MEPS-HC Core Interview

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Attachment 32 -- HC Charge Payment Section

MEPS-HC Core Interview

OMB: 0935-0118

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0118 can be found here:

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MEPS FAMES P12R5/P13R3/P14R1 Charge Payment (CP) Section

DCecember 8, 2008

Charge Payment (CP) Section

BOX_00A

=======

----------------------------------------------------

| CONTEXT HEADER DISPLAY INSTRUCTIONS: |

| DISPLAY PROV.PROVNAME, EVPV.EVNTTYPE, |

| EVPV.EVNTBEGM, EVPV.EVNTBEGD, EVPV.EVNTBEGY, |

| EVPV.EVNTENDM, EVPV.EVNTENDD, EVPV.EVNTENDY, |

| PRND.BEGREFMM, PRND.BEGREFDD, PRND.BEGREFYY, |

| PRND.ENDREFMM, PRND.ENDREFDD, PRND.ENDREFYY, |

| EVPV.RVNAME, FFEE.FFEENAME |

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

| |

| FOR ‘{EVN - DT}’, DISPLAYED IN THE CONTEXT HEADER,|

| DISPLAY THE START DATE OF THE CURRENT ROUND FOR OM|

| EVENTS THAT ARE ‘REGULAR’ GROUP TYPE (EV02A=1 OR |

| NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM EVENTS THAT|

| ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2). |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

BOX_00

======

----------------------------------------------------

| THROUGHOUT THE CHARGE/PAYMENT (CP) SECTION, |

| ENTRY OF ALL DOLLAR AMOUNTS WILL INCLUDE ONLY |

| WHOLE DOLLARS. ENTRY OF CENTS WILL BE DISALLOWED.|

----------------------------------------------------

| SOME ITEMS (CP01B, CP12A, CP14A, CP20, CP23, AND |

| CP25) IN THIS SECTION ALLOW THE ADDITION OF A |

| SOURCE OF PAYMENT FOR THE RU. WHEN THE INTERVIEWER|

| SELECTS THE “ADD” LINK, CAPI DISPLAYS A POP-UP |

| WITH A BLANK ENTRY FIELD AND A SELECTABLE PICK |

| LIST OF SOME COMMON SOURCES AS FOLLOWS: |

| |

| GOVERNMENT SOURCES |

| - ‘MEDICARE’ |

| - ‘MEDICAID/{STATE NAME FOR MEDICAID}’ |

| - ‘SCHIP/{STATE NAME FOR CHIP}’ |

| - ‘VA/(VETERAN’S ADMINISTRATION)/CHAMPVA’ |

| - ‘TRICARE’ |

| - ‘MILITARY FACILITY’ |

| - ‘INDIAN HEALTH SERVICE’ |

| - ‘WORKER’S COMPENSATION’ |

| PRIVATE SOURCES |

| - ‘AARP’ |

| - ‘AETNA’ |

| - ‘BLUE CROSS/BLUE SHIELD’ |

| - ‘CIGNA’ |

| - ‘DELTA DENTAL’ |

| - ‘KAISER/KAISER PERMANENTE’ |

| - ‘UNITED HEALTHCARE’ |

| |

| THE PICK LIST EXPEDITES THE ENTRY OF ONE OF THESE |

| COMMON SOURCES. ONCE THE INTERVIEWER SELECTS FROM |

| THE PICK LIST (OR TYPES AN ENTRY) AND RETURNS TO |

| THE MAIN SCREEN, THE ADDED SOURCE OF PAYMENT |

| APPEARS IN THE ROSTER AS SELECTED. |

----------------------------------------------------

| BEGINNING IN PANEL 13, ROUND 1, THE SOURCE OF |

| PAYMENT PICK LIST GROUPS VA AND CHAMPVA TOGETHER |

| RATHER THAN TRICARE AND CHAMPVA AS PAST ROUNDS |

| HAVE DONE. |

| |

| THE SOP PICK LIST FOR ALL ROUNDS OF PANEL 12 |

| READS: |

| |

| ‘VA/VETERAN’S ADMINISTRATION’ |

| ‘TRICARE/CHAMPVA’ |

| |

| THE PICK LIST FOR ALL ROUNDS OF PANEL 13 READS: |

| ‘VA (VETERAN’S ADMINISTRATION)/CHAMPVA’ |

| ‘TRICARE’ |

----------------------------------------------------

| IF EVENT TYPE IS HH |

| AND |

| HH PROVIDER ASSOCIATED WITH THE EVENT BEING ASKED |

| ABOUT IS FLAGGED AS ‘AGENCY’ OR ‘INFORMAL’, |

| GO TO BOX_26 |

----------------------------------------------------

| IF EVENT TYPE IS MV AND MV01 IS CODED ‘2’ |

| (TELEPHONE CALL) |

| OR |

| IF EVENT TYPE IS OP AND OP02 IS CODED ‘2’ |

| (TELEPHONE CALL), |

| GO TO BOX_26 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_01 |

----------------------------------------------------

BOX_01

======

----------------------------------------------------

| IF EVENT TYPE IS PM AND IS OM TYPE 2 OR 3, GO |

| TO CP03 |

----------------------------------------------------

| IF EVENT TYPE IS PM AND IS NOT OM TYPE 2 OR 3, |

| CONTINUE WITH BOX_02 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_03 |

----------------------------------------------------

BOX_02

======

----------------------------------------------------

| IF PERSON ALREADY FLAGGED AS ‘NO CP INFORMATION |

| FOR PM EVENTS NECESSARY’ FOR THE CURRENT ROUND, GO|

| TO BOX_26 |

----------------------------------------------------

| IF PERSON ALREADY FLAGGED AS ‘CP INFORMATION FOR |

| PM EVENTS NECESSARY’ FOR THE CURRENT ROUND, GO TO |

| CP03 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH CP01A |

----------------------------------------------------

CP01A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}

Now I’d like to ask you about the charges for (PERSON)’s

prescription medicine.

Has (PERSON)’s health insurance or another source of coverage

helped pay for any of (PERSON)’s prescription medications since

(START DATE)?

CODE “NO” IF PERSON REPORTS NO HEALTH INSURANCE OR ANOTHER SOURCE

OF COVERAGE.

YES .................................... 1 {CP01B}

NO ..................................... 2 {CP01C}

REF ................................... -7 {CP01C}

DK .................................... -8 {CP01C}

HELP AVAILABLE FOR DEFINITION OF HEALTH INSURANCE OR ANOTHER SOURCE OF COVERAGE.

----------------------------------------------------

| QUESTIONS CP01A THROUGH CP01C WERE REVISED IN |

| PANEL 12 ROUND 3. STARTING IN PANEL 13, THESE |

| ITEMS WILL BE INCORPORATED IN ALL ROUNDS. |

----------------------------------------------------

CP01B

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {EV}

{EVN-DT}

Who usually helps pay?

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.

TO LEAVE, PRESS ESC.

[1. Name of Source of Direct Payment-35]

[2. Name of Source of Direct Payment-35]

[3. Name of Source of Direct Payment-35]

HELP AVAILABLE FOR DEFINITION OF SOURCE OF PAYMENT.

[Code One]

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE SOURCES-OF-PAYMENT |

| ROSTER. |

----------------------------------------------------

| CONTINUE WITH CP01C |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE ADD AND MULTIPLE SELECT ALLOWED. |

| |

| 2. ADD ALLOWED. THE SCREEN DISPLAYS A LINK “ADD A |

| SOURCE OF PAYMENT” THAT THE INTERVIEWER CAN |

| SELECT. SELECTING THE LINK DISPLAYS A POP-UP WITH |

| A TEXT ENTRY FIELD AND A SELECTABLE LIST OF 15 |

| COMMON SOURCES OF PAYMENT. (SEE BOX_00 FOR A |

| DETAILED LIST). THE INTERVIEWER CAN TYPE A NEW |

| SOURCE OR SELECT ONE FROM THE LIST. UPON RETURN TO|

| CP01B, THE ADDED SOURCE WILL APPEAR ON THE ROSTER |

| AS SELECTED. |

| |

| 3. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE |

| SOURCE OF PAYMENT. |

| |

| 4. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS|

| NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR |

| MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST|

| ENTERED.’ |

| |

| 5. LIMITED EDIT ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, EDITING IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. IF EDIT IS ATTEMPTED WHEN IT IS |

| NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR |

| MESSAGE: ‘EDIT ALLOWED ONLY WHEN SOURCE FIRST |

| ENTERED.’ |

| |

| 6. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES OF PAYMENT THAT ARE NOT |

| PERSON/FAMILY. |

----------------------------------------------------

CP01C

=====

{PERSON'S FIRST MIDDLE AND LAST NAME}

How much did (PERSON) pay out-of-pocket for (PERSON)’s last

prescription?

IF AMOUNT PAID IS NOTHING, ENTER 0.

IF AMOUNT PAID VARIES DEPENDING ON TYPE OF MEDICATION, ENTER

THE OUT-OF-POCKET COST FOR THE LAST PRESCRIPTION FILLED DURING THE

REFERENCE PERIOD.

IF MORE THAN ONE PRESCRIPTION WAS FILLED AT THE SAME TIME, ENTER THE

AMOUNT FOR THE LAST PRESCRIPTION ON RECEIPT.

[Enter $ Amount] ....................... {CP01}

REF ................................... -7 {CP01}

DK .................................... -8 {CP01}

----------------------------------------------------

| HARD RANGE CHECK: $0 - $999,999 |

----------------------------------------------------

CP01COV2

========

OMITTED.

PERCENT:

----------------------------------------------------

| BEGINNING IN PANEL 13 ROUND 2 AND PANEL 12 ROUND |

| 4, CP01C IS ASKED OF ALL PERSONS ASKED CP01A. |

| PERCENT WAS REMOVED FROM CP01 AT THE SAME TIME. |

----------------------------------------------------

CP01

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {EV}

{EVN-DT}

(Do/Does) (PERSON) (or someone in the family) send in a claim

form to the insurance company for (PERSON)’s prescription

medicines or does the pharmacy automatically do this for

(PERSON)’s prescription medicines?

FAMILY SENDS IN CLAIM FORMS ............ 1 {CP03}

PHARMACY AUTOMATICALLY FILES CLAIM ..... 2 {BOX_26}

NOT EITHER TYPE OF SITUATION ........... 3 {BOX_26}

REF ................................... -7 {CP03}

DK .................................... -8 {CP03}

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

[Code One]

----------------------------------------------------

| IF CODED ‘2’ (PHARMACY AUTOMATICALLY FILES CLAIM),|

| OR ‘3’ (NOT EITHER TYPE OF SITUATION), FLAG THIS |

| PERSON AS ‘NO CP INFORMATION FOR PM EVENTS |

| NECESSARY’ FOR THE CURRENT ROUND. |

----------------------------------------------------

| IF CODED ‘1’ (FAMILY SENDS IN CLAIM FORMS), ‘-7’ |

| (REFUSED), OR ‘-8’ (DON’T KNOW), FLAG THIS PERSON |

| AS ‘CP INFORMATION FOR PM EVENTS NECESSARY’ FOR |

| THE CURRENT ROUND. |

----------------------------------------------------

BOX_03

======

----------------------------------------------------

| IF FIRST TIME THROUGH CHARGE PAYMENT FOR THIS |

| PERSON-PROVIDER PAIR AND PAIR WAS FLAGGED AS |

| ‘COPAYMENT SITUATION’ DURING THE PREVIOUS ROUND, |

| CONTINUE WITH CP02 |

----------------------------------------------------

| OTHERWISE, GO TO CP03 |

----------------------------------------------------

CP02

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Before we talk about the charges for (PERSON)’S visit to (PROVIDER)

on (VISIT DATE), let me take a moment to verify some information.

Last time we recorded that (PERSON) (or someone in the family)

usually pay(s) a {$ AMT COPAY} copayment to (PROVIDER). Is

this still the correct copayment amount?

YES .................................... 1 {CP03}

NO ..................................... 2 {CP02OV}

NOT A COPAYMENT SITUATION ANYMORE ..... 99 {CP03}

REF ................................... -7 {CP03}

DK .................................... -8 {CP03}

[Code One]

HELP AVAILABLE FOR DEFINITION OF COPAYMENT.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {$ AMT COPAY}: DISPLAY THE CP11OV1 AMOUNT FLAGGED|

| AS ‘COPAYMENT SITUATION’ DURING THE PREVIOUS ROUND|

| FOR THIS PERSON-PROVIDER PAIR. |

----------------------------------------------------

| IF CODED ‘99’ (NOT A COPAYMENT SITUATION ANYMORE),|

| FLAG THIS PERSON-PROVIDER AND THIS PERSON AS ‘NOT |

| A COPAYMENT SITUATION’ FOR THE CURRENT ROUND. |

----------------------------------------------------

| IF CODED ‘1’ (YES), ‘-7’ (REFUSED), OR ‘-8’ |

| (DON’T KNOW), FLAG THIS PERSON-PROVIDER PAIR AND |

| THIS PERSON AS ‘COPAYMENT SITUATION’ FOR THE |

| CURRENT ROUND AND SET COPAYMENT AMOUNT FROM THE |

| PREVIOUS ROUND AS THE PERSON’S COPAYMENT AMOUNT |

| FOR THE CURRENT ROUND. |

----------------------------------------------------

CP02OV

======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

What is the correct copayment amount?

[Enter $ Amount] ...................... {CP03}

NOT A COPAYMENT SITUATION ANYMORE ..... 99 {CP03}

REF ................................... -7 {CP03}

DK .................................... -8 {CP03}

HELP AVAILABLE FOR DEFINITION OF COPAYMENT.

----------------------------------------------------

| SET DOLLAR AMOUNT ENTERED AT CP02OV AS THE NEW |

| COPAYMENT AMOUNT FOR THIS PERSON-PROVIDER PAIR |

| FOR THE CURRENT ROUND. USE THIS AMOUNT IN CP04. |

----------------------------------------------------

| IF CODED ‘99’ (NOT A COPAYMENT SITUATION ANYMORE),|

| DO NOT FLAG THIS PERSON-PROVIDER AS ‘COPAYMENT |

| SITUATION’ FOR THE CURRENT ROUND. |

----------------------------------------------------

| IF CODED ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW), |

| FLAG THIS PERSON-PROVIDER PAIR AS ‘COPAYMENT |

| SITUATION’ FOR THE CURRENT ROUND AND SET COPAYMENT|

| AMOUNT FROM PREVIOUS ROUND AS COPAYMENT AMOUNT FOR|

| THE CURRENT ROUND. |

----------------------------------------------------

| HARD CHECK: |

| $1 - $50. |

----------------------------------------------------

| HARD CHECK: |

| COPAYMENT DOLLAR AMOUNT MUST BE WHOLE DOLLAR |

| AMOUNT < OR = $50. |

----------------------------------------------------

CP03

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Now I'd like to ask you about the charges for {(PERSON)'s stay

at (HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit to

(PROVIDER) on (VISIT DATE)/the last purchase of {NAME OF

PRESCRIBED MEDICINE} for (PERSON)/the services for (FLAT FEE

GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used by (PERSON)

since (START DATE)/services received at home from (PROVIDER)

during (MONTH) for (PERSON)}.

{Let's begin with the charges from the hospital itself, not

including any separate physician services or lab tests.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR DEFINITION OF CHARGE.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| DISPLAY ‘(PERSON)'s stay at (HOSPITAL) that began |

| on (ADMIT DATE)’ IF EVENT TYPE IS HS. |

| |

| DISPLAY ‘(PERSON)'s visit to (PROVIDER) on (VISIT |

| DATE)’ IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| DISPLAY ‘the last purchase of {NAME OF PRESCRIBED |

| MEDICINE} for (PERSON)’ IF EVENT TYPE IS PM. |

| |

| FOR ‘{NAME OF PRESCRIBED MEDICINE}’, DISPLAY THE|

| NAME OF THE PRESCRIPTION MEDICINE BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘the services for (FLAT FEE GROUP) for |

| (PERSON)’ IF EVENT-PROVIDER PAIR REPRESENTS A FLAT|

| FEE GROUP. |

| |

| DISPLAY ‘the {OME ITEM GROUP NAME} used by |

| (PERSON) since (START DATE)’ IF EVENT TYPE IS OM. |

----------------------------------------------------

| FOR {OME ITEM GROUP NAME}, DISPLAY THE NAME OF |

| THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT, AS FOLLOWS: |

| |

| DISPLAY ‘glasses or contact lenses’ IF THE OM |

| ITEM GROUP IS ‘1’ (GLASSES OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR THE OM EVENT BEING ASKED ABOUT. |

----------------------------------------------------

| FOR ‘{EVN - DT}’, DISPLAYED IN THE CONTEXT HEADER,|

| DISPLAY THE START DATE OF THE CURRENT ROUND FOR OM|

| EVENTS THAT ARE ‘REGULAR’ GROUP TYPE (EV02A=1 OR |

| NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM EVENTS THAT|

| ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2). |

| |

| DISPLAY ‘services received at home from (PROVIDER)|

| during (MONTH) for (PERSON)’ IF EVENT TYPE IS HH. |

| |

| DISPLAY ‘{Let's begin with the charges from the |

| hospital itself, not including any separate |

| physician services or lab tests.}’ IF EVENT TYPE |

| IS HS. |

----------------------------------------------------

| IF PERSON-PROVIDER PAIR FLAGGED AS ‘COPAYMENT |

| SITUATION’ FOR THE CURRENT ROUND, AND THIS EVENT- |

| PROVIDER PAIR DOES NOT REPRESENT A FLAT FEE GROUP,|

| GO TO CP04 |

----------------------------------------------------

| IF ROUND 3 OR 5 AND IF EVENT TYPE IS OM AND OM |

| GROUP TYPE IS ‘ADDITIONAL’ (EV02A=2), CONTINUE |

| WITH CP03A. (NOTE THAT ADDITIONAL OM EVENTS CAN |

| BE ENTERED IN ROUNDS 3 AND 5 ONLY. |

----------------------------------------------------

| OTHERWISE, GO TO CP05 |

----------------------------------------------------

CP03A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Did (PERSON) (or anyone in the family) purchase or rent the

{OME ITEM GROUP NAME} used by (PERSON)?

SELECT ‘NO CHARGE’ IF RESPONDENT VOLUNTEERS OME ITEM GROUP HAD

NO CHARGE BECAUSE IT WAS BORROWED OR FREE FROM A CHARITY, ETC.

PURCHASED .............................. 1 {CP05}

RENTED ................................. 2 {CP05}

NO CHARGE: BORROWED, FREE FROM

CHARITY/ORGANIZATION, ETC. .......... 95 {BOX_26}

REF ................................... -7 {CP05}

DK .................................... -8 {CP05}

[Code One]

CP04

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Is this the type of situation where (PERSON) (or someone in

the family) only paid the {$ AMT COPAY} copayment for this

visit and (PERSON) (do/does) not know the total charge?

YES .................................... 1 {CP37}

NO ..................................... 2 {CP05}

REF ................................... -7 {CP05}

DK .................................... -8 {CP05}

HELP AVAILABLE FOR DEFINITION OF COPAYMENT AND TOTAL CHARGE.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {$ AMT COPAY}: DISPLAY THE CP02OV OR CP11OV1 |

| AMOUNT FLAGGED AS ‘COPAYMENT SITUATION’ FOR THE |

| CURRENT ROUND FOR THIS PERSON-PROVIDER PAIR. |

----------------------------------------------------

| IF CODED ‘1’ (YES), COPY ALL PREVIOUS COPAYMENT |

| CHARGE PAYMENT DATA FOR THE PERSON-PROVIDER PAIR |

| TO THIS EVENT-PROVIDER-PAIR. |

----------------------------------------------------

| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |

| KNOW), IGNORE ‘COPAYMENT SITUATION’ FLAG FOR THIS |

| PERSON-PROVIDER PAIR FOR THIS EVENT (THAT IS, |

| COLLECT CHARGE/PAYMENT INFORMATION FOR THIS EVENT-|

| PROVIDER PAIR). |

----------------------------------------------------

| IF CODED ‘1’ (YES), GO TO CP37 |

----------------------------------------------------

| IF CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T |

| KNOW), CONTINUE WITH CP05 |

----------------------------------------------------

CP05

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

(Have/Has) (PERSON) (or anyone in the family) received

anything in writing, such as a bill, receipt, or statement,

for {(PERSON)'s stay at (HOSPITAL) that began on (ADMIT DATE)/

(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last

purchase of {NAME OF PRESCRIBED MEDICINE} for (PERSON)/the

services for (FLAT FEE GROUP) for (PERSON)/the {OME ITEM GROUP

NAME} used by (PERSON) since (START DATE)/services received at

home from (PROVIDER) during (MONTH) for (PERSON)}?

PROBE: Include anything in writing received by family members

living with (PERSON) as well as those living somewhere else.

YES, AND DOCUMENTATION AVAILABLE ....... 1 {CP08}

YES, BUT DOCUMENTATION NOT AVAILABLE ... 2 {CP08}

NO ..................................... 3 {CP06}

NO, FREE SAMPLE ........................ 4 {CP37}

REF ................................... -7 {CP06}

DK .................................... -8 {CP06}

[Code One]

HELP AVAILABLE FOR DEFINITION OF ANYTHING IN WRITING.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

| ‘NO, FREE SAMPLE’ IS A RADIO BUTTON BELOW THE |

| ENTRY FIELD. |

----------------------------------------------------

| DISPLAY NO, FREE SAMPLE RESPONSE CATEGORY AND THE |

| CORRESPONDING RADIO BUTTON ONLY IF THE EVENT TYPE |

| OF THE EVENT-PROVIDER PAIR IS PM. |

----------------------------------------------------

CP06

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

SHOW CARD CP-1.

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Why (have/has) (PERSON) (or anyone in the family) not received

anything in writing?

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE

SITUATION.}

PAID AT TIME OF VISIT ................... 1 {CP08}

MADE A COPAYMENT ........................ 2 {CP08}

BILL SENT DIRECTLY TO OTHER SOURCE ...... 3 {CP07}

BILL HAS NOT ARRIVED .................... 4 {CP08}

NO BILL SENT:

HMO PLAN .............................. 5 {BOX_04}

VA (VETERANS ADMINISTRATION)/CHAMPVA... 6 {BOX_04}

INDIAN HEALTH SERVICE (IHS) .......... 15 {BOX_04}

MILITARY FACILITY ..................... 7 {BOX_04}

PUBLIC ASSISTANCE/MEDICAID/SCHIP ...... 8 {BOX_04}

WORKER’S COMPENSATION ................. 9 {BOX_04}

PRIVATE HEALTH CENTER/CLINIC .......... 10 {BOX_04}

PUBLIC CLINIC/HEALTH CENTER OR PRIVATE

CHARITY ............................ 11 {BOX_04}

NO CHARGE: TELEPHONE CALL ............. 12 {CP37}

FREE FROM PROVIDER ..................... 13 {CP37}

GOVERNMENT-FINANCED RESEARCH AND

CLINICAL TRIALS ........................ 14 {CP37}

INCLUDED WITH OTHER CHARGES ............ 95

REF .................................... -7 {CP08}

DK ..................................... -8 {CP08}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES AND FLAT FEE.

----------------------------------------------------

| BEGINNING IN PANEL 13, ROUND 1, RESPONSE CATEGORY |

| 6 AT CP06 GROUPS VA AND CHAMPVA TOGETHER. |

| |

| CATEGORY 6 AT CP06 FOR ALL ROUNDS OF PANEL 12 |

| READS: |

| |

| ‘VA (VETERANS ADMINISTRATION)’ |

| |

| CATEGORY 6 AT CP06 FOR ALL ROUNDS OF PANEL |

| 13 AND BEYOND READS: |

| |

| ‘VA (VETERANS ADMINISTRATION)/CHAMPVA’ |

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

| |

| DISPLAY THE INTERVIEWER INSTRUCTION ‘SELECT |

| “INCLUDED WITH OTHER CHARGES” IF THIS IS A FLAT |

| FEE SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT |

| REPRESENT A FLAT FEE. OTHERWISE, USE A NULL |

| DISPLAY. |

----------------------------------------------------

| NOTE: SHOW CARD FOR CODE ‘10’ WILL READ: ‘SCHOOL,|

| EMPLOYER, OR OTHER PRIVATE HEALTH CENTER/CLINIC’. |

| THE SHOW CARD FOR CODE ‘11’ WILL INCLUDE THE |

| FOLLOWING: ‘(INCLUDE COMMUNITY AND MIGRANT HEALTH|

| CENTER, FEDERALLY QUALIFIED HEALTH CENTER, INDIAN |

| HEALTH SERVICE)’. THE SHOW CARD FOR CODE ‘13’ |

| WILL INCLUDE THE FOLLOWING: ‘(PROFESSIONAL |

| COURTESY/FREE SAMPLE)’. THESE CODES HAVE BEEN |

| ABBREVIATED TO CONSERVE SPACE ON THE SCREEN. |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, |

| DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT |

| AVAILABLE FOR A PM EVENT.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT |

| STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE |

| GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A FLAT FEE GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED, AND |

| THE EVENT TYPE IS NOT PM AND EVENT-PROVIDER |

| PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A |

| REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.|

----------------------------------------------------

| INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN |

| PANEL 12 ROUND 3. STARTING IN PANEL 13, IT |

| WILL BE AVAILABLE IN ALL ROUNDS. |

----------------------------------------------------

CP07

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

To whom was the bill sent?

RECORD VERBATIM. TO CONTINUE PRESS TAB AND THEN ENTER, OR SELECT

NEXT PAGE.

[Enter Text] ........................... {CP07OV1}

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

CP07OV1

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: SELECT TYPE OF ORGANIZATION TO WHOM BILL

WAS SENT:

HMO .................................... 1 {BOX_04}

VA (VETERANS ADMINISTRATION)/CHAMPVA.... 2 {BOX_04}

TRICARE ................................ 3 {CP08}

Other Military ......................... 4 {BOX_04}

PUBLIC ASSISTANCE/Medicaid/SCHIP ....... 5 {BOX_04}

Worker’s Compensation .................. 6 {BOX_04}

Private Insurance Company .............. 7 {BOX_04}

INDIAN HEALTH SERVICE (IHS) ............ 8 {box_04}

OTHER ................................. 91 {CP08}

REF ................................... -7 {CP08}

DK .................................... -8 {CP08}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

----------------------------------------------------

| INDIAN HEALTH SERVICE (IHS) WAS INTRODUCED IN |

| PANEL 12 ROUND 3. STARTING IN PANEL 13, IT |

| WILL BE AVAILABLE IN ALL ROUNDS. IT IS DISPLAYED |

| ON THE PICK LIST BETWEEN VA/CHAMPVA AND TRICARE. |

----------------------------------------------------

| BEGINNING IN PANEL 13, ROUND 1, THE RESPONSE |

| CATEGORIES AT CP07OV1 GROUP VA AND CHAMPVA |

| TOGETHER RATHER THAN TRICARE AND CHAMPVA AS PAST |

| ROUNDS HAVE DONE. |

| |

| CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF |

| PANEL 12 READ: |

| |

| ‘VA (VETERANS ADMINISTRATION)’ |

| ‘TRICARE/CHAMPVA’ |

| |

| CATEGORIES 2 AND 3 AT CP07OV1 FOR ALL ROUNDS OF |

| PANEL 13 AND BEYOND READ: |

| |

| ‘VA (VETERANS ADMINISTRATION)/CHAMPVA’ |

| ‘TRICARE’ |

----------------------------------------------------

BOX_04

======

----------------------------------------------------

| IF: |

| - EVENT TYPE IS OM, HH, OR PM |

| OR |

| - EVENT TYPE IS HS |

| OR |

| - THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP, |

| GO TO CP11 |

----------------------------------------------------

| OTHERWISE, GO TO CP10 |

----------------------------------------------------

CP08

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Do you know the total charge for {(PERSON)'s stay at

(HOSPITAL) that began on (ADMIT DATE)/(PERSON)'s visit

to (PROVIDER) on (VISIT DATE)/the last purchase of {NAME OF

PRESCRIBED MEDICINE} for (PERSON)/the services for

(FLAT FEE GROUP) for (PERSON)/the {OME ITEM GROUP NAME} used

by (PERSON) since (START DATE)/services received at home from

(PROVIDER) during (MONTH) for (PERSON)}?

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE

SITUATION.}

YES .................................... 1 {CP09}

NO ..................................... 2

INCLUDED WITH OTHER CHARGES ........... 95

REF ................................... -7

DK .................................... -8

HELP AVAILABLE FOR DEFINITIONS OF TOTAL CHARGE AND FLAT FEE.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| DISPLAY ‘(PERSON)'s stay at (HOSPITAL) that began |

| on (ADMIT DATE)’ IF EVENT TYPE IS HS. |

| |

| DISPLAY ‘(PERSON)'s visit to (PROVIDER) on (VISIT |

| DATE)’ IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| DISPLAY ‘the last purchase of {NAME OF PRESCRIBED |

| MEDICINE} for (PERSON)’ IF EVENT TYPE IS PM. |

| |

| FOR ‘{NAME OF PRESCRIBED MEDICINE}’, DISPLAY THE|

| NAME OF THE PRESCRIPTION MEDICINE BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘the services for (FLAT FEE GROUP) for |

| (PERSON)’ IF EVENT-PROVIDER PAIR REPRESENTS A FLAT|

| FEE GROUP. |

| |

| DISPLAY ‘the {OME ITEM GROUP NAME} used by |

| (PERSON) since (START DATE)’ IF EVENT TYPE IS OM. |

----------------------------------------------------

| FOR {OME ITEM GROUP NAME}, DISPLAY THE NAME OF |

| THE OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT AS FOLLOWS: |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR THE OM EVENT BEING ASKED ABOUT. |

----------------------------------------------------

| FOR ‘{START DATE}’, IN THE CONTEXT HEADER, DISPLAY|

| THE START DATE OF THE CURRENT ROUND FOR OM EVENTS |

| THAT ARE ‘REGULAR’ GROUP TYPE (EV02A=1 OR NOT |

| ASKED) AND DISPLAY ‘JAN 01’ FOR OM EVENTS THAT |

| ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2). |

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

| |

| DISPLAY THE INTERVIEWER INSTRUCTION ‘SELECT |

| “INCLUDED WITH OTHER CHARGES” IF THIS IS A FLAT |

| FEE SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT |

| REPRESENT A FLAT FEE. OTHERWISE, USE A NULL |

| DISPLAY. |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT TYPE OF THE EVENT-PROVIDER PAIR IS PM, |

| DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE IS NOT |

| AVAILABLE FOR A PM EVENT.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE |

| GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A FLAT FEE GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT |

| STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER |

| PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A |

| REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.|

----------------------------------------------------

| IF: |

| CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T |

| KNOW) |

| AND |

| (EVENT TYPE IS OM, HH, OR PM |

| OR |

| EVENT TYPE IS HS |

| OR |

| THIS EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE |

| GROUP), |

| GO TO CP11 |

----------------------------------------------------

| IF: |

| CODED '2' (NO), '-7' (REFUSED), OR '-8' (DON'T |

| KNOW) |

| AND |

| EVENT TYPE IS ER, OP, MV, OR DN |

| GO TO CP10 |

----------------------------------------------------

CP09

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

How much was the total charge for {(PERSON)'s stay at (HOSPITAL)

that began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on

(VISIT DATE)/the last purchase of {NAME OF PRESCRIBED

MEDICINE} for (PERSON)/the services for (FLAT FEE GROUP) for

(PERSON)/the {OME ITEM GROUP NAME} used by (PERSON) since

(START DATE)/services received at home from (PROVIDER) during

(MONTH) for (PERSON)}?

Please include any amounts that may be paid by health insurance

or other sources. {However, please do not include any services

billed for separately such as physician charges or other

services.}

{If charges for procedures such as x-rays, lab tests, or

diagnostic procedures are listed separately on the bill or

statement, include those in the total charge.}

IF WORKING FROM DOCUMENTATION, ENTER TOTAL CHARGES. DO NOT

DEDUCT DISCOUNTS OR DISALLOWED OR DENIED CHARGES.

{SELECT ‘INCLUDED WITH OTHER CHARGES’ IF THIS IS A FLAT FEE

SITUATION.}

AMOUNT ................................. 1 {CP09OV}

INCLUDED WITH OTHER CHARGES ........... 95

[Code One]

HELP AVAILABLE FOR DEFINITION OF WHAT MAKES UP TOTAL CHARGE

AND FLAT FEE.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

| DISPLAY ‘However, please do not include any |

| services billed for separately such as physician |

| charges or other services.’ IF EVENT TYPE IS HS, |

| ER, OR OP. OTHERWISE, USE A NULL DISPLAY. |

| |

| DISPLAY ‘If charges for procedures such as x-rays,|

| lab tests, or diagnostic procedures are listed |

| separately on the bill or statement, include those|

| in the total charge.’ IF CP05 IS CODED ‘1’ (YES, |

| AND DOCUMENTATION AVAILABLE). OTHERWISE, USE A |

| NULL DISPLAY. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

----------------------------------------------------

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| DISPLAY INTERVIEWER INSTRUCTION ‘SELECT “INCLUDED |

| WITH OTHER CHARGES” IF THIS IS A FLAT FEE |

| SITUATION’ IF EVENT-PROVIDER PAIR DOES NOT |

| REPRESENT A FLAT FEE GROUP. OTHERWISE, USE A NULL |

| DISPLAY. |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ DISPLAY THE |

| FOLLOWING MESSAGE: 'THIS CODE IS NOT AVAILABLE |

| FOR A PM EVENT.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE |

| GROUP, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A FLAT FEE GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT-PROVIDER PAIR REPRESENTS A REPEAT VISIT |

| STEM, DISPLAY THE FOLLOWING MESSAGE: 'THIS CODE |

| IS NOT AVAILABLE FOR A REPEAT VISIT GROUP.' |

----------------------------------------------------

| IF ‘INCLUDED WITH OTHER CHARGES’ IS SELECTED AND |

| THE EVENT TYPE IS NOT PM AND THE EVENT-PROVIDER |

| PAIR DOES NOT REPRESENT A FLAT FEE GROUP OR A |

| REPEAT VISIT GROUP, ASK THE FLAT FEE (FF) SECTION.|

----------------------------------------------------

CP09OV

======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

$ AMOUNT:

[Enter $ Amount] .......................

REF ................................... -7

DK .................................... -8

----------------------------------------------------

| IF THE AMOUNT IS $0, GO TO CP37 |

----------------------------------------------------

| IF THE AMOUNT IS NOT $0 |

| AND |

| (EVENT TYPE IS OM OR PM |

| OR |

| THE EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE |

| GROUP |

| OR |

| (EVENT TYPE IS HS AND THE EVENT-PROVIDER PAIR IS |

| NOT FLAGGED AS ‘SEPARATELY BILLING’)) |

| GO TO CP11 |

----------------------------------------------------

| IF: |

| EVENT TYPE IS ER, OP, MV, OR DN |

| AND |

| TOTAL CHARGE IS A NON-ZERO WHOLE NUMBER < OR = |

| $50.00 OR CP090V IS CODED '-7' (REFUSED) OR '-8' |

| (DON’T KNOW), |

| GO TO CP10 |

----------------------------------------------------

| IF THE AMOUNT IS NOT $0, DK, OR REF AND THE EVENT |

| TYPE IS HH, CONTINUE WITH CPO9A |

----------------------------------------------------

| OTHERWISE, GO TO CP11 |

----------------------------------------------------

| SOFT CHECK: |

| SOFT RANGE CHECK: $0 - $100,000 |

| |

| HARD CHECK: |

| AMOUNT CANNOT BE < 0 |

----------------------------------------------------

CP09A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Let me be sure I recorded this correctly. The total charge for

the services received at home from (PROVIDER) during (MONTH)

for (PERSON) was {$ AMOUNT}.

Is that correct?

YES .................................... 1 {CP11}

NO ..................................... 2

REF ................................... -7 {CP11}

DK .................................... -8 {CP11}

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {$ AMOUNT}: DISPLAY AMOUNT ENTERED AT CP09OV. |

----------------------------------------------------

| IF CODED ‘2’ (NO), DISPLAY THE FOLLOWING MESSAGE: |

| ‘USE BACKUP TO CORRECT TOTAL CHARGE FOR THIS |

| MONTH.’ |

----------------------------------------------------

CP10

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Is this a situation in which (PERSON) (are/is) required to pay

a certain set amount each time (PERSON) (visit/visits)

(PROVIDER) regardless of what happens during the visit?

PROBE: For example, is this the type of situation in which

(PERSON) always (make/makes) the same set dollar amount copayment?

YES .................................... 1 {CP11}

NO ..................................... 2 {CP11}

REF ................................... -7 {CP11}

DK .................................... -8 {CP11}

HELP AVAILABLE FOR DEFINITION OF SET AMOUNT AND COPAYMENT.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

CP11

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

How much of the {{AMT TOT CH}/total charge} did anyone in the

family pay for {(PERSON)'s stay at (HOSPITAL) that began on

(ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the

last purchase of {NAME OF PRESCRIBED MEDICINE} for (PERSON)/

the services for (FLAT FEE GROUP) for (PERSON)/the {OME ITEM

GROUP NAME} used by (PERSON) since (START DATE)/services

received at home from (PROVIDER) during (MONTH) for (PERSON)}?

Please include all amounts paid ‘out-of-pocket,’ that is, amounts

paid before any reimbursements.

IF AMOUNT PAID IS NOTHING, DK, OR REF, SELECT ‘DOLLARS’, THEN

ENTER 0, DK, OR RF.

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP11OV1}

PERCENT ................................ 2 {CP11OV2}

[Code One]

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {{AMT TOT CH}/total charge}: DISPLAY ‘{AMT TOT |

| CH}’ IF AN AMOUNT IS GIVEN FOR THE TOTAL CHARGE AT|

| CP09OV. DISPLAY ‘total charge’ IF CP08 IS CODED |

| ‘2’ (NO), ‘-7’ (REFUSED), ‘-8’ (DON’T KNOW), OR IS|

| NOT ASKED. |

| |

| {AMT TOT CH}: DISPLAY THE DOLLAR AMOUNT ENTERED AT|

| CP09OV. |

----------------------------------------------------

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

CP11OV1

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DOLLARS:

[Enter $ Amount] ....................... {BOX_05}

REF ................................... -7 {BOX_05}

DK .................................... -8 {BOX_05}

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

----------------------------------------------------

| WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- |

| PAYMENT-ROSTER. |

----------------------------------------------------

| WRITE 'PERSON/FAMILY' TO THE EVENT’S-SOURCES-OF- |

| PAYMENT-ROSTER. |

----------------------------------------------------

| HARD RANGE CHECK: |

| $0 - $999,999 |

----------------------------------------------------

CP11OV2

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

PERCENT:

[Enter Percent %] ...................... {BOX_05}

HELP AVAILABLE FOR INFORMATION ON AMOUNTS TO INCLUDE.

----------------------------------------------------

| MULTIPLY THE PERCENTAGE ENTERED BY THE TOTAL |

| CHARGE ENTERED AT CP09 TO CALCULATE THE AMOUNT |

| PAID BY THE FAMILY AT CP11. |

----------------------------------------------------

| IF CP09 IS CODED '-7' (REFUSED), OR '-8' (DON'T |

| KNOW), DOLLAR AMOUNT PAID BY FAMILY CANNOT BE |

| CALCULATED. RECORD DOLLAR AMOUNT PAID BY |

| PERSON/FAMILY AS 'DK' OR ‘REF’ AS APPROPRIATE. |

----------------------------------------------------

| WRITE 'PERSON/FAMILY' TO THE RU-SOURCES-OF- |

| PAYMENT-ROSTER. |

----------------------------------------------------

| WRITE 'PERSON/FAMILY' TO THE EVENT’S-SOURCES-OF- |

| PAYMENT-ROSTER. |

----------------------------------------------------

| SOFT CHECK: 1% - 100%. |

| |

| HARD CHECK: |

| IF 0, DK OR RF IS ENTERED, DISPLAY THE FOLLOWING |

| MESSAGE: 0, DK, RF ARE NOT ALLOWED ON THIS |

| SCREEN. SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF. |

----------------------------------------------------

BOX_05

======

----------------------------------------------------

| IF: |

| CP11OV1 OR CP11OV2 IS CODED '-7' (REFUSED) OR '-8'|

| (DON'T KNOW) |

| AND |

| CP08 IS CODED '2' (NO), '-7' (REFUSED), OR '-8' |

| (DON'T KNOW) |

| AND |

| CP10 IS CODED '2' (NO), '-7' (REFUSED), OR '-8' |

| (DON'T KNOW), |

| DISPLAY THE FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT |

| RESOLUTION WILL BE NEEDED FOR THIS CASE. |

| CONTINUE.' THEN GO TO CP37 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH LOOP_01 |

----------------------------------------------------

LOOP_01

=======

----------------------------------------------------

| For each of the following: |

| |

| SOURCE OF DIRECT PAYMENT 1 |

| SOURCE OF DIRECT PAYMENT 2 |

| SOURCE OF DIRECT PAYMENT 3 |

| SOURCE OF DIRECT PAYMENT 4 |

| |

| ask BOX_LP01-END_LP01 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION ON |

| SOURCES OF DIRECT PAYMENTS AND ASSOCIATED PAYMENT |

| AMOUNTS, OTHER THAN PERSON/FAMILY. THE RESPONSE TO|

| CP13OV DETERMINES WHETHER THE LOOP CYCLES AGAIN. |

| SUBSEQUENT CYCLES, IF ANY, COLLECT ADDITIONAL |

| SOURCES OF DIRECT PAYMENT AND ASSOCIATED AMOUNTS. |

| IF CP13OV IS CODED ‘1’ (YES), THE LOOP CYCLES |

| AGAIN. IF CP13OV IS NOT ASKED OR IS CODED ‘2’ |

| (NO), THE LOOP ENDS. |

----------------------------------------------------

BOX_LP01

========

----------------------------------------------------

| IF FIRST CYCLE OF LOOP_01, CONTINUE WITH CP12 |

----------------------------------------------------

| OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE |

| FIRST CYCLE OF LOOP_01), GO TO CP12A |

----------------------------------------------------

CP12

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Has any {other} source already paid {(PROVIDER)} for any of the

charges for {(PERSON)'s stay at (HOSPITAL) that began on

(ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the

last purchase of {NAME OF PRESCRIBED MEDICINE} for (PERSON)/

the services for (FLAT FEE GROUP) for (PERSON)/the {OME ITEM

GROUP NAME} used by (PERSON) since (START DATE)/for services

received at home from (PROVIDER) during (MONTH) for (PERSON)}?

YES .................................... 1 {CP12A}

NO ..................................... 2 {END_LP01}

REF ................................... -7 {END_LP01}

DK .................................... -8 {END_LP01}

HELP AVAILABLE FOR A DEFINITION OF SOURCE AND ‘ALREADY PAID’.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| DISPLAY ‘OTHER’ IN THE QUESTION TEXT IF AN AMOUNT |

| WAS PAID BY PERSON/FAMILY; THAT IS, AN AMOUNT > $0|

| OR 0% WAS ENTERED AT CP11OV1 OR CP11OV2. OTHERWISE|

| USE A NULL DISPLAY. |

----------------------------------------------------

| DISPLAY ‘(PROVIDER)’ IN THE QUESTION TEXT IF |

| EVENT TYPE IS NOT PM OR OM. IF EVENT TYPE IS PM OR|

| OM, USE A NULL DISPLAY. |

----------------------------------------------------

| DISPLAY ‘(PERSON)'s stay at (HOSPITAL) that began |

| on (ADMIT DATE)’ IF EVENT TYPE IS HS. |

| |

| DISPLAY ‘(PERSON)'s visit to (PROVIDER) on (VISIT |

| DATE)’ IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| DISPLAY ‘the last purchase of {NAME OF PRESCRIBED |

| MEDICINE} for (PERSON)’ IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE |

| NAME OF THE PRESCRIPTION MEDICINE BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘the services for (FLAT FEE GROUP) for |

| (PERSON)’ IF EVENT-PROVIDER PAIR REPRESENTS A FLAT|

| FEE GROUP. |

| |

| DISPLAY ‘the {OME ITEM GROUP NAME} used by |

| (PERSON) since (START DATE)’ IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

CP12A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who else paid? PROBE: Anyone else?

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.

TO LEAVE, PRESS ESC.

[1. Name of Source of Direct Payment-35]

[2. Name of Source of Direct Payment-35]

[3. Name of Source of Direct Payment-35]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF- |

| PAYMENTS-ROSTER. |

----------------------------------------------------

| CONTINUE WITH CP13 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

| |

| 2. MULTIPLE ADD ALLOWED. THE SCREEN DISPLAYS A |

| LINK “ADD A SOURCE OF PAYMENT” THAT THE |

| INTERVIEWER CAN SELECT. SELECTING THE LINK |

| DISPLAYS A POP-UP WITH A TEXT ENTRY FIELD AND A |

| SELECTABLE LIST OF 15 COMMON SOURCES OF PAYMENT. |

| (SEE BOX_00 FOR A DETAILED LIST). THE INTERVIEWER|

| CAN TYPE A NEW SOURCE OR SELECT ONE FROM THE |

| LIST. UPON RETURN TO CP12A, THE ADDED SOURCE WILL|

| APPEAR ON THE ROSTER AS SELECTED. |

| |

| 3. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS|

| NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR |

| MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST|

| ENTERED.’ |

| |

| 4. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

| |

| 5. PERSON/FAMILY IS FOR DISPLAY ONLY. THIS SOURCE |

| IS AUTOMATICALLY SELECTED. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES OF PAYMENT. |

----------------------------------------------------

CP13

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much did (SOURCE) pay?

ENTER AMOUNT PAID TO COLUMN 2 OR COLUMN 3.

TOTAL CHARGE: {$XXXXXXXXX}

|----------------------------|--------------------|--------------------|

| ROSTER. SOURCE OF PAYMENT | CP13_02. DOLLAR | CP13_03. PERCENT |

| | AMOUNT PAID | AMOUNT PAID |

|----------------------------|--------------------|--------------------|

| PERSON/Family | [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Enter $ Amount] | [Enter % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Enter $ Amount] | [Enter % Amount] |

|----------------------------|-----------------------------------------|

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09. |

----------------------------------------------------

| DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF |

| PAYMENT. |

| |

| DISPLAY THE RESPONSE TO CP11 IN THE 'DOLLAR AMOUNT|

| PAID' OR ‘PERCENT AMOUNT PAID’ COLUMN FOR |

| PERSON/FAMILY. THAT IS, IF THE RESPONSE TO CP11 |

| IS AN AMOUNT, DISPLAY THE DOLLAR AMOUNT IN THE |

| ‘DOLLAR AMOUNT PAID’ COLUMN. IF THE RESPONSE TO |

| CP11 IS A PERCENTAGE, DISPLAY THE PERCENTAGE |

| AMOUNT IN THE ‘PERCENT AMOUNT PAID’ COLUMN. IF |

| THE DOLLAR AMOUNT AT CP11 IS CODED ‘-8’ |

| (DON’T KNOW), DISPLAY ‘DK’ FOR THE AMOUNT IN BOTH |

| COLUMNS. IF DOLLAR AMOUNT AT CP11 IS CODED ‘-7’ |

| (REFUSED), DISPLAY ‘REF’ FOR THE AMOUNT IN BOTH |

| COLUMNS. |

----------------------------------------------------

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

| FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS |

| ‘DIRECT PAYMENT’. |

----------------------------------------------------

| FEATURES OF THE SOURCE OF PAYMENT MATRIX: |

| |

| 1. INTERVIEWER USES RIGHT AND LEFT ARROW KEYS TO |

| MOVE TO EITHER THE PERCENT OR DOLLAR AMOUNT |

| COLUMN ASSOCIATED WITH THAT SOURCE. |

| INTERVIEWER USES THE UP AND DOWN ARROW KEYS TO|

| MOVE BETWEEN SOURCES. |

| 2. SOURCE COLUMN IS PROTECTED. CURSOR WILL NOT |

| ENTER THIS COLUMN, SO NO CHANGES ARE ALLOWED |

| TO SOURCES AT THIS SCREEN. |

| 3. INTERVIEWER ENTERS EITHER A DOLLAR OR A |

| PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED. |

| AMOUNTS CAN BE CHANGED AS MANY TIMES AS |

| NECESSARY BEFORE THE INTERVIEWER LEAVES THE |

| SCREEN. |

| 4. THE PERSON/FAMILY AMOUNT PAID COLUMNS MAY BE |

| CHANGED OR CORRECTED. NOTE THAT THE SCREEN |

| WILL REQUIRE AN AMOUNT FOR PERSON/FAMILY IN |

| THE DOLLAR COLUMN IN ORDER TO PROCEED. THIS |

| DOLLAR AMOUNT MAY BE ENTERED BY THE |

| INTERVIEWER OR CALCULATED BY CAPI BASED ON % |

| OF TOTAL CHARGE WHERE TOTAL CHARGE IS KNOWN. |

| 5. WHEN CURSOR LEAVES THE CELL AND A DOLLAR OR |

| PERCENTAGE AMOUNT HAS BEEN ENTERED AND THERE |

| IS A TOTAL CHARGE, THE RECIPROCAL AMOUNT WILL |

| BE DISPLAYED. FOR EXAMPLE, IF THE |

| INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR |

| AMOUNT WILL BE CALCULATED USING THE TOTAL |

| CHARGE. THIS DOLLAR AMOUNT WOULD THEN BE |

| DISPLAYED IN THE DOLLAR AMOUNT PAID COLUMN |

| (NEXT TO THE PERCENT AMOUNT PAID COLUMN). |

| 6. IF A SOURCE IS ENTERED IN ERROR, THE |

| INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. |

| 7. INTERVIEWERS WILL BE INSTRUCTED TO ONLY ENTER |

| DIRECT PAYMENTS MADE TO THE PROVIDER AT THIS |

| SCREEN. |

----------------------------------------------------

| SOFT CHECK: |

| $0 - $10,000 |

----------------------------------------------------

| CONTINUE WITH CP13OV |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: EVNT_SOP_1 |

| |

| COL # 1 HEADER: SOURCE OF PAYMENT |

| INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME |

| (PAYM.REIMNAM/PAYF.REIMNAM) |

| |

| COL # 2 HEADER: DOLLAR AMOUNT PAID |

| INSTRUCTIONS: ENTER $ AMOUNT PAID |

| (PAYM.AMTPAID/PAYF.AMTPAID) |

| |

| COL # 3 HEADER: PERCENT AMOUNT PAID |

| INSTRUCTIONS: ENTER % AMOUNT PAID |

| (PAYM.PCTPAID/PAYF.PCTPAID) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR |

| ENTRY. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE |

| ALLOWED TO SOURCES AT THIS SCREEN. |

| |

| 2. THE PERSON/FAMILY AMOUNT MAY BE CHANGED OR |

| CORRECTED. |

| |

| 3. THE INTERVIEWER CAN ENTER A DOLLAR OR A |

| PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED. |

| |

| 4. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY |

| TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES |

| THE SCREEN. |

| |

| 5. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN |

| ENTERED AND THERE IS A TOTAL CHARGE, THE |

| RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,|

| IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR|

| AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. |

| |

| 6. IF A SOURCE IS ENTERED IN ERROR, THE |

| INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES SELECTED AT CP12A FOR THIS |

| EVENT-PROVIDER PAIR AND THE ‘PERSON/FAMILY’ |

| RECORD. |

----------------------------------------------------

CP13OV

======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE

PROVIDER?

YES .................................... 1 {END_LP01}

NO ..................................... 2 {END_LP01}

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

END_LP01

========

----------------------------------------------------

| IF CP13OV IS CODED ‘1’ (YES), CYCLE TO COLLECT |

| NEXT SOURCE OF PAYMENT. |

----------------------------------------------------

| IF CP13OV IS NOT ASKED OR IS CODED ‘2’ (NO), |

| END LOOP_01 AND CONTINUE WITH BOX_06 |

----------------------------------------------------

BOX_06

======

----------------------------------------------------

| IF 'AMOUNT PAID' BY PERSON/FAMILY > $0, CONTINUE |

| WITH LOOP_02 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_07 |

----------------------------------------------------

LOOP_02

=======

----------------------------------------------------

| For each of the following: |

| |

| SOURCE OF REIMBURSEMENT 1 |

| SOURCE OF REIMBURSEMENT 2 |

| SOURCE OF REIMBURSEMENT 3 |

| SOURCE OF REIMBURSEMENT 4 |

| |

| ask BOX_LP02-END_LP02 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_02 COLLECTS INFORMATION ON |

| SOURCES OF REIMBURSEMENT TO PERSON/FAMILY AND |

| ASSOCIATED REIMBURSEMENT AMOUNTS. THE RESPONSE TO|

| CP15OV DETERMINES WHETHER THE LOOP CYCLES AGAIN. |

| SUBSEQUENT CYCLES, IF ANY, COLLECT ADDITIONAL |

| SOURCES OF REIMBURSEMENT AND ASSOCIATED AMOUNTS. |

| IF CP15OV IS CODED ‘1’ (YES), THE LOOP CYCLES |

| AGAIN. IF CP15OV IS NOT ASKED OR IS CODED ‘2’ |

| (NO), THE LOOP ENDS. |

----------------------------------------------------

BOX_LP02

========

----------------------------------------------------

| IF FIRST CYCLE OF LOOP_02, CONTINUE WITH CP14 |

----------------------------------------------------

| OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE |

| FIRST CYCLE OF LOOP_02), GO TO CP14A |

----------------------------------------------------

CP14

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT} {NAME OF PMED}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Has any source reimbursed or paid back anything to (PERSON) (or

anyone in the family) for the amount paid ‘out-of-pocket’?

That is, has any source reimbursed any of the {$/% FAMILY PAID}

paid?

YES .................................... 1 {CP14A}

NO ..................................... 2 {END_LP02}

REF ................................... -7 {END_LP02}

DK .................................... -8 {END_LP02}

HELP AVAILABLE FOR DEFINITION OF SOURCE AND REIMBURSEMENT.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS OM EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF THE OM |

| ITEM GROUP IS ‘1’ (GLASSES OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| {$/% FAMILY PAID}: DISPLAY THE FAMILY DOLLAR |

| AMOUNT PAID IF CP11 IS CODED ‘1’ (DOLLARS). |

| DISPLAY THE FAMILY PERCENT AMOUNT PAID IF CP11 IS |

| CODED ‘2’ (PERCENT). |

----------------------------------------------------

CP14A

=====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who reimbursed or paid anyone in the family back?

PROBE: Anyone else?

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.

TO LEAVE, PRESS ESC.

[1. Name of Source of Reimbursement-35]

[2. Name of Source of Reimbursement-35]

[3. Name of Source of Reimbursement-35]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS OM EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF THE OM |

| ITEM GROUP IS ‘1’ (GLASSES OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF- |

| PAYMENTS-ROSTER. |

----------------------------------------------------

| NOTE: SOURCES OF PAYMENTS AND SOURCES OF |

| REIMBURSEMENTS ARE SELECTED FROM THE SAME RU LEVEL|

| ROSTER OF SOURCES AND ROSTER BEHAVIOR IS THE SAME.|

----------------------------------------------------

| CONTINUE WITH CP15 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE ADD AND MULTIPLE SELECT ALLOWED. |

| |

| 2. ADD ALLOWED. THE SCREEN DISPLAYS A LINK “ADD A |

| SOURCE OF PAYMENT” THAT THE INTERVIEWER CAN |

| SELECT. SELECTING THE LINK DISPLAYS A POP-UP WITH |

| A TEXT ENTRY FIELD AND A SELECTABLE LIST OF 15 |

| COMMON SOURCES OF PAYMENT. (SEE BOX_00 FOR A |

| DETAILED LIST). THE INTERVIEWER CAN TYPE A NEW |

| SOURCE OR SELECT ONE FROM THE LIST. UPON RETURN TO|

| CP14A, THE ADDED SOURCE WILL APPEAR ON THE ROSTER |

| AS SELECTED. |

| |

| 3. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE |

| SOURCE OF PAYMENT. |

| |

| 4. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. IF DELETE IS ATTEMPTED WHEN IT IS|

| NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR |

| MESSAGE: ‘DELETE ALLOWED ONLY WHEN SOURCE IS FIRST|

| ENTERED.’ |

| |

| 5. LIMITED EDIT ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, EDITING IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. IF EDIT IS ATTEMPTED WHEN IT IS |

| NOT ALLOWED, CAPI DISPLAYS THE FOLLOWING ERROR |

| MESSAGE: ‘EDIT ALLOWED ONLY WHEN SOURCE FIRST |

| ENTERED.’ |

| |

| 6. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES OF PAYMENT ON THE ROSTER |

| EXCEPT PERSON/FAMILY. |

----------------------------------------------------

CP15

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much did (SOURCE) reimburse or pay anyone in the family

back?

ENTER THE AMOUNT REIMBURSED IN COLUMN 2 OR COLUMN 3.

PERSON/FAMILY PAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

|----------------------------|--------------------|--------------------|

| ROSTER. SOURCE OF | CP15_02. DOLLAR | CP15_03. PERCENT |

| REIMBURSEMENT | AMOUNT REIMBURSED | AMOUNT REIMBURSED |

|----------------------------|--------------------|--------------------|

| [Display Source of | [Enter $ Amount] | [Enter % Amount] |

| Reimbursement] | | |

|----------------------------|--------------------|--------------------|

| [Display Source of | [Enter $ Amount] | [Enter % Amount] |

| Reimbursement] | | |

|----------------------------|-----------------------------------------|

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09. |

----------------------------------------------------

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS OM EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

| PERSON/FAMILY PAYMENT: {$XXXXXXXXX}: DISPLAY THE |

| DOLLAR AMOUNT ENTERED AT CP11OV1 IF CP11 IS CODED |

| ‘1’ (DOLLARS). DISPLAY THE PERCENT AMOUNT ENTERED |

| AT CP11OV2 IF CP11 IS CODED ‘2’ (PERCENT). |

----------------------------------------------------

| TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| ENTERED AT CP09OV. IF CP08 IS CODED ‘2’ (NO), ‘-8’|

| (DON’T KNOW), OR IF CP09 IS CODED ‘-8’ (DON’T |

| KNOW), DISPLAY ‘UNKNOWN’ FOR {$XXXXXXXXX}. IF CP08|

| IS CODED ‘-7’ (REFUSED) OR IF CP09 IS CODED ‘-7’ |

| (REFUSED), DISPLAY ‘REFUSED’ FOR {$XXXXXXXXX}. |

----------------------------------------------------

| FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS |

| ‘REIMBURSEMENT’. |

----------------------------------------------------

| SOFT CHECK: |

| 0 – 999999 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: EVNT_SOP_1 |

| |

| COL # 1 HEADER: SOURCE OF PAYMENT |

| INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME |

| (PAYM.REIMNAM/PAYF.REIMNAM) |

| |

| COL # 2 HEADER: DOLLAR AMOUNT PAID |

| INSTRUCTIONS: ENTER $ AMOUNT PAID |

| (PAYM.AMTPAID/PAYF.AMTPAID) |

| |

| COL # 3 HEADER: PERCENT AMOUNT PAID |

| INSTRUCTIONS: ENTER % AMOUNT PAID |

| (PAYM.PCTPAID/PAYF.PCTPAID) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE |

| ALLOWED TO SOURCES AT THIS SCREEN. |

| |

| 2. THE INTERVIEWER CAN ENTER A DOLLAR OR A |

| PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED. |

| |

| 3. THE AMOUNT PAID COLUMNS CAN BE CHANGED AS MANY |

| TIMES AS NECESSARY BEFORE THE INTERVIEWER LEAVES |

| THE SCREEN. |

| |

| 4. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN |

| ENTERED AND THERE IS A TOTAL CHARGE, THE |

| RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,|

| IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR|

| AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. |

| |

| 5. IF A SOURCE IS ENTERED IN ERROR, THE |

| INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. IF THE |

| TOTAL AMOUNT REIMBURSED BY ALL SOURCES EXCEEDS THE|

| AMOUNT PAID BY THE PERSON/FAMILY, CAPI DISPLAYS |

| THE MESSAGE ‘SHOULD THIS ANSWER BE ACCEPTED OR |

| CHANGED?’ IF THE INTERVIEWER REENTERS THE SAME |

| AMOUNTS, CAPI WILL ACCEPT IT. |

| |

| 6. INTERVIEWERS WILL BE INSTRUCTED TO ENTER ONLY |

| REIMBURSEMENTS MADE TO THE FAMILY AT THIS SCREEN. |

| |

| 7. THE SAME SOURCE CAN BE FLAGGED AS BOTH A |

| REIMBURSEMENT AND A DIRECT PAYMENT. ONLY THE |

| AMOUNT OF THE DIRECT PAYMENT WILL PLAY INTO THE |

| RESOLUTION PROCESS. |

| |

| 8. POST DATA COLLECTION EDITING WILL BE NECESSARY |

| TO DETERMINE THE NET PAYMENTS OF SOURCES. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES SELECTED AT CP14A FOR THIS |

| EVENT-PROVIDER PAIR. |

----------------------------------------------------

CP15OV

======

ARE THERE ANY OTHER SOURCES OF REIMBURSEMENT?

YES .................................... 1 {END_LP02}

NO ..................................... 2 {END_LP02}

HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.

END_LP02

========

----------------------------------------------------

| IF CP15OV CODED ‘1’ (YES), CYCLE TO COLLECT |

| NEXT SOURCE OF REIMBURSEMENT |

----------------------------------------------------

| IF CP15OV IS NOT ASKED OR IS CODED ‘2’ (NO), |

| END LOOP_02 AND CONTINUE WITH BOX_07 |

----------------------------------------------------

BOX_07

======

----------------------------------------------------

| GO TO BOX_11 |

----------------------------------------------------

BOX_08

======

OMITTED.

CP16

====

OMITTED.

CP17

====

OMITTED.

CP17OV1

=======

OMITTED.

CP17OV2

=======

OMITTED.

BOX_11

======

----------------------------------------------------

| IF CP14 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’|

| (DON’T KNOW) AND CP10 IS CODED ‘1’ (YES), GO TO |

| BOX_09 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_10 |

----------------------------------------------------

| NOTE: THIS BOX SKIPS PEOPLE OVER CP18 (EXPECT |

| ANY REIMBURSEMENT) FOR INDIVIDUALS WHO HAVE |

| ALREADY TOLD US THAT THE PAYMENT WAS A COPAYMENT |

| (CP10 IS CODED ‘1’) AND THEY HAVE NOT BEEN |

| REIMBURSED FOR ANY AMOUNT PAID (CP14 IS CODED |

| ‘2’, ‘-7’, OR ‘-8’). |

----------------------------------------------------

BOX_10

======

----------------------------------------------------

| IF AMOUNT PAID BY PERSON/FAMILY IS > $0, CONTINUE |

| WITH CP18 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_09 |

----------------------------------------------------

CP18

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Do you expect any {other} source to reimburse anyone in the

family for what has been paid?

YES .................................... 1 {CP19}

NO ..................................... 2 {BOX_09}

REF ................................... -7 {BOX_09}

DK .................................... -8 {BOX_09}

HELP AVAILABLE FOR DEFINITION OF REIMBURSEMENT.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| DISPLAY 'OTHER' IF CP14 IS CODED '1' (YES). |

| OTHERWISE, USE A NULL DISPLAY. |

----------------------------------------------------

CP19

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

How much does anyone in the family expect to be reimbursed?

PROBE: Include amounts to be reimbursed from all sources.

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP19OV1}

PERCENT ................................ 2 {CP19OV2}

[Code One]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

CP19OV1

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DOLLARS:

[Enter $ Amount] ....................... {CP20}

REF ................................... -7 {CP20}

DK .................................... -8 {CP20}

----------------------------------------------------

| SOFT CHECK: |

| SOFT RANGE CHECK: $0 - $10,000 |

----------------------------------------------------

CP19OV2

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

PERCENT:

[Enter % Amount] ....................... {CP20}

REF ................................... -7 {CP20}

DK .................................... -8 {CP20}

----------------------------------------------------

| SOFT CHECK: |

| SOFT RANGE CHECK: 1% - 100% |

----------------------------------------------------

CP20

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

From whom do you expect these reimbursements to come?

IF MORE THAN ONE SOURCE OF REIMBURSEMENT, PROBE FOR THE MAIN

SOURCE (I.E., THE SOURCE REIMBURSING THE MOST).

TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.

TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.

TO LEAVE, PRESS ESC.

[1. Name of Source of Direct Payment-35]

[2. Name of Source of Direct Payment-35]

[3. Name of Source of Direct Payment-35]

[Code One]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF- |

| PAYMENTS-ROSTER. |

----------------------------------------------------

| CONTINUE WITH BOX_09 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| |

| 1. MULTIPLE ADD ALLOWED. THE SCREEN DISPLAYS AN |

| “ADD SOURCES” OPTION. SELECTING THE OPTION |

| DISPLAYS A POP-UP WITH A TEXT ENTRY FIELD AND A |

| SELECTABLE LIST OF 15COMMON SOURCES OF PAYMENT. |

| (SEE BOX_00 FOR A DETAILED LIST). THE INTERVIEWER |

| CAN TYPE A NEW SOURCE OR SELECT ONE FROM THE LIST.|

| UPON RETURN TO CP20, THE ADDED SOURCE WILL |

| APPEAR ON THE ROSTER AS SELECTED. |

| |

| 2. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE |

| SOURCE OF PAYMENT. |

| |

| 3. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN. |

| |

| 4. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES OF PAYMENT ON THE ROSTER |

| EXCEPT PERSON/FAMILY. |

----------------------------------------------------

BOX_09

======

----------------------------------------------------

| DETERMINE IF THERE IS AN OVERPAYMENT OR |

| UNDERPAYMENT: SUBTRACT THE TOTAL PAYMENT FROM |

| THE TOTAL CHARGE AT CP09. IF THE ABSOLUTE VALUE |

| OF THE REMAINDER IS > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF THE TOTAL CHARGE, CONTINUE WITH BOX_12 |

----------------------------------------------------

| OTHERWISE, DISPLAY THE FOLLOWING MESSAGE: 'NO |

| CHARGE-PAYMENT RESOLUTION NEEDED FOR THIS CASE. |

| PRESS ENTER TO CONTINUE.' THEN GO TO CP37 |

----------------------------------------------------

BOX_12

======

----------------------------------------------------

| IF CP09OV (TOTAL CHARGE) OR 'AMOUNT PAID' BY ANY |

| SOURCE OF DIRECT PAYMENT (INCLUDING PERSON/FAMILY,|

| BUT EXCLUDING REIMBURSEMENTS) IS CODED '-7' |

| (REFUSED) OR '-8' (DON'T KNOW), DISPLAY THE |

| FOLLOWING MESSAGE: 'NO CHARGE-PAYMENT RESOLUTION |

| NEEDED FOR THIS CASE. PRESS ENTER TO CONTINUE.' |

| THEN GO TO CP37 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_13 |

----------------------------------------------------

BOX_13

======

----------------------------------------------------

| IF THE UNDERPAYMENT IS > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF THE TOTAL CHARGE, CONTINUE WITH CP21 |

----------------------------------------------------

| IF THE OVERPAYMENT IS > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF THE TOTAL CHARGE, GO TO LOOP_04 |

----------------------------------------------------

CP21

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

Does anyone in the family or any other source expect to make

additional payments for {(PERSON)'s stay at (HOSPITAL) that

began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT

DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE} for

(PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the {OME

ITEM GROUP NAME} used by (PERSON) since (START DATE)/services

received at home from (PROVIDER) during (MONTH) for (PERSON)}?

YES .................................... 1 {CP22}

NO ..................................... 2 {LOOP_03}

REF ................................... -7 {LOOP_03}

DK .................................... -8 {LOOP_03}

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

CP22

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

How much more does anyone in the family or any other source

expect to pay?

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP22OV1}

PERCENT ................................ 2 {CP22OV2}

[Code One]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

CP22OV1

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DOLLARS:

[Enter $ Amount] ....................... {BOX_14}

REF ................................... -7 {BOX_14}

DK .................................... -8 {BOX_14}

----------------------------------------------------

| HARD RANGE CHECK: |

| $0 - $999,9999 |

----------------------------------------------------

CP22OV2

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

PERCENT:

[Enter % Amount] ....................... {BOX_14}

REF ................................... -7 {BOX_14}

DK .................................... -8 {BOX_14}

----------------------------------------------------

| HARD RANGE: 1% - 100%. |

| |

| HARD CHECK: |

| IF 0, DK OR RF IS ENTERED, DISPLAY THE FOLLOWING |

| MESSAGE: “0, DK, RF NOT ALLOWED ON THIS |

| SCREEN. SELECT 'DOLLARS', THEN ENTER 0, DK, OR RF.”|

----------------------------------------------------

BOX_14

======

----------------------------------------------------

| IF AN AMOUNT IS ENTERED AT CP22OV1 OR AT CP22OV2 |

| OR IF CP22OV1 OR CP22OV2 ARE CODED ‘-7’ |

| (REFUSED) OR ‘-8’ (DON’T KNOW), DISPLAY THE |

| FOLLOWING MESSAGE: ‘NO CHARGE-PAYMENT |

| RESOLUTION NEEDED FOR THIS CASE. CONTINUE.’ THEN |

| GO TO CP37 |

----------------------------------------------------

LOOP_03

=======

----------------------------------------------------

| For each of the following: |

| |

| SOURCE OF DIRECT PAYMENT 1 |

| SOURCE OF DIRECT PAYMENT 2 |

| SOURCE OF DIRECT PAYMENT 3 |

| SOURCE OF DIRECT PAYMENT 4 |

| |

| ask BOX_LP03-END_LP03 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_03 REVIEWS PAYMENT |

| INFORMATION WHERE AN UNDERPAYMENT HAS BEEN |

| REPORTED AND EITHER VERIFIES THE UNDERPAYMENT OR |

| COLLECTS CORRECTIONS AND ADDITIONAL PAYMENT |

| INFORMATION TO RESOLVE THE UNDERPAYMENT. THE |

| FIRST CYCLE OF THIS LOOP COLLECTS CORRECTIONS OF |

| ERRONEOUS INFORMATION ON DIRECT PAYMENTS AND |

| THE ASSOCIATED AMOUNTS PAID. SUBSEQUENT LOOP |

| CYCLES, IF ANY, COLLECT ADDITIONAL SOURCES OF |

| DIRECT PAYMENT AND ASSOCIATED AMOUNTS. THE |

| RESPONSE TO CP24OV DETERMINES WHETHER THE LOOP |

| CYCLES AGAIN. IF CP24OV IS CODED ‘1’ (YES), THE |

| LOOP CYCLES AGAIN. IF CP24OV IS CODED ‘2’ (NO), |

| THE LOOP ENDS. |

----------------------------------------------------

BOX_LP03

========

----------------------------------------------------

| IF FIRST CYCLE OF LOOP_03, GO TO CP24 |

----------------------------------------------------

| OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE |

| FIRST CYCLE OF LOOP_03), CONTINUE WITH CP23 |

----------------------------------------------------

CP23

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who else paid? PROBE: Anyone else?

[1. Name of Source of Direct Payment-35]

[2. Name of Source of Direct Payment-35]

[3. Name of Source of Direct Payment-35]

----------------------------------------------------

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF- |

| PAYMENTS-ROSTER. |

----------------------------------------------------

| CONTINUE WITH CP24 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE SELECT ALLOWED. |

| |

| 2. MULTIPLE ADD ALLOWED. THE SCREEN DISPLAYS AN |

| “ADD SOURCES OF PAYMENT” OPTION. SELECTING THE |

| OPTION DISPLAYS A POP-UP WITH A TEXT ENTRY FIELD |

| AND A SELECTABLE LIST OF 15 COMMON SOURCES OF |

| PAYMENT. (SEE BOX_00 FOR A DETAILED LIST). THE |

| INTERVIEWER CAN TYPE A NEW SOURCE OR SELECT ONE |

| FROM THE LIST. UPON RETURN TO CP23, THE ADDED |

| SOURCE WILL APPEAR ON THE ROSTER AS SELECTED. |

| |

| 3. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT” THAT SOURCE ONLY, AS SELECTED. |

| |

| 4. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

----------------------------------------------------

| ROSTER FILTER: |

| NONE; DISPLAY ALL. |

----------------------------------------------------

CP24

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

At the moment, it appears that {AMOUNT REMAINING} of the total

charge for {(PERSON)'s stay at (HOSPITAL) that began on (ADMIT

DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT DATE)/the last

purchase of {NAME OF PRESCRIBED MEDICINE} for (PERSON)/the

services for (FLAT FEE GROUP) for (PERSON)/the {OME ITEM GROUP

NAME} used by (PERSON) since (START DATE)/services

received at home from (PROVIDER) during (MONTH) for (PERSON)}

is still unpaid. Let me be sure I have entered everything

correctly.

REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH

RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.

IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.

UNDERPAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

|----------------------------|--------------------|--------------------|

| ROSTER. SOURCE OF PAYMENT | CP24_02. DOLLAR | CP24_03. PERCENT |

| | AMOUNT PAID | AMOUNT PAID |

|----------------------------|--------------------|--------------------|

| PERSON/Family | [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Enter $ Amount] | [Enter % Amount] |

|----------------------------|--------------------|--------------------|

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF |

| PAYMENT. |

| |

| IF THE AMOUNT PAID BY PERSON/FAMILY WAS ADJUSTED |

| AT CP13, DISPLAY ADJUSTED AMOUNT. IF AMOUNT PAID |

| BY PERSON/FAMILY WAS NOT ADJUSTED, DISPLAY |

| THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' |

| COLUMN FOR PERSON/FAMILY. THAT IS, IF THE |

| RESPONSE TO CP11 IS A DOLLAR AMOUNT, DISPLAY THE |

| DOLLAR AMOUNT IN THE ‘DOLLAR AMOUNT PAID’ COLUMN. |

| IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY |

| THE PERCENTAGE AMOUNT IN THE ‘PERCENT AMOUNT PAID’|

| COLUMN. IF THE DOLLAR AMOUNT OR PERCENT AT CP11 IS|

| CODED ‘-8’ (DON’T KNOW), DISPLAY ‘DK’ FOR THE |

| AMOUNT IN BOTH COLUMNS. IF THE DOLLAR AMOUNT OR |

| PERCENT IS CODED ‘-7’ (REFUSED), DISPLAY ‘REF’ |

| FOR THE AMOUNT IN BOTH COLUMNS. |

----------------------------------------------------

| {AMOUNT REMAINING}: DISPLAY THE AMOUNT OF THE |

| CALCULATED UNDERPAYMENT. |

| |

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

| UNDERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| OF THE CALCULATED UNDERPAYMENT. |

| |

| TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| ENTERED AT CP09OV. |

----------------------------------------------------

| FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS |

| ‘DIRECT PAYMENTS’. |

----------------------------------------------------

| SOFT CHECK: |

| WHOLE DOLLAR AMOUNT (INTEGER): 0 - $100,000 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: EVNT_SOP_1 |

| |

| COL # 1 HEADER: SOURCE OF PAYMENT |

| INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME |

| (PAYM.REIMNAM/PAYF.REIMNAM) |

| |

| COL # 2 HEADER: DOLLAR AMOUNT PAID |

| INSTRUCTIONS: ENTER $ AMOUNT PAID |

| (PAYM.AMTPAID/PAYF.AMTPAID) |

| |

| COL # 3 HEADER: PERCENT AMOUNT PAID |

| INSTRUCTIONS: ENTER % AMOUNT PAID |

| (PAYM.PCTPAID/PAYF.PCTPAID) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR |

| ENTRY. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE |

| ALLOWED TO SOURCES AT THIS SCREEN. |

| |

| 2. THE INTERVIEWER CAN ENTER A DOLLAR OR A |

| PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED. |

| |

| 3. NO CORRECTIONS OR UPDATES MAY BE MADE TO SOURCE|

| NAMES OR AMOUNTS OF REIMBURSEMENT. |

| |

| 4. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN |

| ENTERED AND THERE IS A TOTAL CHARGE, THE |

| RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,|

| IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR|

| AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. |

| |

| 5. IF A SOURCE IS ENTERED IN ERROR, THE |

| INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. |

| |

| 6. ONLY NEW SOURCES OF DIRECT PAYMENTS MAY BE |

| ADDED. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES FLAGGED AS ‘DIRECT PAYMENT’ |

| FOR THIS EVENT. |

----------------------------------------------------

CP24OV

======

DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE

PROVIDER?

YES .................................... 1 {END_LP03}

NO ..................................... 2 {END_LP03}

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY

TO PROVIDER.

END_LP03

========

----------------------------------------------------

| IF CP24OV IS CODED ‘1’ (YES), CYCLE TO COLLECT |

| ADDITIONAL SOURCES OF PAYMENT. |

----------------------------------------------------

| IF CP24OV IS CODED ‘2’ (NO), END LOOP_03 AND GO |

| TO BOX_15 |

----------------------------------------------------

LOOP_04

=======

----------------------------------------------------

| For each of the following: |

| |

| SOURCE OF DIRECT PAYMENT 1 |

| SOURCE OF DIRECT PAYMENT 2 |

| SOURCE OF DIRECT PAYMENT 3 |

| SOURCE OF DIRECT PAYMENT 4 |

| |

| ask BOX_LP04-END_LP04 |

----------------------------------------------------

| LOOP DEFINITION: LOOP_04 REVIEWS PAYMENT |

| INFORMATION WHERE AN OVERPAYMENT HAS BEEN REPORTED|

| AND EITHER VERIFIES THE OVERPAYMENT OR COLLECTS |

| CORRECTIONS AND ADDITIONAL PAYMENT INFORMATION TO |

| RESOLVE THE OVERPAYMENT. THE FIRST CYCLE OF THIS |

| LOOP COLLECTS CORRECTIONS OF ERRONEOUS INFORMATION|

| ON DIRECT PAYMENTS AND ASSOCIATED AMOUNTS PAID. |

| SUBSEQUENT LOOP CYCLES, IF ANY, COLLECT ADDITIONAL|

| SOURCES OF DIRECT PAYMENT AND ASSOCIATED AMOUNTS. |

| THE RESPONSE TO CP26OV DETERMINES WHETHER THE LOOP|

| CYCLES AGAIN. IF CP26OV IS CODED ‘1’ (YES), THE |

| LOOP CYCLES AGAIN. IF CP26OV IS CODED ‘2’ (NO), |

| THE LOOP ENDS. |

----------------------------------------------------

BOX_LP04

========

----------------------------------------------------

| IF FIRST CYCLE OF LOOP_04, GO TO CP26 |

----------------------------------------------------

| OTHERWISE (I.E., IF ANY CYCLE SUBSEQUENT TO THE |

| FIRST CYCLE OF LOOP_04), CONTINUE WITH CP25 |

----------------------------------------------------

CP25

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

Who else paid? PROBE: Anyone else?

[1. Name of Source of Direct Payment-35]

[2. Name of Source of Direct Payment-35]

[3. Name of Source of Direct Payment-35]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS OM EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

----------------------------------------------------

| WRITE SOURCES SELECTED TO THE EVENT’S-SOURCES-OF- |

| PAYMENTS-ROSTER. |

----------------------------------------------------

| GO TO CP26 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: RU_SOP_2 |

| |

| COL # 1 HEADER: REIMBURSEMENT SOURCE |

| INSTRUCTIONS: DISPLAY REIMBURSEMENT SOURCE NAME |

| (SRCS.SRCNAME) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE RU-SOURCES-OF-PAYMENT-ROSTER FOR |

| SELECTION. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. MULTIPLE ADD ALLOWED. THE SCREEN DISPLAYS AN |

| “ADD SOURCES OF PAYMENT” OPTION. SELECTING THE |

| LINK DISPLAYS A POP-UP WITH A TEXT ENTRY FIELD AND|

| A SELECTABLE LIST OF 15 COMMON SOURCES OF PAYMENT.|

| (SEE BOX_00 FOR A DETAILED LIST). THE INTERVIEWER |

| CAN TYPE A NEW SOURCE OR SELECT ONE FROM THE LIST.|

| UPON RETURN TO CP25, THE ADDED SOURCE WILL APPEAR |

| ON THE ROSTER AS SELECTED. |

| |

| 2. SELECT ONE. INTERVIEWER MAY SELECT ONLY ONE |

| SOURCE OF PAYMENT. |

| |

| 3. LIMITED DELETE ALLOWED. IF INTERVIEWER ADDS A |

| SOURCE OF PAYMENT, DELETE IS POSSIBLE FOR THAT |

| SOURCE ONLY, AS LONG AS THE INTERVIEWER HAS NOT |

| LEFT THE SCREEN.

| |

| 4. IF ROSTER IS EMPTY WHEN CAPI DISPLAYS SCREEN, |

| DISPLAY THE STANDARD WVS INSTRUCTION: “EITHER THE |

| ROSTER IS EMPTY OR YOUR SEARCH HAS NOT TURNED UP |

| ANY CHOICES.” |

----------------------------------------------------

| ROSTER FILTER: |

| NONE, DISPLAY ALL. |

----------------------------------------------------

CP26

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

The payments you reported for {(PERSON)'s stay at (HOSPITAL) that

began on (ADMIT DATE)/(PERSON)'s visit to (PROVIDER) on (VISIT

DATE)/the last purchase of {NAME OF PRESCRIBED MEDICINE} for

(PERSON)/the services for (FLAT FEE GROUP) for (PERSON)/the

{OME ITEM GROUP NAME} used by (PERSON) since (START

DATE)/services received at home from (PROVIDER) during (MONTH)

for (PERSON)} exceed the charge I have recorded by {$ DISCREPANCY}.

Let me be sure I have all the information recorded correctly.

REVIEW CHARGES AND PAYMENTS WITH RESPONDENT. WORK WITH

RESPONDENT TO CORRECT ERRONEOUS INFORMATION, IF ANY.

IF TOTAL CHARGE NEEDS CORRECTION, BACK UP TO CP09.

OVERPAYMENT: {$XXXXXXXXX} TOTAL CHARGE: {$XXXXXXXXX}

|----------------------------|--------------------|--------------------|

| ROSTER. SOURCE OF PAYMENT | CP26_02. DOLLAR | CP26_03. PERCENT |

| | AMOUNT PAID | AMOUNT PAID |

|----------------------------|--------------------|--------------------|

| PERSON/Family | [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Enter $ Amount] | [Enter % Amount] |

|----------------------------|--------------------|--------------------|

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| CONTEXT HEADER IF THE EVENT TYPE IS NOT ‘PM’ |

| (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL |

| EXPENSES). OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ |

| (OTHER MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE CONTEXT HEADER IF EVENT |

| TYPE IS ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER|

| MEDICAL EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| REPEAT VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE CONTEXT HEADER IF THIS EVENT IS A |

| FLAT FEE STEM. |

----------------------------------------------------

| TOTAL CHARGE: DISPLAY AMOUNT ENTERED AT CP09. |

| |

| DISPLAY 'PERSON/FAMILY' AS THE FIRST SOURCE OF |

| PAYMENT. |

| |

| IF THE AMOUNT PAID BY PERSON/FAMILY WAS ADJUSTED |

| AT CP13, DISPLAY ADJUSTED AMOUNT. IF AMOUNT PAID |

| BY PERSON/FAMILY WAS NOT ADJUSTED, DISPLAY |

| THE RESPONSE TO CP11 IN THE 'AMOUNT PAID' |

| COLUMN FOR PERSON/FAMILY. THAT IS, IF THE |

| RESPONSE TO CP11 IS A DOLLAR AMOUNT, DISPLAY THE |

| DOLLAR AMOUNT IN THE ‘DOLLAR AMOUNT PAID’ COLUMN. |

| IF THE RESPONSE TO CP11 IS A PERCENTAGE, DISPLAY |

| THE PERCENTAGE AMOUNT IN THE ‘PERCENT AMOUNT PAID’|

| COLUMN. IF THE DOLLAR AMOUNT OR PERCENT AT CP11 IS|

| CODED ‘-8’ (DON’T KNOW), DISPLAY ‘DK’ FOR THE |

| AMOUNT IN BOTH COLUMNS. IF THE DOLLAR AMOUNT OR |

| PERCENT IS CODED ‘-7’ (REFUSED), DISPLAY ‘REF’ |

| FOR THE AMOUNT IN BOTH COLUMNS. |

----------------------------------------------------

| (PERSON)'s stay at (HOSPITAL) that began on |

| (ADMIT DATE): DISPLAY IF EVENT TYPE IS HS. |

| |

| (PERSON)'s visit to (PROVIDER) on (VISIT DATE): |

| DISPLAY IF EVENT TYPE IS ER, OP, MV, OR DN. |

| |

| the last purchase of {NAME OF PRESCRIBED MEDICINE}|

| for (PERSON): DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| the services for (FLAT FEE GROUP) for (PERSON): |

| DISPLAY IF EVENT-PROVIDER PAIR REPRESENTS A FLAT |

| FEE GROUP. |

| |

| the {OME ITEM GROUP NAME} used by (PERSON) since |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| services received at home from (PROVIDER) during |

| (MONTH) for (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

| {$ DISCREPANCY}: DISPLAY THE AMOUNT OF THE |

| CALCULATED OVERPAYMENT. |

| |

| OVERPAYMENT: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| OF THE CALCULATED OVERPAYMENT. |

| |

| TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| ENTERED AT CP09OV. |

----------------------------------------------------

| FLAG ALL SOURCES AND ASSOCIATED AMOUNTS AS |

| ‘DIRECT PAYMENTS’. |

----------------------------------------------------

| SOFT CHECK: |

| WHOLE DOLLAR AMOUNT (INTEGER): 0 - $100,000 |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: EVNT_SOP_1 |

| |

| COL # 1 HEADER: SOURCE OF PAYMENT |

| INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME |

| (PAYM.REIMNAM/PAYF.REIMNAM) |

| |

| COL # 2 HEADER: DOLLAR AMOUNT PAID |

| INSTRUCTIONS: ENTER $ AMOUNT PAID |

| (PAYM.AMTPAID/PAYF.AMTPAID) |

| |

| COL # 3 HEADER: PERCENT AMOUNT PAID |

| INSTRUCTIONS: ENTER % AMOUNT PAID |

| (PAYM.PCTPAID/PAYF.PCTPAID) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR |

| ENTRY. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. SOURCE COLUMN IS PROTECTED; NO CHANGES ARE |

| ALLOWED TO SOURCES AT THIS SCREEN. |

| |

| 2. THE INTERVIEWER CAN ENTER A DOLLAR OR A |

| PERCENTAGE AMOUNT FOR EACH SOURCE DISPLAYED. |

| |

| 3. WHEN THE DOLLAR OR PERCENTAGE AMOUNT HAS BEEN |

| ENTERED AND THERE IS A TOTAL CHARGE, THE |

| RECIPROCAL AMOUNT WILL BE DISPLAYED. FOR EXAMPLE,|

| IF THE INTERVIEWER ENTERS A PERCENTAGE, THE DOLLAR|

| AMOUNT WILL BE CALCULATED USING THE TOTAL CHARGE. |

| |

| 4. IF A SOURCE IS ENTERED IN ERROR, THE |

| INTERVIEWER WILL ZERO OUT THE AMOUNT PAID. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES FLAGGED AS ‘DIRECT PAYMENT’. |

----------------------------------------------------

CP26OV

======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DID ANY OTHER SOURCES MAKE ANY PAYMENTS DIRECTLY TO THE

PROVIDER?

YES .................................... 1 {END_LP04}

NO ..................................... 2 {END_LP04}

HELP AVAILABLE FOR A DEFINITION OF PAYMENTS MADE DIRECTLY TO PROVIDER.

END_LP04

========

----------------------------------------------------

| IF CP26OV IS CODED ‘1’ (YES), CYCLE TO COLLECT |

| ADDITIONAL SOURCES OF PAYMENT |

----------------------------------------------------

| IF CP26OV IS CODED ‘2’ (NO), END LOOP_04 AND |

| CONTINUE WITH BOX_15 |

----------------------------------------------------

BOX_15

======

----------------------------------------------------

| RECALCULATE AMOUNT OF UNDERPAYMENT OR OVERPAYMENT.|

----------------------------------------------------

| IF UNDERPAYMENT IS > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF TOTAL CHARGE, CONTINUE WITH BOX_19 |

----------------------------------------------------

| OTHERWISE, GO TO CP37 |

----------------------------------------------------

BOX_16

======

OMITTED.

CP27

====

OMITTED.

CP28

====

OMITTED.

CP28OV1

=======

OMITTED.

CP28OV2

=======

OMITTED.

BOX_17

======

OMITTED.

BOX_18

======

OMITTED.

CP29

====

OMITTED.

CP30

====

OMITTED.

CP30OV1

=======

OMITTED.

CP30OV2

=======

OMITTED.

BOX_19

======

----------------------------------------------------

| IF CP21 WAS ASKED, GO TO CP37 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_20 |

----------------------------------------------------

BOX_20

======

----------------------------------------------------

| IF UNDERPAYMENT IS STILL > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF TOTAL CHARGE, CONTINUE WITH CP31 USING |

| THE DIFFERENCE IN THE DISPLAY. |

----------------------------------------------------

| IF UNDERPAYMENT IS NOT > 3% OR $5 (WHICHEVER IS |

| HIGHER) OF THE TOTAL CHARGE, GO TO CP37 |

----------------------------------------------------

CP31

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

|----------------------------|--------------------|--------------------|

| ROSTER. SOURCE OF PAYMENT | DOLLAR | PERCENT |

| | AMOUNT PAID | AMOUNT PAID |

|----------------------------|--------------------|--------------------|

| PERSON/Family | [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

| [Display Source of Payment]| [Display $ Amount] | [Display % Amount] |

|----------------------------|--------------------|--------------------|

TOTAL CHARGE: {$XXXXXXXXX} DIFFERENCE: {$XXXXXXXXX}

Do you expect anyone in the family to pay any {amount/more}?

YES .................................... 1 {CP32}

NO ..................................... 2 {CP37}

REF ................................... -7 {CP37}

DK .................................... -8 {CP37}

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

----------------------------------------------------

| {amount/more}: DISPLAY ‘amount’ IF PERSON FAMILY |

| PAYMENT IS $0/0%. DISPLAY ‘more’ IF PERSON/FAMILY|

| PAYMENT IS NOT EQUAL TO $0/0% (INCLUDING DON’T |

| KNOW AND REFUSED RESPONSES). |

| |

| TOTAL CHARGE: {$XXXXXXXXX}: DISPLAY THE AMOUNT |

| ENTERED AT CP09OV. |

| |

| DIFFERENCE: {$XXXXXXXXX}: DISPLAY THE AMOUNT OF |

| THE RE-CALCULATED UNDERPAYMENT. |

----------------------------------------------------

| ROSTER DETAILS: |

| TITLE: EVNT_SOP_1 |

| |

| COL # 1 HEADER: SOURCE OF PAYMENT |

| INSTRUCTIONS: DISPLAY PAYMENT SOURCE NAME |

| (PAYM.REIMNAM/PAYF.REIMNAM) |

| |

| COL # 2 HEADER: DOLLAR AMOUNT PAID |

| INSTRUCTIONS: ENTER $ AMOUNT PAID |

| (PAYM.AMTPAID/PAYF.AMTPAID) |

| |

| COL # 3 HEADER: PERCENT AMOUNT PAID |

| INSTRUCTIONS: ENTER % AMOUNT PAID |

| (PAYM.PCTPAID/PAYF.PCTPAID) |

----------------------------------------------------

| ROSTER DEFINITION: |

| DISPLAY THE EVENT’S-SOURCES-OF-PAYMENT-ROSTER FOR |

| DISPLAY. |

----------------------------------------------------

| ROSTER BEHAVIOR: |

| 1. THIS MATRIX IS READ-ONLY. |

----------------------------------------------------

| ROSTER FILTER: |

| DISPLAY ALL SOURCES FLAGGED AS ‘DIRECT PAYMENT’. |

----------------------------------------------------

CP32

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

{NAME OF PRESCRIBED MEDICINE} {OME ITEM GROUP NAME}

How much do you expect anyone in the family to pay?

IS ANSWER IN DOLLARS OR PERCENT?

DOLLARS ................................ 1 {CP32OV1}

PERCENT ................................ 2 {CP32OV2}

[Code One]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

----------------------------------------------------

CP32OV1

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

DOLLARS:

[Enter $ Amount] ....................... {CP37}

REF ................................... -7 {CP37}

DK .................................... -8 {CP37}

----------------------------------------------------

| SOFT CHECK: |

| WHOLE DOLLAR AMOUNT (INTEGER): $0 - $10,000 |

----------------------------------------------------

CP32OV2

=======

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

PERCENT:

[Enter % Amount] ....................... {CP37}

REF ................................... -7 {CP37}

DK .................................... -8 {CP37}

----------------------------------------------------

| SOFT CHECK: |

| 1% - 100% |

----------------------------------------------------

BOX_21

======

OMITTED.

CP33

====

OMITTED.

CP34

====

OMITTED.

CP34OV1

=======

OMITTED.

CP34OV2

=======

OMITTED.

BOX_22

======

OMITTED.

CP35

====

OMITTED.

CP36

====

OMITTED.

CP37

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: WHAT RECORDS WERE USED IN COMPLETING THE

CHARGE/PAYMENT INFORMATION FOR THE {VISIT TO (PROVIDER) ON

(VISIT DATE)/THE VISITS FOR (FLAT FEE GROUP)/THE LAST PURCHASE

OF {NAME OF PRESCRIBED MEDICINE}/the {OME ITEM GROUP NAME}

used by (PERSON) since (START DATE)/services received at home

from (PROVIDER) during (MONTH) for (PERSON)}?

CHECK ALL THAT APPLY.

RESPONDENT’S/FAMILY MEMBER’S MEMORY ....... 1

RESPONDENT’S/FAMILY MEMBER’S CHECK BOOK ... 2

STATEMENT, BILL OR RECEIPT FROM

PROVIDER’S OFFICE ......................... 3

EXPLANATION OF BENEFITS FROM:

MEDICARE ................................ 4

PRIVATE INSURANCE CARRIER ............... 5

CALENDAR .................................. 6

PRESCRIBED MEDICINE BOTTLE, BAG, OR

CONTAINER ............................... 7

OTHER .................................... 91 {CP37OV}

[Code All That Apply]

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

| THE VISIT TO (PROVIDER) ON (VISIT DATE): DISPLAY |

| IF EVENT TYPE IS HS, OP, ER, MV, OR DN. |

| |

| THE VISITS FOR (FLAT FEE GROUP): DISPLAY IF |

| EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP. |

| |

| THE LAST PURCHASE OF {NAME OF PRESCRIBED |

| MEDICINE}: DISPLAY IF EVENT TYPE IS PM. |

| |

| {NAME OF PRESCRIBED MEDICINE}: DISPLAY THE NAME |

| OF THE PRESCRIPTION MEDICINE BEING ASKED ABOUT |

| FOR THIS EVENT. |

| |

| THE {OME ITEM GROUP NAME} USED BY (PERSON) SINCE |

| (START DATE): DISPLAY IF EVENT TYPE IS OM. |

----------------------------------------------------

| {OME ITEM GROUP NAME}: DISPLAY THE NAME OF THE |

| OTHER MEDICAL EXPENSES ITEM GROUP BEING ASKED |

| ABOUT FOR THIS EVENT. |

| |

| DISPLAY ‘glasses or contact lenses’ IF EVENT |

| TYPE IS OM AND THE OM ITEM GROUP IS ‘1’ (GLASSES|

| OR CONTACT LENSES). |

| |

| DISPLAY ‘ambulance services’ IF THE OM ITEM |

| GROUP IS ‘4’ (AMBULANCE SERVICES). |

| |

| DISPLAY ‘orthopedic items’ IF THE OM ITEM GROUP |

| IS ‘5’ (ORTHOPEDIC ITEMS). |

| |

| DISPLAY ‘hearing devices’ IF THE OM ITEM GROUP |

| IS ‘6’ (HEARING DEVICES). |

| |

| DISPLAY ‘prostheses’ IF THE OM ITEM GROUP IS ‘7’|

| (PROSTHESES). |

| |

| DISPLAY ‘bathroom aids’ IF THE OM ITEM GROUP IS |

| ‘8’ (BATHROOM AIDS). |

| |

| DISPLAY ‘medical equipment’ IF THE OM ITEM GROUP|

| IS ‘9’ (MEDICAL EQUIPMENT). |

| |

| DISPLAY ‘disposable supplies’ IF THE OM ITEM |

| GROUP IS ‘10’ (DISPOSABLE SUPPLIES). |

| |

| DISPLAY ‘alterations or modifications’ IF THE OM|

| ITEM GROUP IS ‘11’ (ALTERATIONS/MODIFICATIONS). |

| |

| DISPLAY {TEXT FROM OTHER SPECIFY} IF THE OM ITEM|

| GROUP IS ‘91’ (OTHER). |

| |

| FOR ‘TEXT FROM OTHER SPECIFY’, DISPLAY THE |

| TEXT CATEGORY ENTERED IN THE OTHER SPECIFY |

| FIELD FOR OM EVENTS. |

| |

| FOR ‘{START DATE}’, DISPLAYED IN THE CONTEXT |

| HEADER, DISPLAY THE START DATE OF THE CURRENT |

| ROUND FOR OM EVENTS THAT ARE ‘REGULAR’ GROUP TYPE |

| (EV02A=1 OR NOT ASKED) AND DISPLAY ‘JAN 01’ FOR OM|

| EVENTS THAT ARE ‘ADDITIONAL’ GROUP TYPE (EV02A=2).|

| |

| SERVICES RECEIVED AT HOME FROM (PROVIDER) DURING |

| (MONTH) FOR (PERSON): DISPLAY IF EVENT TYPE IS HH.|

----------------------------------------------------

| IF CODED ‘91’ (OTHER), ALONE OR IN COMBINATION |

| WITH OTHER CODES, CONTINUE WITH CP37OV |

----------------------------------------------------

| OTHERWISE, GO TO BOX_23 |

----------------------------------------------------

CP37OV

======

OTHER SPECIFY:

[Enter Other Specify] .................. {BOX_23}

BOX_23

======

----------------------------------------------------

| IF CP37 IS CODED '3' (PROVIDER'S OFFICE), '4' |

| (EXPLANATION OF BENEFITS FROM MEDICARE), OR '5' |

| (EXPLANATION OF BENEFITS FROM PRIVATE INSURANCE |

| CARRIER) |

| AND |

| EVENT TYPE IS NOT PM OR OM, |

| CONTINUE WITH CP38 |

----------------------------------------------------

| OTHERWISE, GO TO BOX_24 |

----------------------------------------------------

CP38

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: DOES THE PAPERWORK SHOW THAT (PROVIDER) HAS

ANOTHER NAME?

YES .................................... 1 {CP39}

NO ..................................... 2 {BOX_24}

HELP AVAILABLE FOR DEFINITION OF PROVIDER NAME.

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

CP39

====

{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE

PROVIDER} {EV} {EVN-DT/REF-DT}

{REPEAT VISIT: {NAME OF REPEAT VISIT GROUP}/FLAT FEE

GROUP: {NAME OF FLAT FEE EVENT GROUP}}

INTERVIEWER: ENTER OTHER NAME FOR (PROVIDER).

[Enter Medical-Provider-65] .............. {BOX_24}

----------------------------------------------------

| DISPLAY {NAME OF MEDICAL CARE PROVIDER} IN THE |

| HEADER IF THE EVENT TYPE IS NOT ‘PM’ (PRESCRIBED |

| MEDICINES) OR ‘OM’ (OTHER MEDICAL EXPENSES). |

| OTHERWISE, USE NULL VALUE. |

| |

| DISPLAY {EVN-DT} IN THE HEADER IF EVENT TYPE IS |

| NOT ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER |

| MEDICAL EXPENSES). |

| |

| DISPLAY {REF-DT} IN THE HEADER IF EVENT TYPE IS |

| ‘PM’ (PRESCRIBED MEDICINES) OR ‘OM’ (OTHER MEDICAL|

| EXPENSES). |

| |

| DISPLAY ‘REPEAT VISIT: {NAME OF REPEAT VISIT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A REPEAT |

| VISIT STEM. |

| |

| DISPLAY ‘FLAT FEE GROUP: {NAME OF FLAT FEE EVENT |

| GROUP}’ IN THE HEADER IF THIS EVENT IS A FLAT FEE |

| STEM. |

----------------------------------------------------

BOX_24

======

----------------------------------------------------

| IF: |

| EVENT-PROVIDER PAIR REPRESENTS A FLAT FEE GROUP, |

| OR |

| EVENT TYPE IS PM, HS, OM, OR HH, |

| OR |

| PERSON-PROVIDER PAIR ALREADY FLAGGED AS ‘COPAYMENT|

| SITUATION’, |

| GO TO BOX_26 |

----------------------------------------------------

| OTHERWISE, CONTINUE WITH BOX_25 |

----------------------------------------------------

BOX_25

======

----------------------------------------------------

| IF [CP08 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR |

| ‘-8’ (DON’T KNOW)] OR [THE AMOUNT IN CP09 IS SET |

| TO THE COPAYMENT AMOUNT] OR [CP08 AND CP09 WERE |

| NOT ASKED AND CP06 IS CODED ‘5’ (NO BILL SENT: |

| HMO PLAN), ‘6’ (NO BILL SENT: VA), ‘8’ (NO BILL |

| SENT: PUBLIC ASSISTANCE/MEDICAID/SCHIP) OR ‘15’ |

| (NO BILL SENT: INDIAN HEALTH SERVICE)] |

| AND |

| CP10 IS CODED ‘1’ (YES) |

| AND |

| CP11 IS CODED ‘1’ (DOLLARS) AND A WHOLE DOLLAR |

| AMOUNT GREATER (>) THAN $0 AND LESS THAN OR EQUAL |

| (<=) TO $50 IS ENTERED IN CP11OV1, |

| FLAG THIS PERSON-PROVIDER PAIR AS A ‘COPAYMENT |

| SITUATION’, THEN CONTINUE WITH BOX_26 |

----------------------------------------------------

| OTHERWISE, DO NOT SET ANY FLAGS AND THEN CONTINUE |

| WITH BOX_26 |

----------------------------------------------------

BOX_26

======

----------------------------------------------------

| FLAG CP STATUS OF EVENT-PROVIDER PAIR AS |

| ‘PROCESSED’. |

----------------------------------------------------

| END OF CHARGE PAYMENT (CP) SECTION. |

----------------------------------------------------

21-123

File Type	application/msword
File Title	MEPS Charge Payment - P12R5/P13R3/P14R1
Subject	CP Section Item Specifications
Author	Agency for Healthcare Research and Quality
Last Modified By	wcarroll
File Modified	2009-07-08
File Created	2009-07-08