMPTY
SP is Institutionalized =
MRES.SPALIVE=2/AliveAndInstitute
SP is Deceased =
MRES.SPALIVE=3/Deceased.

DESIGN NOTES

2:04:56 PM Wednesday, May 27, 2009

Page 129 of 151

BOX CPS29A

BOX CPS29A

Page Order # :

490

BOX INSTRUCTIONS
( CPS1710 )

GO TO CPS27B_IN - NAVIGATOR ( CPS1677 ).

ASSIGNMENTS

TECHNICAL NOTES
248

SOPPlan

Source of Payment is a HI Plan =
Medicaid: TSOP.TSOPISHI=1/Medicaid
Public: TSOP.TSOPISHI=2/PublicPlan
Private: TSOP.TSOPISHI=3/PrivatePlan
MHMO: TSOP.TSOPISHI=7/MHMO
Tricare: TSOP.TSOPISHI=9/Tricare.
MPDP: TSOP.TSOPISHI=10/MedicarePartD

DESIGN NOTES
HI returns to CPS at BOX CPS29A.

2:04:56 PM Wednesday, May 27, 2009

Page 130 of 151

BOX CPS29B

BOX CPS29B

Page Order # :

500

BOX INSTRUCTIONS
( CPS1720 )	

IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT CPS26 IS A
DISCOUNT MEMBERSHIP PLAN, GO TO CPS29C - DMEMINTRO_CPS (
CPS1722 ).
ELSE GO TO BOX CPS29E - (CPS1737 ).

ASSIGNMENTS

TECHNICAL NOTES
374

SOPDmem

Source of Payment is a Discount Membership Plan =
TSOP.TSOPISHI = 8/DM.

DESIGN NOTES

2:04:56 PM Wednesday, May 27, 2009	

Page 131 of 151

CPS29C

CPS29C

Page Order # :

504

Design Screen Type:
Fields:	

Field 1:

DMEMINTRO_CPS

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
No
No

Roster Name:
Roster Type:
Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "(s)" in parenthesis.


Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

Int. Instr I:

Question Text:

Before we continue, I would like to ask you a few questions about

the discount membership plan(s) you just added.

Int. Instr II:
INPUT FIELDS / ROUTING

2:04:57 PM Wednesday, May 27, 2009	

Page 132 of 151

CPS29C
DMEMINTRO_CPS

Field1:
Cheshire Name:

( CPS1722 )

TEMP

Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS29C_IN - NAVIGATOR ( CPS1724 )

English text: CONTINUE
Attribute
Empty

Route
CPS29C_IN - NAVIGATOR ( CPS1724 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:04:59 PM Wednesday, May 27, 2009

Page 133 of 151

CPS29C_IN

CPS29C_IN

Page Order # :

Design Screen Type:

Instance Navigator

Fields:

Field 1:

NAVIGATOR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
No
No

505

Roster Name:
Roster Type:
Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Display all DM's added at CPS26 SOP Roster.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:05:00 PM Wednesday, May 27, 2009

Page 134 of 151

CPS29C_IN
NAVIGATOR

Field1:
Cheshire Name:

( CPS1724 )

N/A

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TInstanceNavigator
1
No
No

Number Label
1 SelectItemInList	
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS29C - (CPS1725 )

English text: ITEM SELECTED IN INSTANCE NAVIGATOR
SelectContinueInterview	
BOX CPS29D - (CPS1735 )
English text: CONTINUE INTERVIEW SELECTED

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
374

SOPDmem	

Source of Payment is a Discount Membership Plan =
TSOP.TSOPISHI = 8/DM.

DESIGN NOTES

2:05:02 PM Wednesday, May 27, 2009	

Page 135 of 151

BOX CPS29C

BOX CPS29C

Page Order # :

506

BOX INSTRUCTIONS
( CPS1725 )	

CREATE A NEW DISCOUNT MEMBERSHIP PLAN FOR THE SOURCE OF
PAYMENT ADDED AT CPS26 .
GO TO DM4 - DMSERVIC ( DMQ1070 ).

ASSIGNMENTS
DM details are collected on DMEM and DMRO:

DMEM key = DMEM.DMEMBASE + DMEM.DMEMNUM

DMEM.DMEMNUM = Number of DM created at BOX ST69C.

DMRO key = DMRO.DMROBASE + DMRO.DMRODMEM + DMRO.DMRORND

DMRO.DMRODMEM = DMEM.DMEMNUM of DM created at BOX CPS29C.

DMRO.DMRORND = current round.

See detailed instructions below.

DMEMNUM

DMEM.DMEMNUM = highest DMEM.DMEMNUM +

01.

DMEMRNDC

DMEM.DMEMRNDC = current round.

DMRODMEM

DMRO.DMRODMEM = DMEM.DMEMNUM.

DMRORND

DMRO.DMRORND = curent round.

DMHAVE

DMRO.DMHAVE = 1/Yes.

DMNAMEX

DMEM.DMNAMEX = TSOP.TSOPTEXT.

DMSOPFLG

DMEM.DMSOPFLG = 1/Yes.

TSOPTYPE

TSOP.TSOPTYPE = 9/DM.

TSOPDMEM

TSOP.TSOPDMEM = DMEM.DMEMNUM.

TECHNICAL NOTES

DESIGN NOTES
Calls DM section for Discount Membership plans added to SOP roster.
DM returns to CPS at BOX CPS29D.

2:05:02 PM Wednesday, May 27, 2009	

Page 136 of 151

BOX CPS29D

BOX CPS29D

Page Order # :

507

BOX INSTRUCTIONS
( CPS1735 )

GO TO CPS29C_IN - NAVIGATOR ( CPS1724 ).

ASSIGNMENTS

TECHNICAL NOTES
374

SOPDmem

Source of Payment is a Discount Membership Plan =
TSOP.TSOPISHI = 8/DM.

DESIGN NOTES
DM returns to CPS at BOX CPS29D.

2:05:02 PM Wednesday, May 27, 2009

Page 137 of 151

BOX CPS29E

BOX CPS29E

516

Page Order # :

BOX INSTRUCTIONS
( CPS1737 )	

IF AN "OTHER SOURCE OF PAYMENT" ADDED AT CPS26, CREATE AN
OSOP FOR EACH SOURCE OF PAYMENT ADDED AT CPS26 THAT IS AN
"OTHER SOURCE OF PAYMENT" .
GO TO BOX CPS29F - (CPS1739 ).

ASSIGNMENTS
Other Source of Payment details will be collected on OSOP:

OSOP key = OSOP.OSOPBASE + OSOP.OSOPNUM

OSOP.OSOPNUM = Number of Other Source of Payment generated at BOX CPS29E.

Create OSOP record for each OTHER SOURCE OF PAYMENT added at CPS26.

Set OSOP fields as specified below.

OSOPNUM

OSOP.OSOPNUM = highest OSOP.OSOPNUM + 01.


OSOPRNDC

OSOP.OSOPRNDC = current round.


OSOPTEXT

OSOP.OSOPTEXT = TSOP.TSOPTEXT.


TSOPTYPE

TSOP.TSOPTYPE = 4/OSOP.


TSOPOSOP

TSOP.TSOPOSOP = OSOP.OSOPNUM.


TSOPDISP

TSOP.TSOPDISP = "(OTHER)".


TECHNICAL NOTES
339

SOPIsOSOP

Source of Payment is an "Other Source of Payment" =
TSOP.TSOPISHI = 4/NotHIPlanVA, 5/MilitaryPlanNotVA,
or 6/NotSPsPlan.

DESIGN NOTES

2:05:02 PM Wednesday, May 27, 2009	

Page 138 of 151

BOX CPS29F

BOX CPS29F

2:05:02 PM Wednesday, May 27, 2009

Page Order # :

517


Page 139 of 151


BOX CPS29F
BOX INSTRUCTIONS
( CPS1739 )	

CREATE REIMBURSEMENTS FOR AMOUNTS ENTERED AT CPS27 .
GO TO CPS30 - REIMBCOV ( CPS1740 ).

ASSIGNMENTS
Reimbursement details are stored on REIM:

REIM key = REIM.REIMBASE + REIM.REIMNUM.

REIM.REIMNUM = Unique Number assigned to unique payer linked to this charge bundle.

REIM.REIMCOST = COST.COSTNUM for this charge bundle, not part of REIM key.

REIM records are only created for payers where TSOP.TSOPREIM ^= NULL.

TSOP.TSOPREIM may be >= 0, DK, or RF.

Only one REIM record will be created per unique payer per charge bundle.

We do not field REIM records collected in a previous round.

When backing up, if TSOP.TSOPREIM is updated, update existing REIM.REIMAMT =

TSOP.TSOPREIM.

Else create new REIM record.

DETAILS:

For each payer where TSOP.TSOPREIM >=0, DK, or RF:

If there is a REIM where REIM.REIMCOST = this charge bundle COST.COSTNUM and

((TSOP.TSOPTYPE = 1/SPFamily and REIM.REIMTYPE = 1/SPFamily) or
(TSOP.TSOP TYPE = 2/ProvDiscount and REIM.REIMTYPE = 2/ProvDiscount) or
(TSOP.TSOPTYPE = 5/VA and REIM.REIMTYPE = 5/VA) or
(TSOP.TSOPTYPE = 6/Medicare and REIM.REIMTYPE = 6/Medicare) or
(TSOP.TSOPTYPE = 7/OtherMilitaryPlanNotVA and REIM.REIMTYPE =
7/OtherMilitaryPlanNotVA) or
(TSOP.TSOPTYPE = 11/MedicareSubsidy and REIM.REIMTYPE =
11/MedicareSubsidy) or
(TSOP.TSOPTYPE = 12/ExtraHelp and REIM.REIMTYPE = 12/ExtraHelp) or
((TSOP.TSOPTYPE = 4/OSOP and REIM.REIMTYPE = 4/OSOP) and
(TSOP.TSOPOSOP = REIM.REIMOSOP)) or
((TSOP.TSOPTYPE = 9/DM and REIM.REIMTYPE = 9/DM) and (TSOP.TSOPDMEM =
REIM.REIMDMEM)) or
((TSOP.TSOPTYPE = 3/PlanNotMHMO and REIM.REIMTYPE = 3/PlanNotMHMO) and
(TSOP.TSOPPLAN = REIM.REIMPLAN)) or
((TSOP.TSOPTYPE = 8/MHMO and REIM.REIMTYPE = 8/MHMO) and
(TSOP.TSOPPLAN = REIM.REIMPLAN)) or
((TSOP.TSOPTYPE = 10/MedicarePartD and REIM.REIMTYPE = 10/MedicarePartD)
and (TSOP.TSOPPLAN = REIM.REIMPLAN))), then do:
This REIM record is linked to the current round charge bundle for this payer.
Update REIM.REIMAMT = TSOP.TSOPREIM.
Else do;
Create a new current round REIM record for this payer.
Set REIM.REIMAMT = TSOP.TSOPREIM.
Set additional fields on REIM as specified below.
CREATING A NEW REIM RECORD:

BASE.LASTREIM holds the highest REIM.REIMNUM prior to fielding cases. Not all records

2:05:02 PM Wednesday, May 27, 2009	

Page 140 of 151

BOX CPS29F
are fielded. The first time a REIM record is generated in the field, BASE.LASTREIM should
be >= to the highest REIM.REIMNUM fielded. The new REIM.REIMNUM should be
calculated based on BASE.LASTREIM + 001. Each time a REIM record is generated in the
field, BASE.LASTREIM will be updated to match the highest REIM.REIMNUM in the field.
Therefore, each time a REIM record is generated in the field, the new REIM.REIMNUM
should be calculated based on BASE.LASTREIM + 001. See detailed instructions below.
LASTREIM

If creating a new REIM record, set BASE.LASTREIM
to the new REIM.REIMNUM.

REIMNUM

If creating a new REIM record, set new
REIM.REIMNUM = BASE.LASTREIM + 001. This
assumes that BASE.LASTREIM is incremented each
time a REIM record is generated in the field.

REIMRNDC

If creating a new REIM record, REIM.REIMRNDC =
current round.

REIMTYPE

If creating a new REIM record, REIM.REIMTYPE =
TSOP.TSOPTYPE.

REIMPLAN

If creating a new REIM record, if TSOP.TSOPTYPE
= 3/PlanNotMHMO, 6/Medicare, 8/MHMO, or
10/MedicarePartD, set REIM.REIMPLAN =
TSOP.TSOPPLAN.

REIMOSOP

If creating a new REIM record, if TSOP.TSOPTYPE
= 4/OSOP, set REIM.REIMOSOP =
TSOP.TSOPOSOP.

REIMAMT

REIM.REIMAMT = TSOP.TSOPREIM.

REIMDMEM

If creating a new REIM record, if TSOP.TSOPTYPE
= 9/DM, set REIM.REIMDMEM = TSOP.TSOPDMEM.

REIMCOST

If creating a new REIM record, REIM.REIMCOST =
COST.COSTNUM.

TECHNICAL NOTES

DESIGN NOTES

2:05:02 PM Wednesday, May 27, 2009

Page 141 of 151

CPS30

CPS30

Page Order # :

Design Screen Type:

Yes/No

Fields:

Field 1:

REIMBCOV

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

520

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Multi Field display:


Roster/Grid Instructions:

Roster/Grid display:

Report display:


TEXT:

Context Header:

EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)
TOTAL CHARGE = $(TOTAL CHARGE)

Int. Instr I:

DOES THIS REIMBURSEMENT AMOUNT COVER ANY OTHER
EVENTS BESIDES THOSE SHOWN ABOVE?

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:05:03 PM Wednesday, May 27, 2009

Page 142 of 151

CPS30
REIMBCOV

Field1:
Cheshire Name:

( CPS1740 )

CORO.REIMBCOV

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesnodk
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
CPS31 - REIMCODE ( CPS1750 )

English text: YES
No

BOX CPS32 - (CPS1770 )

English text: NO
Attribute
Don't know

Route
BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:05:05 PM Wednesday, May 27, 2009

Page 143 of 151

CPS31

CPS31

Page Order # :

Design Screen Type:	

Code 1

Fields:	

Field 1:

REIMCODE

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

530

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "(S)" in interviewer instructions in parenthesis.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:


EVENT: (CHARGE BUNDLE EVENT)
(CHARGE BUNDLE EVENT) (etc.)

Int. Instr I:


WHAT OTHER TYPE(S) OF EVENT(S) ARE COVERD BY THIS
REIMBURSEMENT?

Question Text:

Int. Instr II:


CHECK ALL THAT APPLY.

INPUT FIELDS / ROUTING


2:05:08 PM Wednesday, May 27, 2009	

Page 144 of 151

CPS31

2:05:15 PM Wednesday, May 27, 2009

Page 145 of 151


CPS31
REIMCODE

Field1:
Cheshire Name:

( CPS1750 )

NONE
REPLACES THE FOLLOWING CHESHIRE VARIABLES:
1=REIM.REIMSBL
2=REIM.REIMSBD
3=REIM.REIMDU
4=REIM.REIMER
5=REIM.REIMIP
6=REIM.REIMOP
7=REIM.REIMIU
8=REIM.REIMHHP
9=REIM.REIMOHH
10=REIM.REIMMP
11=REIM.REIMOM
12=REIM.REIMPM

Item Text display:
Item Text:
Label:

Label Position:

Field Type:

Type Name:

Answers Allowed:

Drop Down List:

Lookup File:

Lookup File Name:


Enumerated
TREIMCode
12
No
No

FieldSize:
Min Value:
Max Value:
Mask:

Number Label
1 SBL
2

Route
CPS32 - REIMCOMMENT ( CPS1760 )
English text: SEPARATELY BILLING LAB (SL)
SBD
CPS32 - REIMCOMMENT ( CPS1760 )

3

English text: SEPARATELY BILLING DOCTOR (SD)
DU
CPS32 - REIMCOMMENT ( CPS1760 )

4

English text: DENTAL (DU)
ER

5

English text: HOSPITAL EMERGENCY ROOM (ER)
IP
CPS32 - REIMCOMMENT ( CPS1760 )

6

English text: HOSPITAL INPATIENT STAY (IP)
OP
CPS32 - REIMCOMMENT ( CPS1760 )

7

English text: HOSPITAL OUTPATIENT VISIT (OP)
IU
CPS32 - REIMCOMMENT ( CPS1760 )

8

English text: INSTITUTIONAL STAY (IU)
HP

CPS32 - REIMCOMMENT ( CPS1760 )

CPS32 - REIMCOMMENT ( CPS1760 )

English text: HOME HEALTH PROFESSIONAL (HP)

2:05:25 PM Wednesday, May 27, 2009

Page 146 of 151

CPS31

9

HF

CPS32 - REIMCOMMENT ( CPS1760 )

10

English text: OTHER HOME HEALTH (HF)
MP

CPS32 - REIMCOMMENT ( CPS1760 )

11

English text: OTHER VISITS TO MEDICAL PROVIDERS (MP)
OM
CPS32 - REIMCOMMENT ( CPS1760 )

12

English text: OTHER MEDICAL EXPENSES (OM)
PM
CPS32 - REIMCOMMENT ( CPS1760 )
English text: PRESCRIBED MEDICINES (PM)

Attribute
Don't know

Route
CPS32 - REIMCOMMENT ( CPS1760 )

BACKGROUND VARIABLE ASSIGNMENTS
If more than one REIMBURSEMENT was entered at CPS27, the response to CPS31 
REIMCODE should be copied to REIMCODE for each REIM generated. See instructions
below.
REIMCODE

Set REIM.REIMCODE = CPS31 - REIMCODE for all
REIMs generated at CPS27.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:05:28 PM Wednesday, May 27, 2009

Page 147 of 151

CPS32

CPS32

Page Order # :

Design Screen Type:	

No Entry

Fields:	

Field 1:

REIMCOMMENT

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

540

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:

Question display:

Always display "(PROVIDER(S), DATE(S), ETC.)" in parenthesis.


Multi Field display:


Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:	

PLEASE ENTER A COMMENT TO RECORD ANYTHING ELSE
YOU KNOW ABOUT THIS REFUND (PROVIDER(S), DATE(S),
ETC.)

Question Text:
Int. Instr II:
INPUT FIELDS / ROUTING

2:05:29 PM Wednesday, May 27, 2009	

Page 148 of 151

CPS32
REIMCOMMENT

Field1:
Cheshire Name:

( CPS1760 )

TEMP

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX CPS32 - (CPS1770 )

English text: CONTINUE
Attribute
Empty

Route
BOX CPS32 - (CPS1770 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

2:05:31 PM Wednesday, May 27, 2009

Page 149 of 151

BOX CPS32

BOX CPS32

Page Order # :

550

BOX INSTRUCTIONS
( CPS1770 )

GO TO BOX CPSBEG - (CPS1010 ).

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

2:05:31 PM Wednesday, May 27, 2009

Page 150 of 151

BOX CPSEND

BOX CPSEND

Page Order # :

690

BOX INSTRUCTIONS
( CPS1785 )

GO TO NEXT SECTION. .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

2:05:31 PM Wednesday, May 27, 2009

Page 151 of 151
File Type	application/pdf
Author	hubbard_r
File Modified	2010-04-02
File Created	0000-00-00